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Care, Culture, and Education 

Nursing Students' Perceptions 

of Care and Culture: 

Implications for Practice 

Submitted by 

Pauline Rita Wright 

In partial fulfillment of the requirements 

For the degree of 

Doctor of Philosophy 

Lesley University 
May 19, 2010 

© All Rights Reserved 

Today' s nurses work and live in a multicultural society where they encounter patients 
whose backgrounds are different from theirs, and who need care from nurses who are 
both proficient in their work and knowledgeable about the role that culture plays in 
patient treatment. In this study, 45 student nurses enrolled in a baccalaureate program at a 
northeastern urban college completed a survey about their perceptions of care and culture 
including their relevance and application to the practice of nursing. Findings based on 
qualitative analyses indicated that parents and family were instrumental in students' 
learning about care and a combination of family and educators influenced their learning 
about culture. Responses revealed that while the importance of obtaining specific cultural 
information from patients through effective communication was noted, the use of a 
medical interpreter was considered important by only one student. This finding is 
problematic since students were unaware of the importance of utilizing interpreter 
services when caring for a patient who has limited knowledge of the English language. 
The findings of this survey suggest the need for further transcultural education on the 
baccalaureate nursing level specifically as it pertains to communication with patients of 
diverse cultures in the provision of care. 


This journey would not have been complete without the help of my daughters Michelle 
Stines Joy and Danielle Stines. I would also like to acknowledge my senior advisor and 
committee chair Professor Marion Nesbit, committee members Professor Don Anderson 
and Professor Maria de Lourdes Serpa who provided the discipline necessary to 
accomplish this goal and lastly, Professor Dina Comnenou who was on my committee for 
the first phase of this project. Thank you all for your support and faith in me. 

"As a way of motivating people, cultivating fear is easier than investing the time and 
effort necessary to engender respect. Respect requires greater knowledge, and in my 
experience the more you know, the less you fear. " 

Michael J. Fox 

Table of Contents 

Chapter I. Introduction 6 

Chapter II. Literature Review 12 

A. The Role of Care in Nursing 12 

1. Historical perspectives 13 

2. Definitions of care that embrace empathy 19 

3. Learning care 24 

4. Contrasting functional and relational care in nursing 25 

5. Personal attributes of caring related to nursing 29 

6. The universal concept of a caring nurse 31 

7. Implications for the profession 32 

8. Boston's Forgotten Nightingale 34 

B. Culture and Nursing 37 

1 . Nursing history 38 

2. Military nursing 44 

3. Men as nurses 45 

4. The impact of immigration on nursing 47 

5. Cultural traditions for nursing 51 

6. The influence of communication on nursing 53 

7. The creation of a culturally competent nurse 55 

8. Implications for nursing 59 

C. Adult Learning's Impact on Care and Culture in Nursing 61 

1. Historical perspectives 61 

2. Adult development 64 

3. Teaching 65 

4. Teaching styles 66 

5. Learning 69 

6. Learning styles 72 

7. Adult learning theory 74 

8. Classroom environment 78 

9. Curriculum 81 
10. Nursing education and the processes used in teaching care 

and culture 84 

Chapter III. Methods 88 

A. Statement of the problem and context for research 88 

B. Instrument development 89 

C. Participants and data collection 90 

Chapter IV. Findings 93 

A. Demographics 93 

B. Questions 95 

C. Themes 106 

Chapter V. Discussion 109 

A. Discussion, analysis and interpretation of findings 109 

B. Limitations 118 

C. Implications 118 

Chapter VI. Conclusions 124 

Tables 127 

Figures 128 

References 129 

Appendices 160 

A. Lesley University Internal Review Board Approval 161 

B. Curry College Internal Review Board Approval 162 

C. Letter of Participation 163 

D. Informed Consent Form 164 

E. Survey 166 

F. Textbooks 168 

G. Student Quotations 169 

Chapter I: Introduction 

Nurses live and work in a multicultural world and need to be knowledgeable 
about culture and how it affects the quality of care given to patients. Knowing how to 
communicate effectively with patients includes an understanding of language. In a 
diverse city such as Boston, many patients who access the healthcare system are not 
proficient in the dominant English language and as such, would need the assistance of an 
interpreter when discussing health issues. Tufts Medical Center which is situated in 
downtown Boston has "an average of 3800 'interpreter encounters' each month" (2010). 
This information is astounding and supports the notion that schools of nursing include the 
topics of care and culture in their general curriculum. 

However, since there is no uniformity in what students learn about these subjects, 
their application to practice, or their importance to the nursing profession in general, I 
undertook this study as an attempt to identify how student nurses view culture and care in 
relation to nursing practice. The intent here is twofold: to use the information gained in 
this study of student nurses' perceptions about care and culture to inform curriculum 
development so nursing faculty can teach students to address patients' culture as they 
learn clinical skills and prepare to deliver care in various health care settings; and to 
indicate extensions of this topic for future study and exploration. 

This topic is one of great importance as hospital patient populations grow 
increasingly diverse. As mentioned above, "Tufts Medical Center and Floating Hospital 
for Children have one of largest interpreter services departments in the region, making 
translation services available in over thirty- seven languages, as well as video sign 
language interpreting" (2009, p. 1). Because of the need for accuracy in medical 

treatment, it is critical for nurses to learn the skills necessary to communicate effectively 
with their patients in order to assure a positive outcome in patient care. Therefore 
accessing interpreter services is a necessary component for providing culture sensitive 
patient care. 
Personal background and context 

My interest in culture and my belief in the importance of caring began when I was 
a child growing up in New Bedford, Massachusetts, a seaport city with a diverse 
population. The citizens of my native city who were of English, Portuguese, Norwegian, 
Polish, Greek, Syrian, Cape Verdean, Chinese, French, Italian, Irish, and Lebanese 
descent brought their culture and religious beliefs with them and demonstrated it in the 
way they lived and conducted business. For instance, in my neighborhood my family 
shopped for food at the Polish meat market for ham, pickles, and pumpernickel bread, the 
Portuguese bakery for sweetbread and rolls, the French bakery for pastries and cookies, 
the Jewish bakery for bagels and cakes, and the Greek candy store for ice cream, 
chocolates, and Easter bunnies. Families enjoyed trying specialties of other cultures and 
sharing their own. 

I remember family friends who were from cultures different from ours, yet our 
immediate neighborhoods were pretty much divided by ethnic background. Each 
nationality had its own church or synagogue and many had schools where classes were 
given in English as well as in the language of the ancestral homeland. Growing up in a 
multicultural environment gave me a taste of other cultures and led to my appreciation of 
the richness of diversity. In fact I thought that every city was this way. What I learned 
later in early adulthood dispelled this notion, as I realized that most others I met did not 


share a similar experience or feel the same way about diversity. 

As I reflected on my belief in the value of cultures other than my own, I came to 
understand the importance of the role of family and how families perceived the world. 
My mother and grandmothers were the prime caregivers for my family. These women 
taught me by their example, how to care for myself, my brother, the people I interacted 
with on a daily basis, my community, as well as my treasured dolls on whom I practiced 
and modeled what I learned. The influence of these important women in my family led 
me to consider nursing as a career path for carrying out the values they instilled for the 
importance of caring for others. 

My mother valued education so highly that she found a way to pay for 12 years of 
parochial schooling in a French Catholic neighborhood school. After graduating from St. 
Anthony High School, one of the many French Canadian institutions in the city, I entered 
Catherine Laboure School of Nursing in Boston, Massachusetts. Leaving New Bedford to 
pursue higher education in "the big city" was perceived as a major move. The 
geographical change into life in a metropolitan location was not the one that affected me 
the most, however. For the first time in my life, I came across people of Asian and 
African American descent and, moreover, was led to understand that these people were to 
be feared. At first I was apprehensive of these people who looked so different from me 
and those from my New Bedford upbringing. I wondered why I was warned to be wary 
of them; however, when I became more acquainted with the students who were different 
from me, I realized that in contrast to nursing educators' cautions, we had many common 
values and very similar goals. I have carried this realization, one which affirmed the way 
I was raised, with me ever since. It has affected profoundly the way I live and work, 

including my choice of a dissertation topic. 

After graduating from nursing school, I entered the United States Air Force Nurse 
Corps where I was further exposed to different cultures, values, and traditions. This latter 
experience was instrumental in allowing me to witness how people who were not of the 
dominant culture were treated. I found the study of nursing to be not only strenuous but 
exceedingly grueling. As I sat in nursing classrooms and listened to the lectures taught 
from a seemingly irrefutable, one size fits all, medical model, I often asked myself why I 
was drawn to this profession. My answer came when as a young United States Air Force 
officer I was sent to nurse the injured troops involved in the Vietnam War. My 30 bed 
Intensive Care Unit at Clark Air Base in the Philippines allowed me to see caring at its 
best. In this setting I saw death through the eyes of my patients who were my age. I also 
saw the fright and courage they exhibited and held their hands and comforted them as 
they drew their last breath. Following the teachings of my nursing instructors not to cry 
or show emotion in front of the patient was extremely difficult. My peers and I would 
later gather after work in an intimate group to discuss our daily ordeals and to 
commiserate, cry, and comfort each other. The tragedies we experienced made us grow 
up rapidly and forever changed our outlook on life, war, and the political system that 
allowed us to witness these horrors. 

After leaving the military I continued working in hospitals as an Intensive Care 
Nurse and further observed cultural differences. I also realized the need to communicate 
in the individual's language and the importance of understanding the cultural context for 
treatment. Later, as a faculty member and then as an administrator of a nursing program, I 
had the opportunity to work with people from other countries who wanted to be nurses. 


Learning about the health care systems and wellness practices of the nursing students I 
taught, gave me insight on how to care more effectively for patients whose health beliefs 
were different from mine. This revelation made me realize the importance of studying 
both care and culture because of their complex inextricable relationship. 

As a seasoned nurse, working in the educational arena, I was made privy to a 
caring attitude that was somewhat different from the one I had lived through in my 
clinical settings. I worked with nurses who cared immensely for their multicultural 
students both in the clinical and classroom surroundings. These kindhearted nurses acted 
as role models for the future nurses they were educating. A few nursing instructors went 
so far as to lend their students a textbook so that they could study. Others provided 
emotional encouragement when the student felt like he/she was never going to succeed in 
nursing while some cried with sadness or joy with their students. These selfless acts of 
caring were extremely important to both the recipient and the giver. 

During my nursing career, my work assignments have taken me to large urban 
areas as well as to small towns and suburbs. Further, as a military nurse I had the 
opportunity to be stationed not only in various sections of the United States, but also in 
Asia, Europe, and Central America. Collectively, I have had the opportunity to work with 
patients, nurses, healthcare workers, faculty and students of different ages, ethnicities, 
cultural, and educational backgrounds. 

The cultural awareness I developed and the caring interactions I encountered 
broadened my outlook on my life as a nurse and the possibilities for improving the 
practices of the profession. While faculty and administrator of a nursing program, 
I became acutely aware that nurses who had not had exposure to or experiences with 


other cultures required more instruction in these areas. This revelation increased my 
interest regarding how nursing instructors could better teach culture and care to nursing 
students from various backgrounds, with the goal of serving patients more effectively. 

Teaching the nurses of the future is a challenge as well as a reward. In light of the 
nursing shortage, it is imperative that nursing instructors acknowledge and address 
increasing cultural diversity of patient populations and understand how, where, when, and 
why they teach their students to be caring and culturally competent. 

The scholarly basis for this work is presented in Chapter II: The Literature 
Review. The Methodology section follows and includes the research study and findings. 
The Discussion and Implications sections address the relationship of this study with 
previous research and current curriculum and pedagogical practices in nursing education. 


Chapter II: Literature Review 

The scholarly work that serves as a foundation for this study draws from three 
areas: the role of care in nursing; the relationship between culture and nursing; and, the 
impact of education on adult learners in nursing. 

The Role of Care in Nursing 

Caring is an attribute that has been embraced by the nursing profession since early 
times as it refers to providing for another's wellbeing. Caring is a concept that is linked 
with strong emotions like love, when a person willingly gives to another, and with 
situational use, such as when showing kindness and concern in attending to those in need. 

The act of caring is the foundation upon which nursing is built. Throughout time, 
nurses have been told by their profession that they must care for their patients 
unconditionally even though this may be difficult in certain situations. Caring is also a 
quality nurses believe they exhibit in their daily work life. In fact nurses believe that they 
are the only ones who care for the well-being of their patients and that no other 
profession can emulate them. Nurses consider caring, a characteristic that has 
traditionally been assigned to women, to be the core of their profession. 

In order to understand the influence of care on nursing, it is necessary to review 
the historical perspectives of the profession. The study of history assists nurses in 
understanding how the notion of care emerged in nursing, how care impacts the patient- 
nurse relationship, and how nurses will continue to practice care. The positive and 
negative aspects of nursing care are addressed as well as how care can be taught in 
schools of nursing and healthcare settings alike. Finally an example is presented in an 


effort to make the reader appreciate how a truly caring nurse overcame adversity to 
follow the teachings of her heart. 

The history behind care and the profession of nursing is examined because in 
order to understand care in today's nursing environment it is necessary to review how 
care developed as a core value in the nursing profession. The terms care and empathy are 
defined and their differences and similarities are identified. These characteristics are 
drawn from the review of works by Noddings (1986), Roach (1987), and Watson (1990a) 
among others. 

In this section, the attributes of caring are related to nursing care. The concept of 
the "caring" nurse is examined from a universal perspective as is the notion of how a 
caring nurse is developed and nurtured. Finally, a brief description of Boston's forgotten 
Nightingale, Frances Slanger, is presented as the ultimate example of a caring interaction 
between a nurse and her patient. 
Historical perspective 

Historically nursing has been seen as a caring profession. Throughout the years, 
those who have entered the profession "have been socialized by nursing schools, 
hospitals, and professional organizations to feel personally responsible for the care and 
comfort of patients" (Weinberg, 2003, p. 153). Nurses as the healthcare givers within 
the medical community who spend the most time with patients, take the time to actively 
listen, get to know the families, and are in a special position to act as liaisons between 
their colleagues in the healthcare field and patients. Therefore, because of these personal 
interactions, nurses understand that without care and communication the patient's 
environment is greatly compromised. 


Caring is also a characteristic that has traditionally been assigned to women, 
mothers, and nurses. Since the majority of nurses are women Noddings' (1986) comment 
that "...women often define themselves as both persons and moral agents in terms of 
their capacity to care" (p. 40), seems particularly relevant here. Nursing has attracted 
young women to the profession over the years because of the values of opportunities for 
nurturing, and caring. 

The notion of submissiveness was not widely tested and nurses became 
subservient to the male dominated medical profession (Luttrell, 1992, p. 50). Nurses were 
therefore "trained" to take orders from doctors and to carry out their directives without 
question. Creative thinking was not encouraged because nurses involved in the 
conduction of these actions were expected to do so out of blind obedience. This top-down 
authoritarianism lead to the development of nurses who were self-effacing and self- 
critical and thus remained "silent about their practices and talk(ed) only about their caring 
and compassion" (Nelson and Gordon, 2006, p. 177). 

While subordination of nurses by doctors can still be seen today, in the last fifty 
years the field of nursing has attempted to redefine itself so that it is more respected as on 
par with others who treat patients. Being a caring and warm person is not enough in 
today's professional milieu. As Roach (1987, p. 3) noted "caring has been used as a 
popular catch-all in commercials, advertising, posters, and billboards" as a way of 
presenting a caring image to the public about the scope of nursing. This view of caring 
which is rampant in nursing today is more detrimental than helpful to the profession as 
the term care loses its significance. 

Nursing is an old profession, and examples of caring and empathy are found in 


the Bible. Martha and Mary who were friends of Jesus, cared for and nursed their ailing 
brother Lazarus until he died. The grief stricken sisters solicited the help of Jesus during 
their time of need; and, Jesus, sensing how Mary and Martha felt about the loss of their 
beloved brother, resurrected Lazarus from the dead. In this example, caring for the sick 
and infirm was exhibited through the behavior of close attention and loving concern 
modeled by Jesus. (John, ch. 11, v. 32-44) 

In early India pious men were selected to care for the sick and to assist them with 
their spiritual needs. This work was considered an honor for these men. During the 
Middle Ages nursing was carried out by religious sisters and brothers who turned their 
monasteries into hospitals for the care of the sick and destitute. These religious had a 
profound effect on nursing that is prevalent even today. With the advent of the Crusades, 
nursing entered the realm of the battlefields of Europe, Northern Africa, and the Middle 
East. Today nursing still plays an integral part in the modern military. 

Not everyone entered the military for pious reasons. For example, some like Walt 
Whitman, the American poet, became a military nurse for personal reasons. Upon hearing 
that his brother had been wounded during the Civil War, Whitman not only cared for his 
brother, but also he went on to nurse the wounds of other soldiers. As "an early 
practitioner of holistic nursing, he incorporated encouragement, active and nondirective 
listening, and intentional use of touch into his nursing care" (Ahrens, 2002, p. 2). 
Whitman believed that care in the context of hope and love saved lives. 

Modern nursing evolved in England during the late 1800s when Florence 
Nightingale, a friend of Queen Victoria, opened a school for the training of nurses. 
Nightingale's schools were founded on a principle of absolute authority implying 


that nurses did what they were told. Nurses were not encouraged to think for themselves 
or to talk to their patients about their concerns and fears. 

The provision of care in a relational sense, an important aspect in nursing today, 
was not widely encouraged. Patients were not allowed to express themselves or to voice 
what ailed them. Furthermore, patients were isolated from family and friends and so they 
had no one to speak to about their physical, spiritual, and emotional needs. To quote 
Leininger, "contrary to what many nurses attribute to Florence Nightingale, she did not 
focus specifically on the phenomenon of care. Her major focus was patients, the 
environment, and the conditions to support care. Nightingale did not define or explain the 
concept of care" although it was apparent to those around her that she cared deeply for 
the soldiers she nursed during the Crimean War (1988, pi 2). 

Although relational care was of little concern to the nurse "trained" in the formal 
Nightingale model, care was exhibited when conditions were set to meet the physical 
needs of the patients. This way of thinking and the treatment accorded to the patients 
continued in the hospital based schools of nursing for over fifty years and eventually 
carried over to the academic setting when schools of nursing began granting degrees. 
Nightingale's philosophy is still paramount today in nursing programs in the United 
States and Western Europe and in many instances student nurses continue to be treated 
with little empathy or care by their instructors. This behavior by the nursing instructors 
produces an undesirable model of empathy and care for students who must in turn 
attempt to empathize and care for their patients. Fortunately today, an attempt is being 
made to rectify this lack of concern for the other. Happily, as some schools of nursing are 
attempting to introduce courses on caring interactions in the curriculum, Gordon and 


Nelson reiterate Leininger when they emphasize that 

nurses must examine the history of their profession as 'virtuous workers' and 
understand the power that what we call the 'virtual script' has over the nursing 
profession. The virtual script bases the presentation of nursing on characteristics 
such as kindness, caring, compassion, honesty, and trust worthiness' attribute 
associated with 'good women' . This script sentimentalizes and trivializes the 
complex skills, including caring skills, nurses must acquire through education 
and experience - not simply individual inclination. (2005, p. 63) 
Unfortunately the nursing profession is at times not open to learning from other 
disciplines. This may be the consequence of an elitist attitude that deems nursing as the 
only caring profession in healthcare, and some nurses readily accept as true the belief that 
they are the only profession capable of delivering "high-quality care" (Weinberg, 2003, 

While nurses care deeply for their patients, busy work schedules and 
insufficient staffing may make it appear that nurses lack concern for the wellbeing of 
their patients. In today's world of managed care, cost constraints, and a paucity of 
qualified personnel, time for quality of care may be set aside in the push to accomplish 
technical procedures and routine tasks. Barlett and Steele refer to the fact that "Patient 
care could be industrialized" (2006, p. 1 14). This dilemma can be seen in the manner in 
which nurses interact with their peers, other healthcare workers, patients, and the 
patient's family members. Yet nurses report that they want to find time to listen 
attentively to their patients. 

Traditionally nurses have been taught in school to beware of becoming too 


involved with the patient for fear that this interaction could affect the way they care for 
patients. However, since "nursing is a caring profession; part of caring is maintaining 
communication and ensuring that trust continues throughout the interactions between the 
nurse and the patient" (Guido, 2004, p. 363). 

Nurses at times lack care for each other by not listening to their peers and 
dismissing their concerns regarding patient care and working conditions. A an example 
when any of my nurse colleagues and I call out sick the supervisor will coax us into 
coming to work sick and even make us feel guilty by telling us that we are leaving 
the clinical unit short staffed. This lack of consideration given to ill nurses makes them 
feel culpable and in desperation they will come to work ill and consequently undermine 
their health as well as that of their patients and colleagues. This lack of care toward 
nurses' and patients' wellbeing in deference to the need to meet legal coverage is 
a problem in the American healthcare system. 

Nurses are at the patient's bedside around the clock. Therefore, "a good nurse is 
able to see what is not going well" (Boisvert, 1994, p. 3) and thus is in a position to listen 
to the patients' concerns and feelings. Consequently, nurses can then assist the patients in 
exploring these feelings and aiding in making decisions about what is beneficial for their 
wellbeing and health. The act of caring can be accomplished while the nurse is changing 
a dressing or administering medications. Care can also be carried over to interactions 
with a patient's family. When student nurses witness care, they are able to incorporate 
this behavior into their own practice of nursing. 

Nurses are in a unique position because they can care for patients, students, and 
other staff members in the clinical setting. As Roach so aptly notes, 


care has become a popular expression in the language of nursing 
but their claims must be substantiated. Care is also a major 
component of the metaparadigm of nursing for many nurses. 
Nurses can no longer assume that care and health values are alike 
or even similar terms culturally. The myth that whatever is good 
for one client will be good for others regardless of cultural values 
and background must be dispelled because it is limiting nurses' 
therapeutic effectiveness and client satisfaction. (1988, pp. 13-15) 
Definitions of care that embrace empathy 

Many definitions of care and caring exist in the literature and this section includes 
also the relationship of empathy to care as it relates to nursing and nursing education. 
While functional care, or attending to patient's medical needs, is understandable, the 
relational aspects of care are more difficult to grasp. One of the key aspects of the 
relational characteristics of care is empathy. 

The concept of care often embraces empathy. "The word empathy entered the 
English vocabulary as a translation of the Greek ematheia" (Singer, 2001, p. 2) and refers 
affection and passion. To be empathic, implies that one listens attentively in order to 
experience what the other is feeling. This is done with the understanding that the 
listener is aware that he/she and the other are two separate feeling beings. For being 
empathic lets the other know that the listener is there and available to help the other 
explore and understand his feelings. 

Empathy allows patients to feel better about their situation even though it may not 
change their circumstances. As Reynolds, Scott, and Austin state "if clients are able to 


perceive the amount of empathy existing in a helping relationship, they are in a 
position to advise professionals on how to offer empathy. However, the client's 
perception of empathy has generally been ignored in the construction of measures of 
empathy" (2000, p. 5). Rather than be ignored by nurses and other healthcare workers, it 
is necessary that nurses learn to pay more attention to what their patients are saying about 
how they feel and what they need. What patients say has a profound effect on how they 
will be cared for and how they will cope with illness and prescribed treatments 

Care involves "a feeling with" the other and this relationship is termed "empathy" 
(Noddings, 1986, p. 30). This connection between care and empathy allows nurses to be 
concerned with the well being of their patients. Roach identifies qualities that nurses 
should possess when caring for patients. These include compassion, competence, 
confidence, conscience, and commitment. Compassion is "a response of participation in 
the experience of another; a sensitivity to the pain and brokenness of the other; a quality 
of presence which allows one to share with and make room for the other" (Roach, 1987, 
p. 58). Roach thus equates compassion with empathy which suggests that nurses should 
be empathic when caring for patients. 

Roach affirms that "caring is the means, the medium, the mode through which the 
human being is a being-in-the-world." She further states that "Caring is essential, not 
only to the development of the human being, but to the development of the caring of the 
human being. And that human development is dependent not only on being cared for, but 
also on being able to care" (1987, p. 2). For Roach care is the essential ingredient that 
keeps humans alive. Care is carried out when children are nurtured by their caregivers 
and they, in turn, learn to care for others. This caring cycle continues with each 


subsequent generation. 

Erikson states that "caring is an objective, impersonal concept in the sense that 
health personnel do not sufficiently have regard for the unique individual human being. 
The caring caritive, love, is based on the fact that nurses try to serve by seeing and 
confirming the othei' (as cited in Gaut and Boykin, 1994, p. 6). Erikson further asserts 
that nursing, which is a humanistic discipline, is a caring science that has its roots in all 
aspects of human life. Nurses care for patients from newborns through the elderly, in 
ways that they may not fully understand because caring is a complex phenomenon. 

From another perspective, "caring is the means or tool used to put nursing 
concepts into practice through a process founded on reverence for life, love of self and 
others, and concern for improving world conditions" (Forsyth, Delaney, Maloney, 
Kubesh and Story, 1989, p. 165). This reverence for life challenges nursing instructors to 
teach caring concepts to students as a way of improving the quality of life for all 
individuals. Higgins believes states that "...human care requires a deep respect for life" 
(1996, p. 136). For without respect for life there can be no caring. 

To Kapborg and Bertero "caring is central to human experience and nursing, and 
involves a commitment to human beings" (2003, p. 185). The authors further attest that 
the profession of nursing has emphasized the concept of care but has failed to clearly 
define what care is to nursing. To them caring involves the interaction of knowledge and 
skills as well as taking care of the entire human being. It is necessary for nursing to 
identify where and when care is needed and how care impacts nursing and can lead to 
positive implications for patients, student nurses, and healthcare workers alike. 

Leininger is emphatic when she states that "human care is one of the most 


essential and powerful forces to help people recover from illness, maintain health, 
and survive" (1998, p.l 1). For without care, a person is not going to thrive or live. For 
this reason nurses need to be truly caring individuals without prejudice or discrimination. 

"Caring is an essential feature and expression of being human" (Boykin and 
Schoenhofer, 2001, p. 1). Caring is a humanistic process, as Erikson reminds us that 
sustains life and ensures the perpetuation of future human beings. 

Caring is the act of showing kindness or being present for the other in his or her 
time of need. This action can last for a fleeting moment or a lifetime depending on the 
circumstances surrounding the caring. Included in the relational aspects of caring is the 
experience of empathy which is the act of being in the world of another as if it were your 
own. As Shea states "empathy is one person feeling what the other person feels as if one 
were the other person" (2003, p. 62). To be empathic means knowing and feeling as the 
other knows and feels in a particular situation. This is a difficult achievement for the 
nurse who has not been in a situation where empathy is practiced. 

"Empathy is a developmental reality: it develops as an adult self develops. This 
development is along the lives of a shift from seeing the person as physical to seeing the 
person as psychological, a shift from seeing the person as exterior to seeing the person as 
interior" (Shea, 2003, p. 72). Empathy involves a letting go of one's self in order to better 
understand the other. For this reason, empathy is closely allied to care and ultimately 
leads to love. Empathy, consequently, encompasses the caring interactions that are 
believed to be the foundation of nursing. Empathy allows the nurse to enter into and 
understand the world of another person and to communicate this understanding to the 
patient. Thus the practice of empathy leads to more meaningful caring interactions 


between nurses, students, and patients. "Empathy is a way of being" (Egan, 1986, p. 95). 
Hence when practicing empathy the nurses listen to the patient by putting themselves in 
the other's place, understanding how the other feels, and subsequently caring deeply for 
this other person. 

As Jordan noted "without empathy there is no intimacy, no real attainment of an 
appreciation of the paradox of separateness within connections" (1991, p. 69). Empathy 
is what allows nurses to understand what the patient is experiencing without actually 
experiencing the pain. For nurses to truly empathize they "must have a well-differentiated 
sense of self in addition to an appreciation of and sensitivity to the differences as well as 
the sameness of the other. Empathy always involves surrender to feelings and active 
cognitive structuring; in order for empathy to occur, self boundaries must be flexible" 
(p. 69). Being empathic necessitates that nurses put themselves forward in such a way as 
to focus entirely on the patient; however, it does not warrant that nurses forget who they 
are and what their obligations are not only to themselves but to their family, friends, and 
other patients. Separating one's self while still being connected takes practice to 
accomplish this skill successfully. 

Using myself as an example, as a nurse I developed my own style of caring which 
involved treating everyone as an equal. While serving in the United States Air Force, I 
nursed patients who were from allied as well as enemy factions without regard to their 
political position. This was no easy task since I was not to judge the actions of these 
patients; I was to take care of their health needs and assist them to return to their optimal 
wellbeing. This was daunting at times because of the situations I found myself in; yet as a 
nurse I felt ethically bound through the Florence Nightingale Pledge that I took at 


graduation from nursing school to equitably care for anyone in need. 

"As human beings we want to care and be cared for" (Noddings, 1986, p. 7). 
Functional care may involve performing acts that one dislikes in order to ease a patient' s 
pain or distress, just as relational care might require being present with a patient's family 
member who has lost a loved one or with a patient who faces a difficult diagnosis and 
surgical procedure. In dramatic contrast, functional care may involve helping a patient 
through a painful labor and delivery, while relational care may be rejoicing with a mother 
who has just delivered a healthy baby. As Roach states "caring is the human mode of 
being. It is the most common, authentic criterion of humanness and is expressed through 
love or compassion, sorrow or joy, sadness or despair" (Roach, 1987, p. 2). 
Learning to care 

The basics of care originate in the home where children learn caring from their 
Parents and family members. Everyone has the capacity to care; however, the mode and 
degree of caring varies from person to person. Children learn functional caring from 
their parents, who provide them with food, clothing, and shelter. They also learn the 
relational care that involves empathy and love. As babies grow they are cared for by 
family members who in turn teach them how to care for their siblings, pets, toys, and 
later those outside the immediate family. When they are old enough to attend school a 
new set of caregivers, namely teachers, begin to influence how children care for others. 
Later as children enter adulthood they begin to emulate their parents in the act of caring 
for their significant other and children. Thus caring is continuous through the generations. 

As Noddings remarked "apprehending the other's reality, feeling what he feels as 
nearly as possible, is the essential part of caring from the view of the one-caring. The 


one-caring, in caring, is present in her acts of caring for caring is largely reactive and 
responsive" (1986, p. 16). That is to say, that nurses react by responding to patient needs 
with care. The attitude of the nurse is influential in how the patient feels cared for. 
Further the motivation elicited in caring is directed toward the welfare, protection, or 
enhancement of the one being cared-for. The manner in which care is manifested is 
evident in how parents care for their children and nurses care for their patients and how 
they present themselves as role models of care. 

In nursing, "caring involves stepping out of one's own personal frame of 
reference and into the other's. For when nurses care, they consider the other's point of 
view, his objective needs, and what he expects" (Noddings, 1986, p. 19). Individual ways 
of caring may not be alike yet they are ways of caring. Care may be manifested 
differently for each individual because one's perception of how one was cared for is very 
personal and profound and cannot be dismissed. 

Roach maintains that "individuals care because they are human beings, and they 
select particular professions because they care. The capacity to care is rooted in their very 
nature and this capacity to care can be enhanced, called forth, or inhibited by the 
educational experience of the student, and most importantly by the presence or absence of 
caring models" (Roach, 1987, p. 8). This is an altruistic way of looking at care since 
nurses have varying reasons for entering the profession. 
Contrasting functional and relational care in nursing 

Nursing relies on care for its very existence. Nurses utilize care in different ways 
when tending to the sick. A functional form of care refers to following the physician's 
orders in meeting patients' physical needs. In this respect, nurses are called on to manage 


the patients' daily requirements for nutrition and bodily needs in addition to the provision 
of performing procedures and administering medications. Care can also be manifested 
relationally. This type of care can be communicated non- verbally by a look or touch or 
verbally through a kind word, or by attentive listening and conversation. Although 
most care is given to make the other feel better, not all acts of caring are dispensed in a 
positive way. 

For instance during World War II, the nurses of Nazi Germany participated in 
active euthanasia of the infirmed and elderly believing they were doing what was right 
for the good of their patients and their nation. As one nurse accused in the Munchner 
Schwesternprozess (nurses' trial at Munich) stated, "When giving the dissolved 
(poisoned) medicine, I proceeded with a lot of compassion. . .1 took them lovingly and 
stroked them when I gave the medicine" (Benedict and Kuhla, 1999, pp.246, 254). These 
nurses equated their heinous measures to acts of caring. 

Shields (2005, p. 2) states that "education for registration in nursing is universally 
centered on principles of caring and caring is seen as the essence of nursing." However, 
she noted that there is a sinister side to care as was demonstrated by these Nazi nurses 
who believed that killing was part of doing what was right for their patients. This 
unusual aspect of "care" resulted from the notion that nurses were inculcated with ideas 
of obedience and subjugation to the medical profession and that by virtue of their 
"nurse's training" they had an obligation to follow their superiors' orders without 
question as to whether they were doing right or wrong. 

On the other hand, Noddings (1986, p. 55) notes that "conflict may arise between 
the perceived need of one person and the desire of another; between what the cared-for 


wants and what we see as his best interest; between the wants of the cared-for and the 
welfare of the persons yet unknown." This statement would assist the nurses not involved 
in the Nazi atrocities to understand how the German nurses were able to carry out their 
orders without questioning them. These nurses firmly believed that they were working for 
the "common good" of the nation and not of mankind. 

A contrast to the Nazi nurses is Italian chemist Primo Levi who spent most of 
World War II at the concentration camp in Auschwitz. Levi spent his time in the camp 
caring for his fellow prisoners by keeping their spirits up and encouraging them to think 
beyond their present situation. Levi (1996, p. 180) states "I and my two French 
companions were consciously and happily willing to work at last for a just and human 
goal, to save the lives of our sick comrades." Levi's unselfish act is an example of 
profound caring for another person. 

The handmaiden theory where female nurses deferred to the male doctor's 
authority is not considered to be a natural female response to human needs. In fact Jolley 
and Brykczynska (1993, pp. 45-46) state that this mentality is the "outcome of a system 
which openly supports separations between cure and care, while covertly relying upon 
nurses to fill the gap between." In addition one should not consider nursing to be a 
natural female response to caring. In addition, anti-intellectualism in nursing is not the 
cause but the effect of its deferential status in healthcare organizations. 

Gordon and Nelson (2005, p. 64) found that before the advent of Florence 
Nightingale, "nursing was considered the domain of religious women and servants. 
Religious women were portrayed as angels and non religious nurses were not considered 
to be respectable." This idea led to the suggestion that nurses were "Angels of Mercy" 


who were there to care for patients from birth to death. It also allowed for nurse 
reformers like Nightingale to make it possible for women to find purposeful work. This 
idea was also introduced in Russia in 1815 when the Empress Maria Fedorovna 
established the order of Compassionate Widows. According to Bessonov (2009, p. 8) 
these war widows who were literate, were "trained" to care for the sick in hospitals and 
private homes alike. Nursing thus became the first social activity for women outside the 
home to gain acceptance among respectable classes. "Nursing in particular, was born of 
care, organized for care, and professionalized through care" (Roach, 1987, p. 12). 

As noted by Leininger, "some of the major factors influencing care differences 
are closely related to differences in the clients' social structure, cultural context, and 
values. Nurses must learn to use care concepts with precision and skill comparable to 
some medical caring modes" (1988, p. 16, 18). Nurses need to be aware of cultural 
differences surrounding care and learn to respect their patients if they are to provide 
effective nursing care. When they become informed about culture and care, nurses can 
use this knowledge in ways that are congruent with a patient's values. 
Leininger says that 

because culture is so much an integral part of daily actions 
and thinking, nurses seldom pause to reflect on how the culture 
of nursing care influences care practices and attitudes. The pre- 1965 
cultural values of deference to authority figures; of being 
other-directed, active doers, and less intellectual sharers; of 
imitation of the physician's role; and of handling practical and sundry 
tasks in the environment have been some of the many traditional 


cultural values influencing care in the United States (1988, p. 21). 

These nurses tend to uphold and endorse traditional values by resisting changes 
they view as belonging to the medical profession; however, nurses educated from 1965 
on have less difficulty dressing more casually and have a more collegial relationship with 
physicians. These contrasts in attitudes do not make nurses from an older era better or 
worse than nurses from a more modern time they just make them different. 
Personal attributes of caring related to nursing 

The American Association of Colleges of Nursing, an accrediting agency for 
baccalaureate and masters entry-level nursing programs, has identified seven values 
deemed to be the basis for nursing care. These ideals are: altruism, esthetics, human 
dignity, justice, freedom, equality, and truth. These principles were specifically 
recognized because "caring and respect are essential values guiding nursing in a practice 
that honors compassion and competence" (Gaut and Boykin, 1994, p. 50). Compassion is 
needed in order to provide the patient an atmosphere where caring is carried out by an 
empathic nurse who exhibits a competent manner that will enhance health and well 
being of the one being cared for. 

As stated earlier, the attributes of caring originate from one's family and 
upbringing and are dependent on how one was cared for as a child. Watson (1990b, pp. 
63-64) affirms that "women in spite of all their gains, remain largely invisible in the 
human consciousness" and that "if caring is to be sustained, those who care must be 
strong, courageous and capable of inner love, peace, and joy - both in relation to 
themselves and others." This statement implies that nurses must be advocates for their 
patients who are in a vulnerable position vis-a-vis the healthcare team who may be 


making decisions the patient does not want or understand. 

"To humanistically 'care' requires the presence and use of the nurse 'self and the 
sharing of the 'self with another" (Chipman, 1991, p. 175), that is to say, that nurses 
give of themselves by sharing themselves with the patients they are caring for. For 
without this sharing, the care received by the patient will not allow for growth and 
healing. This a "caring moment involves an action and a choice by both the nurse and the 
other" (Watson, 2000, p. 9) who allows the nurse to deliver the needed care. 

Morse, Bottorff, Anderson, O'Brien, and Solberg note that "The Theory of 
Human Care" developed by Watson, states "the kind of relationships and transactions 
that are necessary between the caregiver and the care receiver to promote and to protect 
the patient's humanity influence the patient's healing potential" (2006, pp. 7-8). This 
theory emphasizes the psychological, emotional, and spiritual dimensions of care which 
are necessary components for patient well-being. The authors also found that the Sunrise 
Model used by Leininger in her "Theory of Transcultural Care Diversity and Universality 
alerted nurses to the need to consider cultural values and practices that influence patterns 
and meanings of care" (pp.7-8). Nurses therefore must be culturally sensitive to how 
patients view, receive, and understand the care they are receiving. 

According to Boykin and Schoenhofer "developing the fullest potential for 
expressing caring is an ideal and the belief that all persons are caring entails a 
commitment to know self and other as caring persons" (2001, pp. 2-3). They further state 
that the one who cares must be willing to know not only one's self but also others. A 
common belief with these authors is that all persons are caring and that caring grounds 
the focus of nursing as a discipline and a profession because "the nurse enters into the 


world of the other person with the intention of knowing the other as a caring person" (p. 
3). Nurses care willingly for the sick in an effort to provide a sense of being valued as a 
worthwhile human being. 
The universal concept of a caring nurse 

The concept of caring is universal; however it is not defined universally. People 
care for themselves and others by emulating how they were cared for. Student nurses 
enter the profession in order to care for the sick. They are taught by instructors who may 
have ways of caring that differ from those of the students and the parents who raised 
them. As student nurses mature into the profession, they develop their own unique ways 
of caring for patients. Three examples come to mind. Two are positive instances of care 
while the other may be viewed as a truly negative example of care. 

The first example of care involves health care attorney Kenneth Schwartz. 
When Schwartz died of lung cancer in the mid 1990s, he left a legacy for those who cared 
for him while he was a patient at Massachusetts General Hospital in Boston. This legacy 
called The Schwartz Center Rounds was created as "a safe place for hospital staffers to 
express the frustrations, fears, and sadness that can reverberate during the drive home" 
(Huff, 2006, p. 98). The Schwartz Center Rounds which are scheduled monthly in over 
100 hospitals throughout the United States allow healthcare workers to speak about their 
concerns of dealing with issues of patient care. The participants share their experiences 
and elicit support from their colleagues. This act of caring by Schwartz for those who 
cared for him when he was ill is helping to spread the notion that care is beneficial to all 
who participate in this altruistic behavior. 

The second example is that of the Nazi nurses in Germany during World War II. 


These nurses who were "trained" along Nightingale's doctrine of unquestionable 
compliance to one's superiors, believed that they were acting in a caring manner when 
they blindly followed orders resulting in the deaths of the elderly, the infirmed, and the 
mentally challenged. Although these nurses viewed their behaviors as expressions of 
care, others viewed their acts as monstrous. These nurses carried their "training" in 
obedience to the ultimate end by killing their patients in the name of care. 

The final model of care involves former United States President, Jimmy Carter, 
who grew up in Plains, Georgia as the son of a farmer and a nurse. His parents showed 
him caring examples in their daily lives when his father gave food and land to his 
sharecroppers and his mother cared for the sick, not only in the local hospital, but in their 
homes as well (Carter, 2001, p. 59). After he left office, Carter became involved with 
Habitat International. As a member of this organization, Carter has devoted much of his 
time and energy in aiding homeless people build homes for themselves and their families. 
This significant act of caring is aiding to eradicate homelessness. (Slavitt and Loveman, 
1994, p. 4) 

These cases illustrate how care can be beneficial and detrimental when viewed 
from different perspectives. One can also argue that the "care" delivered by the Nazi 
nurses was not care because it caused harm to a great number of innocent people who 
were considered "undesirable" by the government. 
Implications for the profession 

In order to develop as a profession, nurses need to devote themselves to self 
development, including coming to learn in ways Belenky et al. (1986) termed procedural 
and connected. Learning intentionally how to respect others and self while learning about 


the context of others' needs and experiences eventually leads nurses to "channel their 
increasing sense of self into their growing capacity to care for others" (p. 46). Nurses 
value their patients and go to great lengths to provide them with physical, emotional and 
at times spiritual care. The spiritual care may be seen as hand-holding, listening, and 
praying. Nurses are with their patients in times of happiness and sadness from birth to 
death. Although nurses may see these activities as part of their daily routine, these caring 
interactions are in fact evidence of empathy. As Siegel aptly states "the only real reason 
to stay in (medicine) was to offer people a friendship they can feel, just when they need it 
most" (1986, p. 18). Offering friendship in the manner described reveals how important 
care and empathy are for the caring professions. 

The Kaiser Permanente Medical Group has developed "The 4 Es Model" 
(Engage, Empathize, Educate, and Enlist) to assist physicians in becoming empathic. 
This model is being used in medical schools and hospitals in the Western United States to 
make physicians more aware of opportunities where they can use empathy when 
interviewing patients (Hardee, 2003, p. 4). In addition this model also lends itself to the 
teaching of empathy in schools of nursing. In order to implement care in the curriculum, 
the instructors must possess and practice both empathy and care in their own professions. 
By modeling empathy and care nursing instructors emulate a positive behavior for 
student nurses who will then conduct themselves in a way that conveys care to their 
patients. These actions in turn provide patients with a sense that nurses are sincere in 
their endeavors to provide the understanding and support necessary for healing and 
acceptance of the human condition. 

As a nurse my colleagues and I have often been referred to as "Angels of 


Mercy". This designation is a misnomer since angels are heavenly bodies who do not 
inhabit the earth. Nurses do not look upon their work as being out of the ordinary and 
they would not give themselves such an exalted title. This is not to say that nurses have 
not been God's messenger because there have been many times when they have been 
called upon to sit with a dying patient, to hold his hand, and to even give him permission 
to let go and die. Being in these situations is very humbling; yet as much as this angelic 
designation is flattering, it does not make a nurse an "angel". 

Leininger has identified several factors that make up the culture of nursing in the 
United States. These include the fact that: 1. the culture of nursing relies heavily on 
material goods and technologies in education and client care, 2.there is an increasing 
focus on the nurse's self-interests and a decrease in the value of culturism which is the 
outward orientation of a person toward others with the desire to help others rather than 
oneself, 3. there exists a concept of rights or egalitarianism for all nurses, 4. nurses may 
or may not perceive themselves as caregivers, and 5. whether care is considered worthy 
of investments in the form of money for research, education, and practice. Because these 
issues are so important in nursing today, Leininger (1998, pp. 22, 26) firmly believes that 
"nurses must help the public to understand nursing as a caring profession and 
demonstrate the powers and effectiveness of care to help people recover from illnesses 
and disabilities and maintain wellness." In other words, nurses must be pro-active in what 
they do and how they perform their skills. 

Boston's forgotten Nightingale 

Frances Slanger demonstrates the truly caring nurse. As a young Polish immigrant 
to the United States, she survived many forms of discrimination including nationality, 
religion, education, gender, and socio-economic status. Her strong Jewish faith gave her 


the foundation necessary to pursue her goals to be a nurse and minister to her patients 
with care, empathy, and love. 

Frances was the daughter of a fruit peddler from the South End of Boston, 
Massachusetts. Her poverty may have hindered her education but it did not deter her 
determination to surmount this obstacle and become a nurse. Her dream of being a nurse 
motivated her to study in order to obtain her high school diploma. The achievement of 
this milestone led her to enter Boston City Hospital School of Nursing from which 
she graduated in 1937. After obtaining her license as a Registered Nurse, Frances 
worked at Boston City Hospital honing the skills that would assist her in her biggest 
challenge. When not at work at the hospital, Frances found the time to assist her family 
and neighbors in meeting their health needs. 

The onset of World War II was looming as Slanger was deciding where she was 
most needed as a nurse. The invasion of Poland, and the massacre of many of her 
relatives stirred in her the desire to do more. Thus in 1943 she applied to enter the United 
States Army Nurse Corps in order to care for the wounded soldiers who were protecting 
the freedom she loved. In June of 1944, Frances was one of the first nurses to land in 
Normandy, France where she worked in a field hospital and lived in a tent while her 
hospital moved through France and Belgium. 

Frances, who was a quiet and thoughtful nurse, was beloved by her co-workers. 
She pulled her weight without complaint and worked long hours tending to the sick and 
wounded. "Frances' caregiver bent had worn such a deep groove in her life that even the 
thought of straying from it triggered guilt. Caregivers hate to cause others pain. They live 
to ease others' pain" (Welch, 2004, p. 1 13). This attitude led to her most noteworthy act 


of care and empathy when she nursed a wounded German Prisoner of War. In fact while 
she was out on the battlefield she may have asked herself the following question that 
comes from the heart, "Must I ignore the reality of the other's hatefulness toward me (if 
such exists)?" (Boykin and Schoenhofer, 2001, p. 24). It was at this time that "Frances 
looked into the eyes of the young German soldier. She then knelt next to him, raised her 
arm toward him, and dabbed his forehead with a cool rag" (Welch, 2004, p. 169). In a 
moment of profound love, she set aside her nationality, religion, and contempt for the 
Germans to minister to the enemy who was her patient. 

In October, 1944 2 n Lt. Frances Y. Slanger made the ultimate sacrifice and act of 
caring when her hospital was shelled by the Germans. Memories of her loving care 
bolstered the servicemen stationed in Europe because her life and death exemplified the 
deepest caring action one can give to another human being. 


Culture and Nursing 

The study of culture 1 has a profound impact on today's nurse. Since "cultural 
inheritances undeniably cut across social classes, it is in these cultural inheritances that 
much of our identity is constituted" (Freire, 2003, p. 71). Although aware of their own 
ethnic background, nurses have not always been sufficiently attentive to the importance 
of culture in their daily lives let alone in healthcare surroundings. 

It is in the healthcare setting; however, that nurses meet patients of different 
traditions and experiences which have a deep influence on how patient care is perceived 
and received. Here again, it is important to reflect on Leininger's statement about the 
importance of "how care is experienced and known to people of different cultures, and 
how care is linked with religion, language, politics, economics, and culture values" 
(1998, p. 1 1). Culture not only affects the nurse's understandings and behaviors but also 
those of their patients. Nurses need to be sensitive to how care is experienced and 
understood by people of different cultures. 

The history of nursing as it refers to culture will be discussed including the 
influence of immigration on nursing, and definitions of culture and communication will 
be addressed. Further, three nursing models relating to culture are addressed. The models 
include The Leininger Sunrise Model to Depict the Theory of Cultural Care Diversity and 
Universality, The Purnell Model for Cultural Competence, and The Giger and 
Davidhizar Transcultural Assessment Model. These models can be used to teach culture 
to nursing students but also to nurses in the practice setting. 

All nurses grow up with their own cultural identities, yet on a daily basis they 

1 For the purpose of this dissertation culture refers primarily to cultural diversity. 


encounter patients and colleagues who have a culture different from their own. Many 
nurses have difficulty understanding the elements of culture, and some may fear people 
of diverse cultures. These misunderstandings and apprehensions eventually may lead to 
distrust and, in the worst instances, possibly to a lack of quality nursing care. By studying 
another culture and coming to appreciate the values and practices of that culture, nurses 
can learn to identify similarities and dissimilarities between their culture and that of the 
patients they care for. They can also learn about aspects of different cultures that 
influence patient care and healing in important ways. 

This chapter is intended to explain why nurses need to be aware that, "each 
cultural world operates according to its own internal dynamic, its own principles, and its 
own laws - written and unwritten" (Hall, 1990, p. 3). Consequently, by studying culture, 
nurses can begin to break down stereotypical barriers and promote understanding 
between themselves, their patients, and student nurses who will follow in their footsteps. 
Nursing history 

In order to understand why nurses should study culture, it is important to examine 
the history of nursing. As Hjorth states, "the history of a profession is the basis for a 
deeper understanding of the identity of a profession and thus its possibilities" (2006b, p. 
1). Though now a predominately female profession, nursing has roots reaching back in 
time to the religious societies who took care of the poor, the orphans, and the infirmed of 
all ages, as well as the military who cared for those wounded in combat. Early religious 
societies of brothers and nuns, and the volunteers who cared for those injured in the 
military were the forerunners of today's nursing profession. Although not formally 
trained or educated as nurses, these devoted people helped the underprivileged in their 


time of need. 

In the late 19 th century a well-to-do English woman named Florence Nightingale 
approached Queen Victoria and asked her help in the establishment of a school for 
training women to become nurses. Nightingale who studied briefly with the Protestant 
deaconesses at Kaiserswerth, Germany (Bostridge, 2008, p. 97) and later worked as a 
nurse in Turkey during the Crimean War understood the importance of public health and 
nursing care under austere conditions. The combined efforts of Queen Victoria and 
Nightingale laid the foundation for modern-day nursing. Nightingale's theories on 
"sanitation, health, nursing, and nursing education" (Ellis & Hartley, 1998, p. 135) spread 
throughout Europe, Canada and the United States. Interestingly, "the development of 
nursing in Russia after the Crimean War followed an entirely different path" (Bessonov, 
2009b, pp. 1-2). The nurses who returned home from the Crimea were either retired or 
worked in military hospitals. This action by the Russian government thus left the future 
of nursing in the hands of the doctors. 

In understanding the role of culture in nursing, it is important to note that the first 
schools of nursing in the United States were established in the 1890s in large 
metropolitan hospitals as a form of generating cheap labor. Unlike the women of an 
earlier age who were either nuns, prostitutes or prisoners, the future nurses of Florence 
Nightingale's time came from families of "good character," which is to say, that the 
families of the nurses were respected by the community. Some women who became 
nurses were first generation Americans from Western Europe. To them nursing was 
appealing because it offered an opportunity to obtain an education, secure employment 
and provide money for their families (McGoldrick, 1996, p. 553). 


Cultural heritage and personal factors of these student nurses receded into the 
background as they were expected to become a homogenized group of learners. 
Typically, the women lived in a nurses' residence attached to the hospital where they 
attended classes taught by physicians and nursing supervisors. These early nurses were 
trained in an austere environment where obedience was of paramount importance. The 
women had little personal time available for individual pursuits. In exchange for their 
education, the women worked 12 to 16 hour shifts in the hospital six, sometimes seven 
days a week. On Sunday they were obliged to attend church, and in the afternoon they 
were allowed to visit their family, if nearby, for a couple of hours. Upon graduation, 
these nurses were expected to work at the hospital where they had trained and continued 
to live in the nurses' residence. (Canadian Museum of Civilization Corporation, 2002, p. 
3) This practice thereby ensured the hospital of a readily available nursing staff. After 
several years of nursing practice, some of these nurses who had worked closely with the 
male physicians became not only the supervisors but also the instructors for the new 
student nurses that conformed to and protected the hospital's culture, by keeping the 
nurses busy and, as a result, pushing their personal interests and connections aside as they 
were placed in a seven day insular pattern that was focused on the hospital rather than 

After several years of practice, some of these nurses who had worked closely with 
the male physicians became not only the supervisors but also the instructors for the new 
student nurses, thus perpetuating the culture of the hospital by exclusion of outsiders as 
teaching faculty. The women were the chosen few who had come to identify and conform 
fully to doctors' and hospital expectations, buying into the system as it were. The 


physicians continued to teach anatomy and physiology while the nursing instructors 
taught bathing, medication administration, and comfort measures to the students. For 
many of these women, nursing became their life for unlike the male doctors they served, 
they were expected to be selfless, to give themselves over to the hospital's culture and 
practice. The result of this gender disparity was that countless nurses abandoned their 
dreams of marriage and raising a family in order to care for the sick. (Ellis and Hartley, 

Early 20 th century hospital- run schools of nursing followed the same guidelines 
of having classes taught by physicians and nurse supervisors. Nuns dedicated to caring 
for the poor and the infirmed ran many of these hospital-based schools. They, and their 
military counterparts, came from a cultural background that demanded obedience and 
subservience. Therefore, these nuns and early nurses assumed the stern, authoritarian, 
and dominating traits of their 19 th century instructors. Again students had very little 
freedom and had to account for all of their time. They had study hours, quiet time and 
curfews where they were required to sign in and out of the residence. Any breach in the 
rules resulted in the nurse being punished. Twelve hour shifts were common and the 
duties of the nurse included not only patient care but cooking, laundry, and housekeeping 
chores as well. These rules and regulations also applied to the graduate nurses who lived 
in the nurse's residence. Many of these regulations supporting a workplace culture of 
subservience and depersonalization continued until the demise of the hospital schools of 
nursing in the late 20 th century. These nurses were expected to be the "handmaiden to the 
doctor" in other words, obedient and never questioning the doctor's orders. (Ellis and 
Hartley, 1998, p. 143) 


These early schools had strict requirements which barred men and African 
Americans who were required to have their own schools of nursing. This practice 
perpetuated segregation of the races and the sexes and continued until nursing 
education moved into the academic realm (Clay, 2008, p. 4; Aetna, 2003, p. 1). 

The self-regulatory basis for the field of nursing shifted in the 20 th century when 
three important events occurred that impacted nursing and nursing education. "In 1903, 
the passage of the first nursing laws set standards for nursing education and practice" 
(Kelly, 1991, p. 51). Nursing education became more externally regulated and New York 
became the first state to require licensing exams as a minimum requirement, with the goal 
to protect the public. Licensing examinations became the norm after graduation and 
nurses who wanted to work in other states had to request approval from the Board of 
Nursing before they could become employed. 

In 1920, as the profession of nursing developed, private foundations took interest. 
For example, the Committee for the Study of Nursing Education was funded by the 
Rockefeller Foundation. Nursing pioneers Annie W. Goodrich, M. Adelaide Nutting, and 
Lillian Wald published the Goldmark Report in 1923. This report stated that "the quality 
of existing programs was inadequate" and that "education took precedence over service 
to a hospital, with training based on an educational plan rather than on service needs" 
(Winslow et al, 1922, p.l). This decision implied uniformity for the nursing programs 
because it set specific guidelines on what was to be taught and practiced in these schools. 
As an outcome of this report in recognition of the need for additional training, Yale 
University in New Haven, Connecticut opened its school of nursing in order to prepare 
nurses on the baccalaureate level. 


In the 1920s and 1930s diploma schools of nursing began to offer similar 
educational programs and licensing of nurses was instituted on a state-by- state basis in 
order to provide continuity of care to the sick. During World War II the demand for 
nurses increased in order to support the war effort. As a result, the 1940s saw the advent 
of the practical nurse program that graduated nurses in two years rather than three or four 
years and the Cadet Nurse Corps which prepared nurses for future military service. Not 
surprisingly, these programs conformed to military cultural expectations of conformity. 

In 1948 Esther Lucille Brown, a social anthropologist with the Russell Sage 
Foundation, recommended that nursing education move out of the hospital and into an 
academic setting. Predictably the report was perceived as threatening, and "the report 
received mixed reviews... since some hospital administrators considered it a subversive 
document, fearing that it had economic security implications for nurses. These 
administrators did not appreciate the fact that the authoritarianism of hospitals was 
pinpointed" (Kelly, 1991, pp. 68-69). The homogeneity and conformity of nursing 
education shifted when as a result of this report, some schools began to affiliate 
themselves with local communities and four year colleges while others closed entirely. A 
key point to note here is the moving nursing into the college setting did away with the 
notion of training nurses and introduced concept of educating nurses. 

Thus after the Korean War nursing education moved from the hospital into a more 
academic setting where degrees were offered. The field of nursing opened up, and it was 
at this time that African American women who had attended segregated hospital schools 
of nursing and men were allowed to study in the community college nursing programs 
(Buerhaus, Staiger, et al, 2009, p. 165). 


At the beginning of the 21 st century, only a handful of nursing programs remained 
under the auspices of the hospitals. Nursing was now fully ensconced in colleges offering 
associate, bachelor, and masters entry-level degrees. However, the change in the 
educational environment had yet to dispel the demands for a culture of obedience. 
Although less restrictive than their hospital counterparts, collegiate nursing programs 
continued to have instructors who command and demand respect and obedience to the 
norms and practices of the academic institution. This behavior by instructors towards 
students of nursing is what Freire would term oppression. He states that "One of the basic 
elements of the relationship between oppressor and oppressed is prescription. Every 
prescription represents the imposition of one's individual choice upon another, 
transforming the consciousness of the person prescribed into one that conforms to the 
prescriber's consciousness. Thus, the behavior of the oppressed is a prescribed behavior, 
following as it does the guidelines of the oppressor" (Freire, 2003, pp. 46-47). In other 
words, the harsh treatment by the nursing instructors, many of whom were nuns or former 
military nurses who learned obedience from the church's and military's doctrines, was 
meant to perpetuate itself by making the oppressed student a harsh nurse who would 
carry on the behavior exhibited by the former instructors. 
Military nursing 

Nurses have been an integral part of the military in all wars involving the United 
States. Although nurses have cared for the wounded since before the Civil War, it was 
not until 1901 that the Army Nurse Corps came about. In 1908 the Navy Nurse Corps 
was established. These two branches of the service allowed American military nurses to 
serve in World War I and later in World War II. In 1949 the Air Force Nurse Corps was 


formed when it split from the Army. During the Korean War the Air Force Nurse Corps 
joined its military sisters in tending the sick and wounded. At the time of these wars, men 
who were registered nurses were excluded from practicing their profession in the military 
because nursing was considered a profession practiced by females and not males. In fact 
the nurses who were men were relegated to working as corpsmen or nursing assistants. In 
was not until 1955 when President Eisenhower signed the Bolton Act that these men were 
finally allowed to join their sisters as military nurses. Today they are accorded full 
military benefits as "they serve parallel to their female counterparts. . ." (U. S. Army, nd, 
p. 3). Today both men and women have equal rank and privileges as military nurses. 
Many have furthered their education through the military and now hold senior nurse 
management positions in the Army, Navy, and Air Force. 
Men as nurses 

It is important to look further at gender here and its relationship with culture. Men 
have been nurses since the beginning of time. In fact the world's first school of nursing 
was founded in India in 250 B.C. and only accepted men who were pure enough to 
become nurses. In 300 A.D. a group of men known as the Parabolani opened a hospital 
and provided care to the victims of Europe's Black Plague. Later St. Benedict founder of 
the Benedictines and St. Alexis founder of the Alexian Brothers opened and operated 
schools of nursing devoted to the education of men. The Alexian Brothers continue to 
operate hospitals throughout the United States and Europe. (Kozier, Erb, et al. 2004, 
pp.2-4; Wilson, 1997a, p.6) 

Early men in nursing represented other than the dominant White culture. The first 
identified American man in nursing was Friar Juan de Mena, a man with Hispanic 


origins, who was shipwrecked off the coast of Texas during the Spanish invasion in 1554. 
In 1783 James Derham a slave from New Orleans, Louisiana began working as a self- 
taught nurse in order to purchase his freedom. After the Civil War, Derham went on to 
study medicine in Philadelphia where he became the first African American physician in 
the United States. 1888 saw the opening of The Mills School for Nursing and St. 
Vincent's Hospital School for Men in New York City (Wilson, 1997b, pp. 7-8). These 
first schools trained men to nurse sick males and did not allow them to study pediatrics or 
maternity because these areas involved the care of children and women. 

At the beginning of the 20 1 century women nurses began to organize, and in 1917 
the American Nurses Association was founded. This forerunner in nursing societies for 
the betterment of nursing education and patient care excluded men until 1930. This 
association was also instrumental in excluding men from military nursing believing that 
women were more capable of men in rendering nursing care (Kozier et al., 2004, pp. 20- 
21). "In the latter half of the 20 l century men were finally admitted to once all-female 
schools of nursing. It was at this time that men finally returned to their historical role as 
caring and nurturing nurses" (Wilson, 1997b, p. 10). Finally, men were allowed to 
practice their profession in every area of nursing. 

The plight of men can be summed up in the following statement: 
As a man in nursing, Luther Christman, an icon in nursing, 
encountered more barriers than most nurses. In fact, if he wrote 
a tell-all book, many nurses would be embarrassed by the blatant 
sexism he experienced. He goes on to say that women in nursing 
blocked his path to becoming a nurse and later tried to prevent his 


moving ahead with progressive ideas such as graduate education 

and faculty practice. In spite of his experiences, Christman went 

on to become one of the most honored nurses in the history of 

nursing around the world. (Sullivan, 2002, p. 12) 
Many women feared that men would take over nursing as they had medicine and felt 
threatened. At the start of the 21 st century Christman, who married a nurse with whom he 
attended school, was finally recognized as an influential nurse leader. 
The impact of immigration on nursing 

Immigration to the United States came in waves from the earliest of colonial 
times to the present. Immigrants came for various reasons, including the escape from 
religious and political oppression, the flight from famine, to seek employment, and 
the desire to provide a better life for their children and themselves. Some later 
immigrants came to this country in order to join family members who were already living 
in the United States. 

The first influx of immigrants arrived during the colonial era between 1600 and 
1760. "Chief among these newcomers were 250,000 Scots-Irish, 125,000 Germans who 
were the second most significant European minority... and 2,000 Huguenots from France. 
Of note is the fact "that in Colonial America religions and their identities were often 
intertwined" (Dinnerstein and Reimers, 1999, pp. 1, 10) thus making religious vocations 
superior to secular careers. Immigrants coming to America were not openly welcomed by 
the British colonists who not only seemed to forget their own immigration status but also 
considered themselves to be the elitist gatekeepers. 

Further, the British colonists distrusted anyone whose native language was not 


English and whose religion was Jewish or Catholic. In addition, they viewed the 
immigrants as inferior second-class citizens who were not entitled to the rights and 
privileges enjoyed by the British colonists. The colonists feared that the new immigrants 
would take over the land and impose their language, customs and religious beliefs on 

The English colonists and later Americans of the majority group 
appreciated the cheap labor that the newcomers could provide, 
but expected them to absorb existing customs while shedding 
their own as quickly as possible. Minority group members were 
despised for their ignorance of English, their attachment to cultures 
and faiths prevalent in the Old World and their lack of knowledge 
of the American way. (Dinnerstein and Reimers, 1999, p. 15) 
The new immigrants worked as indentured servants for the wealthy where they 
performed farm labor, household chores, and childrearing skills in order to eke out a 

The next large group of immigrants who came between 1789 and 1890 were 
mostly from Western Europe and Canada. Again these immigrants came to the United 
States because "of poor economic conditions in their native lands and prospects for a 
better life" (Dinnerstein and Reimers, 1999, p. 18). They came to work in factories and 
later those with skilled crafts opened shops in the cities. These new Americans had 
children who were better educated and led the way in industry, education, and medicine. 
The mid 19 th century saw an influx of Chinese immigrants who were selected to 
work on the transcontinental railroad while the 20 th century saw the arrival of immigrants 


who were displaced during and after World War I and World War II. Many of these 
immigrants were well educated professionals who were often able to secure positions of 
importance in this country. In the latter half of the century immigrants from the war torn 
areas of Asia came to the United States to better their lives. According to the 2000 U.S. 
Census, today's immigrants are from Africa, Asia and Central and South America. Like 
their earlier counterparts, these new arrivals come to the United States for the same 
reasons listed above. 

One group of Americans who came to the United States for very different reasons 
is known collectively as African American. The new immigrants came from Africa on 
European-owned slave ships in order to provide cheap labor for wealthy white 
Americans. These slaves were torn not only from their countries but their families, 
customs, and religion. Once in the United States, the plight of the slaves continued for 
they were denied their freedom, a relationship with their families, an education, 
healthcare, and the basic dignities of human life. (More Hines and Boyd-Franklin, 1996, 
p. 68) 

The United States as a nation of immigrants has contributed greatly to healthcare 
especially in medicine and nursing. Immigrant pioneers were instrumental in opening 
hospitals to care for their own in an environment that respected and honored the language 
and practices of the particular cultures. Some of the early Boston hospitals include 
Carney, Beth Israel, and New England Deaconess. Carney first opened in South Boston 
in 1863 and cared for the Irish; Beth Israel which opened in 1916 cared for Jews; and, 
New England Deaconess, founded in 1896, cared for people of the Anglican faith. At that 
time it was not unusual for different religious denominations to operate hospitals for their 


faithful. According to Linenthal "hospitals were created as symbols of a community's 
pride, as tangible evidence of people caring for one another." He further states "many 
people felt that hospitals should provide for the souls as well as for the bodies of those 
housed within" (1991, p.71). 

The immigrants of both the 20 th and 21 st centuries continue to come for religious 
and political reasons and for the opportunity to make a better life. Like those who 
came before them and from whom most of us are descended their ideals, family values, 
and cultures continue to blend to form the American society we know today. It is 
important to note that because the children of these early immigrants intermarried over 
the years, most Americans now share two or more cultures. Although they are descended 
from more than one ethnic background, many Americans tend to associate more with one 
culture than another. This may be due to the fact that the family favored one ethnic 
background over another or that the dominant parent's culture prevailed. In an attempt to 
become more Americanized, some first generation Americans had a tendency to deny 
their ethnic background and refused to speak the language of their parents. In order to 
succeed, some of these early Americans changed their names and even denied their 
cultural heritage. What is amazing is that their children and grandchildren are interested 
in their family origins and attempt to learn as much as they can about their cultural roots. 
These younger Americans do this by learning the language of their ancestors, doing 
genealogical research and returning to the ancestral homeland for visits. There are many 
personal reasons for this including finding a way to feel more connected to their past. 
(Dinnerstein and Reimers, 1999, p. 18; McGoldrick, Giordano and Pearce, 1996, p. 25) 

Unlike the immigrants of yesteryear, the most recent emigres are opting to keep 


their culture and language by blending it with their new American culture. To them being 
bilingual or trilingual is not a sign of inferiority as it was in times of old but rather an 
indication that they can be part of two very distinct cultures and still be American. These 
new Americans want to embrace both cultures and identities in their adopted country. 
This blending of cultures brings new life and vitality to the United States as it allows 
those living here to experience new ideas and outlooks that were once unknown or 
unwelcome. This country continues to be a melting pot which struggles to encompass and 
restrain the new and the old simultaneously. This dichotomy, albeit uncomfortable for 
some Americans, is what makes the country diversified and challenges healthcare 
(Leininger and McFarland, 2002, p. 264). 
Cultural traditions for nursing 

Culture and nursing traditions provide structure and continuity in the delivery of 
nursing care. Madeleine Leininger, a nurse anthropologist who has devoted her life to 
care and culture, developed the notion of transcultural nursing. She states that 
Transcultural 2 Nursing refers to a formal area of humanistic and 
scientific knowledge and practices focused on holistic culture 
care (caring) phenomena and competencies to assist individuals 
or groups to maintain or regain their health (or well-being) and 
to deal with disabilities, dying, or other human conditions in 
culturally congruent and beneficial ways. 
(Leininger and McFarland, 2002, p. 84) 
Further, transcultural nursing is concerned with the provision of nursing care in a manner 
that is sensitive to the needs of individuals, families, and groups who represent diverse 

2 For the purpose of this dissertation transcultural and multicultural are used as synonyms. 


cultural populations within the society. The major aim of transcultural nursing is to 
understand and to assist varied cultural groups with their nursing and health care needs. 

In order to understand this concept more fully, the nurse needs to be familiar with 
the common terms that are present in regards to culture and nursing. For Leininger and 
McFarland, culture "refers to patterned lifeways, values, beliefs, norms, symbols, and 
practices of individuals, groups, or institutions that are learned, shared, and usually 
transmitted intergenerationally over time" (2002, p. 83). In other words, nurses are aware 
of how culture affects health care practices. This knowledge is of utmost importance in 
assessing, planning and delivering health care to any individual. This knowledge allows 
nurses to formulate plans of care that are specific for the individual because the plan 
takes into account not only the patient's disease but also how the patient perceives the 
illness and how coping with the health status will be managed. 

In one's practice setting, nurses meet persons who are of a different culture 
than the one that dominates the care setting. This diversity of culture involves 
meanings of health and wellness, values and practices that may be unfamiliar to the 
nurse, and respecting the customs the patient brings to the healthcare setting. (Leininger 
and McFarland, 2002, p. 83; Campinha-Bacote, 2003, p. 1) Purnell (2003, p.2) suggests 
that at times nurses may feel sensitive about another' s culture and may fear saying 
something offensive. This sensitivity can easily lead to serious miscommunication and 
misunderstandings between the nurse and the patient. 

Once nurses become culturally aware of the diversity of the patients, self- 
information and in-depth explorations of one's cultural and professional background 
may occur. This process should involve the recognition of one's biases, prejudices, and 


assumptions about individuals as well as becoming aware of the external signs of 
diversity such as clothing and food choices. (Campinha-Bacote, 2002, p. 182; 
Purnell, 2003, p. 2) As this awareness takes hold, nurses can decide to be culturally 
knowledgeable by seeking and obtaining a sound educational foundation about diverse 
cultural and ethnic groups. This course of action involves understanding others as they 
are and not as nurses would like them to be. This knowledge helps nurses to be more 
culturally competent in assessing patient needs. Being culturally competent requires 
a conscious effort by nurses since it involves being aware of attitudes and behaviors 
that can enhance or deter the outcomes of care. (Tripp-Reimer, Brink, and Saunders, 
1984 p. 79; Purnell, 2000, p. 43; Purnell, 2003, p 2; Leininger and McFarland, 2002, p. 

By being comfortable in caring for patients of diverse cultures, nurses become 
empowered to look beyond the obvious and begin to understand that culture transcends 
nursing care. This transcendence leads nurses to making culturally sensitive decisions 
through careful communication with the patient and the patient's family. This in turn 
allows the patients to be knowledgeable about their personal welfare and the 
achievement of their personal health goals. 
The influence of communication on nursing 

"Perception is at the core of interpretation and is affected by many contextual 
dimensions consisting of past experiences, sociocultural context, emotions, motivation, 
cognition, ability, developmental capacity, and gender" (Pacquiao, 2000, p. 5). Many 
nurses' first impressions are lasting impressions. However, nurses need to go beyond 
this first encounter which clouds the perception of what one thinks about the other and 


look further at what is seen in order to understand and know the other. Nurses need to be 
aware that "Ninety percent of culture is invisible. It's the bottom part of the iceberg - 
people's values, beliefs, history and geography - all those things that really make people 
act the way they act" (Gelbtuch, 2009, p. 6). This process takes time and practice because 
nurses must set aside personal feelings and biases in order to see the patient more clearly. 

Nurses must also understand that communication is a social act that reflects 
how people live, relate, and get along with others. Since language differences are 
probably the single most important obstacle to providing culturally relevant health care, 
ignorance of cultural differences can lead to gross misunderstandings of nonverbal 
behavior. For that reason it is important for nurses to know that in order for 
communication to be successful, the message being sent must be clear, delivered 
properly, and comprehended (Tate, 2003, p. 214). A clear message is one that is sent so 
that the receiver understands what is being said while proper delivery indicates that the 
language used to convey the message is recognized by the receiver. Comprehension 
indicates that the receiver knows what the message states and that it can be acted upon 

In order to communicate effectively with a patient from another culture, nurses 
need to be cognizant of the factors that can facilitate the interaction. Facework, plays a 
major role in this communication interaction. "The concept of "face" is about identity 
respect and other-identity consideration issues within and beyond the actual encounter 
episode" (Ting and Toomey, 2004, p. 73). Associated with facework is the notion of 
politeness which is extremely important when communicating with anyone; however, 
when speaking with people from another culture, politeness or respect is of utmost 


necessity in order to preserve and maintain mutual-face. 

Language attitudes are also important when communicating since violations in the 
principle of language attitudes, or how persons speak to each other may cause serious 
communication misunderstandings. Speakers have "the impression that as long as we are 
aware of cultural differences, we will be able to "understand" people from other cultures 
and engage successfully in intercultural encounters" (Ladergaard, 1998, p. 182). The way 
people speak and interact with each other has an effect on how the message is delivered 
by the speaker and how it is interpreted by the receiver. Agar states that "the speaker's 
intentions are the most important raw material for frame building and that what Anglo- 
Americans think of as 'lies' aren't really lies at all. They're just normal, proper social 
discourse, discourse that considers group members more than American discourse does" 
(Agar, 2002, pp. 159-160). This point is important for nurses to keep in mind when 
dealing with patients from other cultures. What nurses may think of as untruths or 
evasive behavior may be normal dictates or behaviors of the culture. 
The creation of a culturally competent nurse 

Culture influences how people determine if they are ill and how they care for 
themselves. For example, the use of traditional folk practices to prevent illness has been a 
tradition of care for many cultures over time. Some of these preventive measures may 
involve magic and religion as well. (Purnell, 1999, p. 334) Therefore, when caring for 
patients who use alternative medical treatments, nurses need to ask these patients where 
and how they get their health care. When planning care, nurses should try as much as 
possible to incorporate the patient's traditional measures with modern medicine; in so 
doing, nurses are accepting the fact that the patients may be more inclined to use 


practices that are beneficial to their well-being. 

Cultural groups vary in the nature of support they receive from and offer their 
members. For example in some societies the elderly are cared for at home instead of in a 
nursing home where care is provided by nurses instead of the family. Nurses need to gain 
an understanding of the cultural groups for which they are providing care in order to be 
familiar with what the patient and family are seeking. Nursing interventions that are 
culturally relevant and sensitive to the needs of the patient decrease the likelihood of 
stress and conflict arising from cultural misunderstandings. (Campinha-Bacote, 2002, 
p.l) In order to be efficient, nurses need to be sensitive to their own cultural biases and 
behaviors as well as to those of their patients. 

Many tools exist to assist faculty to teach culture to nursing students; however, 
before faculty members can be effective in this area, they must "demonstrate knowledge 
of the cultural differences and similarities" that enhance their "ability to manage the 
impression" others have about them. (Pacquiao, 2000, p. 6) Similar to faculty in other 
professions, nursing faculty come from different backgrounds and cultures and also have 
preconceived ideas of how other people live. Therefore, nurses must evaluate and come 
to terms with their understandings and biases of others before they can teach culture to 
student nurses. Because the "goal of nursing education is to educate a diverse population 
of nurses and to teach all nurses culturally competent practices" (Rew, Becker, Cookston, 
Khosropour, and Martinez, 2003, p. 256) instructors must be committed to following 
through with the notion of being culturally competent. In order to facilitate this process, 
three models for the study of culture are discussed in the next segment. 

The Leininger Sunrise Model to Depict the Theory of Cultural Care Diversity and 


Universality "is a guide to discover new knowledge or to confirm knowledge of cultural 
informants." This theory developed by Madeleine Leininger, a nurse anthropologist, 
states that culture care universality "refers to commonalities or similar culturally based 
care meanings (truths), patterns, values, symbols, and lifeways reflecting care as a 
universal humanity" (Leininger and McFarland, 2002, pp. 80-83). This model looks at 
what people have in common. Further, it also looks at cultural differences and how nurses 
can take this knowledge and develop plans of care for individual patients. 

The Purnell Model for Cultural Competence is a tool that can be used by all 
healthcare givers to assess, plan, deliver, and evaluate the care being dispensed to all 
patients. This model by Larry Purnell, a nurse from Appalachia, "was originally 
developed to provide an organizing framework for nurses to use as a cultural assessment 
of the patient. The model is an ethnographic approach to promote cultural understanding 
about the human situation during times of illness, wellness, and health promotion" 
(Purnell, 2000, p. 40). By using this tool nurses and other healthcare workers can 
individualize their patient's plan of care by incorporating the patient and the family in the 
development of this arrangement. When care is personalized, the patient feels empowered 
and develops a trusting relationship with the nurse. 

The Giger and Davidhizar Transcultural Assessment Model "postulates that each 
individual is culturally unique and should be assessed according to six cultural 
phenomena: 1. communication, 2. space, 3. social organization, 4. time, 5. environmental 
control, and 6. biological variations." The nursing model is based on the idea that culture: 

• is a patterned behavioral response that develops over time, 

• is the result of acquired mechanisms that may have innate influences, 


• is shaped by values, beliefs, norms, and practices that are shared by members of 
the same cultural group, 

• guides our thinking, doing, and being and becomes patterned expressions of who 
we are, 

• implies a dynamic, ever-changing, active, or passive process and, 

• guides actions and decision-making while facilitating self-worth and self-esteem. 
(Giger and Davidhizar, 2002, pp. 185-187) 

Use of this model assists nurses in looking more closely at the dominant culture as 
well as the represented cultures in the society in an attempt to better understand the 
patient being cared for. 

By using these nursing models, "the nurse continuously strives to achieve the 
ability and availability to effectively work within the cultural context of a client, 
individual, family or community and requires nurses to see themselves as becoming 
culturally competent, rather than being culturally competent" (Campinha-Bacote, 2003, 
p. 3). Being competent implies that one is all-knowing about a given culture while 
becoming competent implies that nurses are continuously striving to learn more about 
culture and how it impacts patient care. Care must be adapted in a way that is consistent 
with the patient's culture. (Andrews and Boyle, 2002, pp. 178, 180; Campinha-Bacote, 
2002, p. 184; Leininger, 2002, p. 190; Purnell, 2002, p. 2) In order for this to happen, 
nurses must make use of the above models to enhance cultural awareness in becoming 
more competent when caring for patients of diverse backgrounds. 

In today's multicultural world it is important for nurses to understand cultural 
differences and similarities because the use of knowledge regarding cultural diversities 


has considerable relevance to the practice of nursing, medicine, and other healthcare 
specialties. A person's reaction to illness, health maintenance, daily activities, body 
discomforts, change in lifestyle, food preferences, and various caring and curing 
treatment practices are all linked to cultural beliefs, values, and experiences. 

There are many reasons for nurses to study how culture influences health care. 
Three explanations are: (1.) Nurses tend to be ethnocentric in their approach to health 
care delivery and they tend to believe that their own professional health practices are 
superior to the health norms and practices of other cultural groups. This attitude leads 
nurses to want to impose their "superior" cultural practices on the patient's "deviant" 
culture. (2.) By studying different cultures, nurses are better able to understand their own 
culture and why they react negatively or positively towards others. (3.) The relevance of 
cultural diversity to the nursing profession becomes clear if one assumes that cultural 
patterns are an integral part of providing safe, effective and evidence based nursing care. 

A cultural approach to understanding others recognizes that these persons may be 
trying to satisfy needs that are fairly common across cultural backgrounds but that 
attitudes and behavior of individuals are to a large extent culturally determined. Culture 
serves as a guide to persons on the ways in which they fulfill their needs; it determines 
what actions and kinds of behavior are considered acceptable (Leininger and McFarland, 
2002, p. 9). 
Implications for nursing 

The nursing profession has come a long way in the last century, however; there is 
still room for improvement. Today nurses come from diverse ethnic backgrounds which 
they cannot completely deny. Culture is inextricably linked to and often forms the 


foundation from which they come. Along with their knowledge and experience, nurses 
bring to the profession their behaviors, biases and prejudices which influence how they 
interact with patients, staff and student nurses. What is important, however, is that nurses 
be mindful of this phenomenon and differentiate their own cultural background so that 
patients from other cultures can be understood and treated with respect. 

As the twentieth century has grown into the twenty- first, the demand for more 
culturally aware nurses have grown. Surprisingly, while seminars and workshops are 
being presented to introduce seasoned nurses to cultural awareness, schools of nursing 
lag behind even though they have a distinct advantage in that the teaching of culture 
could be integrated throughout the curriculum. The next section addresses nursing 
education, particularly as it relates to teaching nurses about care and culture. 


Nursing Education: Adult Learning's Impact on Care and Culture in Nursing 

As a nurse educator and administrator I observed that the nursing students of the 
21 st century are, for the most part, adult learners who bring with them a wealth of 
educational knowledge as well as work experience. They are a culturally diverse 
population who vary in age from 17 to 65 or older and many of them are choosing 
nursing as a second career. Because of their knowledge and background, these new 
students are to be treated as adult learners. 

Nursing instructors who have traditionally worked with recent high school 
graduates often times find it difficult to work with students who may be older and more 
learned than they are. Nursing instructors need to be aware of the needs of the current 
student nurse population so that they can facilitate how these students learn what is 
needed to become competent registered nurses. 
Historical perspectives 

Historically education was for the sons of the wealthy and not for their daughters 
who were raised to be wives, homemakers, and care for their family. Women were 
trained to manage the home while men were taught trades and professional skills. The 
poor, on the other hand, were left to develop skills that would be useful in their work for 
the rich. 

The early nurses, who were recruited by nuns, came from the ranks of prostitutes 
and prisoners. These women were taught the nursing skills necessary to care for the sick 
and poor of the community. This practice continued until the end of the 19 th century 
when Florence Nightingale of England began reforming the image and culture of nursing. 


Nightingale who was a friend of Queen Victoria proposed educating virtuous women of 
means to assist physicians in the hospital care of patients. These early nurses were 
dressed to resemble maids and wore caps on their heads and aprons over their long 
dresses. They lived in the housing provided by the hospital and attended classes that were 
taught by physicians and the matrons or nursing supervisors of the hospital. (Mowbray, 
2006, p. 21) 

At the dawn of the 20 th century, schools of nursing remained situated in the 
hospital setting. After World War I a number of colleges and universities opened nursing 
departments in order to educate women who were interested in caring for the sick. The 
advent of World War II saw the introduction of the practical nurse program; an 
accelerated nursing program that produced nurses in 12 to 18 months. Although licensed, 
these nurses function in less critical areas of care than do registered nurses. In the 1950s 
the junior or community colleges began offering two year nursing programs which 
granted an Associate Degree and allowed the graduate to sit the licensing examination for 
Registered Nurse. The last half of the 20 th century saw the closure of most of the diploma 
hospital-based nursing programs and the inception of new entry level Bachelor of Science 
and Masters in Science nursing programs. These programs were primarily designed for 
applicants who had degrees in areas other than nursing and were established in the hope 
of easing the shortage that is plaguing nursing today. However, these nursing preparatory 
programs only fuel the debate over entry into practice. While many countries have 
mandates university level education for their nurses, the United States continues to lag 
behind. Presently, North Dakota is the only state requiring a baccalaureate degree in 
nursing "as a minimum educational credential" (Gordon, 2005, p.418). 


As the focus on the importance of adult learning has increased, it is interesting 
that a one time society thought that education was only for children. Since the world has 
become smaller and more complex this notion has vastly changed. Educators now know 
that learning occurs at any age as older adults return to school to obtain a high school 
diploma or a college degree. Sometimes in spite of adverse reactions from family and 
friends, these adults are fulfilling lifelong learning goals. Now with the introduction of 
on-line classes, more adults are able to take advantage of learning without leaving their 
homes, with fewer disruption to family life. Educators must be aware that even with on- 
line classes the target of the teaching is the student (Caffarella, 2001, p.l 1). 

Nursing is also being affected by these new trends in education. Traditionally 
nursing was taught in a classroom or simulation laboratory and students practiced their 
skills for lengthy periods of time before going into the clinical setting of the hospital to 
care for patients. Also students had very little say about their course of study and relied 
heavily on what was dictated by the curriculum and what they learned from their 
instructors. The early educators and reformers in nursing also had to assuage physicians 
by downplaying nurses' knowledge and skills in order to emphasize their virtue and 
ethics. This practice was demeaning because nurses were taught to do as they were told 
and not to think for or about themselves, but to follow through on doctors' orders as they 
"served" their patients. Accordingly, "today's nurses are under increasing pressure to 
concretely connect nursing practice and patient outcomes" (Gordon and Nelson, 2005, 
pp. 65, 67) by learning critical thinking skills to apply when caring for multicultural 
patients. In order to understand this expectation and to understand better how to instruct 
future nurses, it is beneficial important for nurse educators to be familiar with the 


principles of adult development and education and development. 
Adult development 

As mentioned above, adults return to school for various reasons. The current 
student nurse population is older and has more experience than their predecessors and as 
such this unique adult grouping may find themselves temporarily reverting to Erikson's 
developmental stage of identity versus role confusion. These career-changing students 
returning to school, face opposition to their decisions from family, friends, and 
co-workers. Thus achieving their goals may be more difficult because of the barriers that 
have been created for them both at home, at work, and at school. 

The gap in age between learner and teacher may also factor in, as instructors 
could also find themselves in Erikson's stage of generativity versus stagnation when they 
are in the process of educating the next generation of nurses. Proficient instructors can 
make this stage of development work to their advantage by using their creativity and 
wide knowledge base to enrich student learning. (Erikson, 1963, pp. 266-267) Instructors 
of al ages, though, benefit by knowing the developmental stages they help students 
attempt to make meaning and extend their learning with and serve effectively the patients 
in their care. 

Sometimes the students themselves are the same age or older than instructors. 
Hiemstra who has done extensive research on how older adults, especially women, 
process information, remember, and learn, states that "individual differences among older 
learners exist" and include the fact that persons who are "55 and older can learn new 
skills, become increasingly more self- directed, and be taught to use their past 
experiences in learning new material" (1993, pp. 6-8). This observation is important for 


teachers and learners alike. Instructors need to be aware of the various teaching and 
learning styles that are most effective in the classroom, laboratory, and clinical setting, 
while students should be familiar with their individual styles of learning. 

Teaching nursing students can be a challenge for today's instructors. The 
mainstream student who was a recent high school graduate is rapidly being replaced by 
the adult student who has work and life experience and maybe even a degree or two. 
These new nursing students require instructors who are attuned to their ways of learning. 
Also these students are asking that their instructors teach them what is necessary to 
achieve success in their new chosen profession. 

Based on the above, instructors need to know that "student motivation and 
learning are enhanced when the teacher is closely and purposefully involved with them" 
(de Tornyay and Thompson, 1987, pp. 167-168). Students need to feel that their 
instructors are knowledgeable and that they are willing to work diligently with them so 
that they can thrive both in the classroom and most importantly in the clinical setting. 
Furthermore, instructors should be aware that the successful transfer of knowledge and 
skills to the clinical area takes time and effort in order to be realized fully. By 
remembering how they were as student nurses, instructors can empathize with their 
students and help them find ways of coping with the clinical experience. 

Teaching takes practice, and since many of today' s instructors teach the way they 
were taught, students may not readily grasp what is valued and how the nursing hierarchy 
has evolved. Teachers of nursing may inadvertently make it difficult for students to 
recognize any of nursing's hidden messages. (Dicklemann, 1993, p. 97; Jolley and 


Brykczynska, 1993, p. 83) Therefore, nursing instructors must be cognizant of how and 
what they teach and try not to overwhelm the student. Also instructors of nursing need to 
admit that, "If students are to have a relevant and positive learning experience it must 
reflect and prepare them for reality" (Hewison and Wildman, 1996, p. 759). This reality 
should include that fact that nurses care for culturally diverse patients. 
Teaching styles 

Up until the late 1990s nurses could obtain a masters degree in nursing with a 
focus on education. This concentration of study consisted of 2 or 3 nursing education 
courses and a classroom practicum. Although this was a minimum requirement, few 
nursing instructors studied basic educational theory. This lack of a sound educational 
background disposed many nurses to be biased to their own literature. In other words, if 
the article, book, or course made no mention of nursing or if a course was taught by an 
instructor from another discipline, a lack of appreciation by nursing faculty existed. 
Nursing traditionally views its pedagogy as having little or no bearing on adult education 
theories and principles. 

To compound the situation, many institutions of higher learning closed their 
nursing education departments in the 1990s in favor of the Nurse Practitioner (NP) 
programs. These latter programs were more lucrative than the nursing education 
programs because government funding was better. Some ten years later with an ever 
increasing shortage of nursing faculty and a lack of nurse practitioner positions especially 
in large metropolitan areas, the universities are re-thinking this issue. Some colleges and 
universities with nursing departments are now establishing a two-semester certificate 
program in nursing education for nurses with a Masters degree in nursing in an effort to 


prepare qualified instructors (Gordon, 2005, pp. 331-333). 

As an educator and nursing program administrator, I observed worked with many 
nurse practitioners who were hired as nurse educators even though they had no 
background in teaching. They in fact were learning on the job and were becoming 
frustrated because they had difficulty identifying the level of students' learning needs. 
They were cognizant of the nurse education preparation programs yet few were willing to 
invest the time and money necessary to become instructors. This was an exasperating 
ordeal for those of us who were trying to teach the next generation of nurses. 

Schaefer and Zygmont state that "although faculty members may use a variety of 
methods in an attempt to meet individual student learning styles and to promote learning, 
these learning activities may take place in settings which the academic environment 
makes it impossible to achieve a student- centered approach" (2003, p. 244). Nursing 
faculty need the time and the resources necessary to develop their teaching skills so that 
the student can benefit from the learning process. These authors along with Oermann 
further recommend that: 1. faculty members discuss both formally and informally ways 
to improve the climate of learning, 2. junior faculty be mentored by a senior faculty 
member, and 3. faculty members work together with administrators to find ways to 
eliminate the barriers to achieving a student-centered learning environment. (Schaefer 
and Zygmont, 2003, p. 244; Reilly and Oermann, 1992, p. 196) 

Instructors know that teaching can be a daunting experience since "the task for the 
teacher is to build on the capacity for theory to enhance experience and for experience to 
enhance theory" (Tenant and Pogson, 1995, p. 156). Since most teachers use the 
traditional lecture as their primary strategy, the transmission of facts from teacher to 


student relies less on experience and more on presentation that requires only recall of 
facts as the activities most frequently utilized in the classroom. Further, many of the 
questions asked by these instructors require only a recall to answers without the 
comprehension of important larger concepts or the ability to think critically. Belenky et 
al. (1986) describe this way of learning as one of received knowing, in which learners do 
not integrate knowledge with experience pr engage in dialogue to form connections with 
the ideas of others, but rather accept memorize points as standard. This style of teaching 
points to the necessity for the use a variety of methods including opportunities for early 
clinical experiences in order to capture the essence of learning and thus enable the 
students to feel more secure and safe in school. 

In some nursing school settings where Learning Activity Packages (LAPs) are 
used, students bear the responsibility for teaching themselves by using these LAPs as an 
outline of what they need to know for class. Given that student nurses are expected to 
teach their patients about health and wellness issues, they require the presence of a role 
model to facilitate their education. Some suggestions that teachers can make use of 
include: assuring that all students are engaged in the class activities, selecting teaching 
styles that work best and fine-tune them to meet the institutional goals, allowing students 
to work in their strongest learning styles in order to build self-confidence, giving students 
the opportunity to work in all learning modes, and observing students so that their 
learning styles can be identified. (Morse, Oberer, Dobbins and Mitchell, 1998, p. 42; 
Silver, Strong and Perini, 2000, pp. 32, 34-35) Variety in learning allows the student to 
explore new styles which may enhance the way they view a topic. Also if the classroom 
is deemed a safe haven for student exploration and the teacher fosters new learning 


styles, and presents opportunities for the student to integrate their learning, the students 
will find the educational experience not only more enjoyable but more meaningful and 
ultimately useful. Belenky et al. (1986) appreciate the process and benefit of connected 
knowing, in which the learner and the object or person of the learning experience are both 
considered important, and whereby, the learner through respectful observation and 
dialogue comes to understand the perspective of the other. This process is key to 
recognition of patient cultural contexts toward achieving accurate diagnoses and 
providing appropriate successful treatment protocols. 

Learning begins with an infant's parents as teachers. The parents or caregivers 
teach the child to distinguish right from wrong and how to survive in this complex world. 
As the child grows, formal learning through the elementary school system becomes of 
paramount importance. It is at this time that the child realizes how to integrate various 
ways of learning. Some ways of learning may seem simple while others are more 
complex. As the child continues to develop and learn a sense of what is needed 
educationally and later professionally in life emerges. If children are taught how to learn 
in a positive manner they will like learning and find ways to enhance or embellish this 
learning; however, if children's learning is inadequate; they may feel frustrated and later 
fail in their efforts to achieve in school. Erikson addresses this in his stage of industry 
versus inferiority. Through exposure to diverse ways of learning, the child's preferences 
start to become known. If the teacher aids in developing the preferred styles than the 
child will enjoy the learning process. For the child with poor learning habits, the teacher 
must work diligently with the student in order to promote the development of the good 


habits needed for success. These ways of learning can then be carried through to higher 
education in the adult years (Erikson, 1963, p. 268). 

Adults who come to higher education with positive learning experiences may be 
more open to trying new learning styles in a way to enhance education. Learning can be a 
difficult process if early experiences were not positive or if guidance for the student is 
lacking. Because adults carry with them their learning skills from childhood, it is 
therefore necessary to identify and enhance the positive learning styles and find ways to 
suppress negative habits that developed during the earlier school experience. In 
following Erikson' s theory some adults who are having difficulties with acquired poor 
learning habits may need the assistance of the instructor to find ways to turn the negative 
patterns into positive ones (1963, p. 268). 

Faculty members deal with adult learners from different generations and these 
learners may have developed styles that are different from those of the instructor. This 
dilemma may pose a challenge for both the instructor and the student especially when 
a traditional 18 year old high school graduate entering nursing school has been joined by 
the second-career, middle-aged parent who is returning to school after a long hiatus. 
Nursing faculty thus need required to be aware that some of their students may be older 
and more experienced in life than they are and adjust their curriculum and pedagogy to 
accommodate the range in age and background of their students. 

In my work as an administrator in an associate degree granting nursing program, I 
observed that many older students come to nursing with college degrees and the skills to 
advocate for themselves. They also have goals they wish to attain within a certain 
timeframe. These savvy students pose a challenge to traditional nursing faculty because 


they tend to question authority and expect responses to their queries and they want a 
return on their educational investment. 

These adults continue their educational pursuits for various reasons. For instance, 
professionals like physicians and nurses are mandated by their licensing boards to have a 
certain amount of continuing education in their field of expertise as a requirement to 
renew their license. Other adults may attend informal job training classes related to their 
work or enroll in formal college courses in order to advance in their present jobs or to 
procure another position. There are adults who are also returning to school because they 
are changing careers and want to acquire the language and professional skills that will 
make them more marketable. Some immigrants come to this country with a wealth of 
education and experience only to find that they cannot work in their professions either 
because their credentials are not considered adequate by United States standards or 
because they need to have a working knowledge of English in order to write the multiple 
choice licensing exam. 

Tenant and Pogson ". . .hold the view that the relationship between teachers and 
adult learners should be participative and democratic and characterized by openness, 
mutual respect, and equality" (1995, pp. 3, 171). Additionally, adult students want to be 
treated as peers and respected for their knowledge and experience in the workforce. They 
do not want to be coddled, demeaned or taken for granted. So even though they are new 
to the nursing profession, adult nursing students expect their instructors to treat them as 
adults and not talk down to them. 

Nursing school is a difficult undertaking for any student. This fact is attested by 
Benner (1994) who incorporated the Dreyfus Model of Skill Acquisition and 


Development to identify the five phases a student nurse passes through from: novice, 
advanced beginner, competent, proficient, and expert in nursing. As a novice, a nurse has 
no experience and is taught the basics of weight, pulse, and blood pressure measurement. 
This is a skills oriented phase where learning takes place in a nursing laboratory setting. 
Advance beginners start to concentrate on remembering what they have been taught in 
class and in the laboratory function under supervision in a clinical setting. The competent 
nurse is the one who has been in a single position for 2-3 years and is beginning to set 
long range goals. The proficient nurse sees the entire situation and is guided by past 
experience, whereas the expert nurse who has an extensive background to draw on, is 
able to consider a larger range of solutions to a problem by thinking critically. (Benner, 
1984, pp. 31-32) Benner believes that the Dreyfus Model has implications for both the 
nursing curriculum and continuing professional education since expertise takes a while to 
develop. She also believes that most nurses can eventually function at the advanced level 
but that very few will become experts. 
Learning styles 

Each nursing student comes to the classroom with a different way of learning. 
Although many of these students are unaware of how they learn, a competent and 
resourceful instructor can aid them in identifying these behaviors. One method that can 
be used is a learning style inventory such as the one used by Conner (2004, p. 34). The 
learning style inventory is a form of self-assessment that assists students in identifying 
the best way they learn. 

Self "assessment is an enlightening experience, and is the beginning of the 
transformation to developing personal insight and strategic thinking" (Wolf, Bradle & 


Nelson, 2005, p. 57). An individual can come to learn about his or her learning style 
through the process of self-assessment and gain insights that help the learning process. 
"Learning styles classify different ways people learn and how they approach information. 
The use of a learning styles assessment provides the learner the opportunity to learn how 
one is likely to respond under different circumstances and how to approach information 
in a way that best addresses particular needs" (Conner, 2004, p. 34). Adults who take a 
learning styles inventory might be relieved to discover their particular way of learning. 
For years they may have had an inclination of how they learn and might be delighted 
when they actually verify their particular style. Having this knowledge can empower the 
student by assisting one to focus on a particular style and therefore develop ways of 
learning that create success. Consequently the use of self-assessment is beneficial not 
only for the learner but also for the teacher. With this knowledge, both the teacher and the 
student can work as peers to develop a plan of activities that will enhance learning. One 
limiting factor to the learning styles inventory is that it can label a student and 
consequently limit growth in the learning process. 

According to Morse et al (1998, p. 42), "learning styles involve perceptual 
strengths and processing styles." They identify these strengths as visual, auditory, tactual, 
and kinesthetic and further state that most people "are either global learners or analysis 
learners." Global learners are the ones who need to know what they need to know and 
why they need to learn it, while analytic learners understand best when information is 
introduced sequentially and factually. As a result, this information enables students to 
learn new material by using their primary strength while reinforcing their secondary 
strength. Knowledge of learning styles therefore, can enhance the experience of being a 



Since most students favor one or two styles of learning over the others, these 
techniques can be strengthened through practice in the classroom and application in the 
clinical setting. It is necessary for teachers to look at how they are presenting 
information and to use various ways of conveying knowledge to their students. This 
transferal of data can be accomplished with the employment of handouts, the viewing of 
videos, and question and answer periods in class. In the laboratory, learning can take 
place through demonstrations, simulation, and the practice of skills. Ultimately it is the 
teacher's responsibility to find a balance that is appropriate for all involved. Students, for 
the most part, like creative approaches which help them develop better critical thinking 
skills which are consistent with student-centered learning. (Silver et al., 2000, p. 31; 
Schaefer and Zygmont, 2003, p. 239) 
Adult learning theory 

"Learning typically occurs through active participation in the experience and 
subsequent analysis of the experience" (Tenant and Pogson, 1995, p. 171). This is very 
evident in nursing since students learn the didactic content in class, practice their nursing 
skills in the laboratory, and then are supervised giving nursing care to patients in a 
clinical setting. David Kolb known as an experiential learning theorist developed an 
inventory that assists learners to identify their own learning preferences. He describes 
four styles that a person goes through when involved in a new learning situation. These 
include: 1. Concrete Experience (CE) or abstract conceptualization-how learners take in 
information such as learning from personal involvement and relying on feelings; 2. 
Reflective Observation (RO) or active experimentation-how learners internalize 


information which includes learning by observing and listening before making a 
judgment; 3. Abstract Conceptualization (AC) or learning by thinking and analyzing 
ideas rather than using feelings to solve problems; and, 4. Active Experimentation (AE) 
which is learning by doing or taking action. Kolb further differentiates his model by 
identifying learners as: 1. activists, those who feel concrete experience, 2. reflectors, the 
ones who watch and think, 3. theorists, learners who form abstract concepts and 
generalizations, and 4. pragmatists, students who involve themselves in active 
experimentation, (as cited in Motter-Hodgson, 1996, p. 2) 

By observing students, teachers can begin to decipher the learning styles that are 
prominent in their class. David Kolb in association with Roger Fry developed four basic 
learning style categories which are converger, diverger, assimilator, and accommodator. 
They further realized that there are strengths and weaknesses associated with each 
learning style and that being locked into one style can put a learner at a disadvantage, (as 
cited in Smith, 2001, p. 3) Learners have a primary and a secondary learning style and to 
a lesser extent utilize other styles to complement their own learning. Tenant (as cited in 
Smith, 2001) points out that "the model provides an excellent framework for planning 
teaching and learning activities and is useful as a guide for understanding learning 
difficulties, vocational counseling, and academic advising" (p.ll). 

Gardner asserts that the theory of Multiple Intelligences (MI) can be used to 
describe individual learning styles. In 1966 while at Harvard University, Gardner became 
a part of Project Zero, which provided an environment for him to explore his interest in 
human cognition. A product of this project was the development of the theory of Multiple 
Intelligences. Gardner defines "intelligence as the ability to: 1. solve problems 


that one encounters in real life (such as critical thinking in nursing); 2. generate new 
problems to solve (this occurs when the nurse assesses the patient's condition); 3. and, 
make something or offer service that is valued within one's culture, (nursing care is 
offered to all regardless of circumstances). (Silver et al, 2000, p. 7) 

Gardner' s Multiple Intelligences are listed here with implications for nursing in 
parenthesis: 1. Verbal-Linguistic (V) or the ability to manipulate words (nurses need 
good communication skills); 2. Logical-Mathematical (L) used for establishing cause 
and effect relationships (medication administration and intravenous therapy); 3. Spatial 
(S) or thinking in images (seeing the entire patient from head to toe with each assessment 
in order to determine condition changes); 4. Musical (M) which is the ability to produce 
music (using soothing music to calm an anxious patient); 5. Bodily-Kinesthetic (B) which 
relates to the manipulation of one's body (using proper body mechanics when rendering 
care); 6. Interpersonal (P) where one works with others (multiple layers of interactions in 
nursing); 7. Intrapersonal (I) for those who prefer to work alone (e.g., continuing one's 
education); and, 8. Naturalist (N) identifies those who are highly attuned to the natural 
world of plants and animals (working with the body; anatomy and physiology and 
knowing when it is ill). (Gardner, 2004, p. 5; Silver et al, 2000, p. 7) Gardner's theory 
assists researchers to think about how students learn in their own creative ways. This 
theory can also be used by nursing instructors to energize student learning and to assist 
the nurse to be more aware of how patients learn. This knowledge is then used to develop 
teaching aides for clinical use. 

Mezirow is the author of transformational learning that "pertains to 
epistemic cognition... where learning is understood as the process of using a prior 


interpretation to construe a new or revised interpretation of the meaning of one's 
experience as a guide to future action" (2002, p. 5). Transformational learning is a way to 
solve problems by defining or reframing them. This involves becoming more reflective 
and critical, being more open to the perspectives of others, and being less defensive and 
more accepting of new ideas. Mezirow's work supports Belenky et. al.'s (1986) 
recognition of the importance of connected knowing. 

With the idea of the importance and benefit of connections in mind, the nursing 
profession could benefit from being more open to exploring how other disciplines apply 
teaching and learning theories in their respective educational settings. Mezirow (2002) 
states that "transformative learning can be an intensely threatening emotional experience 
in which the learner becomes aware of the assumptions underestimating ideas and those 
supporting emotional responses to the need for change" (p. 7). Students must be open 
to change in order to take advantage of transformation in their learning experiences. 
Students who refuse to change miss out on important learning opportunities that 
enrich their learning and their practice of nursing. 

According to Mezirow "in fostering transformative learning efforts what counts 
is what the individual learner wants to know" (2002, p. 31). In a classroom setting, the 
teacher and the student need to communicate what is important to each of them in the 
teaching and learning processes. The teacher of adults recognizes that learners are 
responsible for acquiring and enhancing their own understanding and skills. Therefore the 
role of the educator is one of; 1. helping learners focus on and examine the assumptions 
that underlie their beliefs, feelings, and actions; 2. assessing the consequences of the 
assumptions; 3. identifying and exploring alternative sets of assumptions; and, 4. treating 


the validity of assumptions through effective use of reflective dialogue. This can be 
accomplished by having a verbal dialogue in the class where expectations are examined, 
assessed, determined to be valid, and finally acted upon. Students need to know firsthand 
what is needed for them to be successful in the learning process and individual 
adjustments require the consensus of both the instructor and the student (Mezirow, 2002, 
p. 31). 

Teachers need to be aware of what is transpiring in their class. For instance, 
student behaviors in the classroom can indicate that they are having difficulty with the 
presentation of the content. For example, a visual learner might have difficulty in a class 
where the teacher lectures and does not make use of visual aids. In contrast, an auditory 
learner may have difficulty with commotion. Morse states that "women need more quiet 
during learning while men tend to be more visual, tactual, and kinesthetic" (1998, p. 44). 
In addition to setting up adequate pedagogical considerations, "instructors should be 
clinically competent, use effective evaluation strategies, be well prepared for teaching, 
explain concepts clearly, be approachable, and communicate clear explanations." 
(Gignac-Caille, 2001, p. 352) Students need to have well-prepared role models if 
they are expected to be caring and culturally competent in the delivery of care. 
Classroom environment 

Song and Hill point out "that the context where learning takes place influences the 
level of learner autonomy that is allowed in the specific context" ((2007, p. 38). Therefore 
the learning environment can be either beneficial or detrimental to the teacher and the 
student, and may need adjustment for different classes. For example, for both men and 
women, aspects of learning styles may change according to age where the older student 


may require brighter lighting or a different time schedule for class. Besides learning and 
teaching styles, teachers need to be aware of the preferred learning condition in the 
classroom. The placement of furniture, lighting, climate control, and sound are part of the 
physical environment that motivates student learning as well as their emotional state. 
Teachers also need to ascertain if students like to work alone or with others as part of the 
social setting. The physical needs of the students are also important for learning since 
sight, hearing, and mobility require necessary considerations in the learning environment. 
Since students and faculty spend extensive amounts of time in the nursing classroom the 
environment must be safe, uncluttered, clean, and conducive to learning. 

Given that "the learning climate established by the teacher has a major impact on 
how well students are able to achieve (their) goal" (de Tornyay and Thompson, 1987, p. 
166), it behooves the instructor to do all that is possible to maintain an atmosphere that 
fosters student growth. If students are happy in their educational setting they will be 
excited about the learning process. Furthermore, "...the classroom should be an exciting 
place, not boring." (hooks, 1994, p. 7) Consequently teachers need to be aware of how 
they present course content and be vigilant as to what is transpiring in their class so that 
they can correct any negativity before it becomes rampant. 

In addition, "the clinical instructor plays a key role in the development of 
professional nurses by providing an environment conducive to (safe) practice. The 
National League for Nursing has developed core competencies for nurse educators. The 
eight competencies are to: 

• Facilitate Learning 

• Facilitate Learner Development and Socialization 


• Use Assessment and Evaluation Strategies 

• Participate in Curriculum Design and Evaluation of 
Program Outcomes 

• Function as a Change Agent and Leader 

• Pursue Continuous Quality Improvement in the 
Nurse Educator Role 

• Engage in Scholarship 

• Function within the Educational Environment 
(NLN, 2007) 

To be a safe and effective teacher of nurses, faculty should encompass the above- 
mentioned competencies in their practice. "Therefore the instructor's strategies for 
teaching are critical to developing this environment and fostering learning in the clinical 
area." (Gignac-Caille, 2001, p. 347) Because students are culturally diverse and they 
encounter patients from different cultures, the instructor needs to make sure that no one is 
slighted and that cultural considerations of both students and patients are addressed. 
Students need to be familiar with the clinical setting they are studying in so that they can 
enrich their learning and render the best of care to their patients. 

The impact of teaching care and culture has a profound effect on the students and 
the faculty. Because of this "the administrator of a caring-based nursing program directs 
all actions toward creating, maintaining, and supporting a caring environment in which 
knowledge of the discipline can be discovered" (Boykin, 1994, p. 7). If the administrator 
is not encouraging a caring-based environment and fostering the study of culture, the 
instructors will not be able to demonstrate care to the students who represent a multitude 


of cultures. This negative attitude toward care and culture has a ripple effect which makes 

itself known in how the student cares for her peers and his patients. 


The majority of nursing students today are adults who come with years of work 
experience and educational degrees. These students who are culturally diverse bring their 
learning habits and values into the new educational setting. Since these can pose a 
challenge for both the student and the instructor, it is necessary for a teacher of nursing to 
be familiar with how students learn and "to respond to the needs of culturally diverse" 
(Wilby, 2009, p. 57). This knowledge should be incorporated in the instructor's teaching 
plan which is intended to be used to assist the student in identifying learning styles. 
Oftentimes, the adult learner is unaware of how learning takes place and therefore, 
may be unable to change learning styles or to modify old ways of learning. An instructor 
who is knowledgeable in learning theory can thus identify and assist the student in these 
areas. This information will enable the student to perform more efficiently in the 
classroom and more confidently in the clinical setting. 

"The theory and practice of nursing are vitally connected. Classroom and clinical 
learning experiences are about the knowledge and practice of nursing which are 
inseparable in the study and doing of nursing" (Boykin and Schoenhofer, 2001, p. 35). 
Theory and practice need to be integrated over the program and reflected in the 
curriculum which is the blueprint employed to teach nursing students. A carefully crafted 
blueprint allows the curriculum to flow in a way that benefits the student and ultimately 
the patient. 

Effective curriculum content needs to address learning styles. For example in 


developing effective curriculum, the following information is important to keep in mind: 
visual learners are linguistic and spatial and learn best through written language. They 
also tend to write down directions. To increase the learning of these students the teacher 
can employ graphs, charts, and handouts. Kinesthetic learners enjoy moving and touching 
while they are in class. They can best be assisted with their learning when teachers 
incorporate action-oriented activities such as movement, or manipulation. The 
laboratory setting allows students to move around as they are learning to perform nursing 
tasks and perfecting their clinical skills. 

Curriculum developers working with Kolb's model would include strategies using 
the four learner types. The first is Concrete/Reflective, where the instructor motivates 
students who like explanations by asking "why" questions. Building in assignments that 
involve "why" questions is helpful for these learners. The second is Abstract/Reflective, 
where the curriculum material is presented in an organized, logical way that leads to 
mastery of These learners respond best to "what" questions. The third learning type is 
Abstract/ Active, and addresses curriculum that incorporates getting to "how" questions. 
The instructor might set up the curriculum with carefully defined tasks, whereby students 
learn content and are challenged to work in small groups to learn together and in which 
basic clinical skills learning including giving and receiving feedback is involved. The 
fourth is the Concrete/ Active learner who benefits from curriculum that includes "what 
if questions and applies course material in new situations to solve problems (Conner, 
2004b, p. 1). For this learner, the instructor can maximize opportunities that enable 
students to discover their unique characteristics and strengths in approaching and solving 
problems and expand their knowledge of cultural differences through exploring ways that 


different cultures view situations and solve problems. 

When incorporating Gardner' s theory of Multiple Intelligences into curriculum 
design, teachers can incorporate student learning styles into content presentation, class 
activities, and out of class assignments by using a variety of different approaches that 
appeal to and engage students' multiple intelligences, e.g., use of creative writing and 
formal speaking for verbal linguistic learners, audiotapes for auditory learners, laboratory 
exercises, sculpture, and mind mapping exercises for students who prefer spatial 
intelligence and role playing for bodily kinesthetic learners. When dealing with the 
interpersonal intelligence planning group projects makes sense; on the other hand, 
building in thinking strategies and opportunities for personal reflection work better with 
intrapersonal intelligence. For the naturalist intelligence, laboratory experiments and 
field trips to observe application of theory in different patient settings are possibilities to 
build into curriculum planning. 

Another component of the curriculum that instructors present is hidden from 
students. At times "the student is exposed to both an implicit curriculum of education and 
a hidden curriculum" (Jolley and Brykczynska, 1993, pp. 27-28, 61). This type of 
curriculum includes acquiring the accepted behaviors of the profession such as learning 
the skills of interpersonal interaction and becoming confident in handling new situations 
in a local hospital setting. Learning about the hidden agenda in the nursing curriculum 
can be a daunting feat for a student nurse who is trying to understand what it means to be 
a caregiver. 

One example of an implicit curriculum can be seen in the caregiver model that 
evolved from the training school founded by Florence Nightingale where character and 


obedience were emphasized throughout the curriculum, and care was viewed as a hands- 
on (rather than empathic) process in the delivery of physician's orders. This model 
reinforced the physician's demand that the nurse be obedient and selflessly devoted to 
both the doctors and the patient. As a result of this implicit curriculum, nurses were 
removed from decision making and placed in a subservient role. Put politely, "nursing 
became the discipline of caring and the physician was the professional responsible for 
curing which was seen as a much more valuable commodity" (Chipman, 1991, p. 171). 
To a limited extent, this differentiation is still seen in many of today' s nursing 
educational and practice settings. 
Nursing education and the processes used in teaching care and culture 

The term "nurses' training", popular until the latter part of the twentieth century, 
has been replaced by the more professional idiom "nursing education". As previously 
stated this changeover occurred when the schools of nursing moved out of the hospital 
realm and into the college setting. Today, it is more common to teach nurses to think 
critically and to incorporate evidence cased principles in their practice so that they can 
care for patients and inform the physician of any changes in the patient's condition. 
Nurses are also encouraged to be pro-active and to act as patient advocates. Nowadays, 
nurses work more cooperatively with the physicians and in some instances are being 
treated more like peers than handmaidens. These strides taken by nurses may seem to be 
enormous, yet the nurse continues to be less regarded than the physician (Gordon, 2005, 
p. 93-93). 

In 1990 the National League for Nursing (NLN), the accrediting body for nursing 
programs in the United States, introduced a resolution that called for caring to be the core 


value in schools of nursing curricula. The NLN also called for enhancing caring practices 
between faculty and students. However, this practice is only possible when the climate of 
the school is supportive of caring practices. Beck believes that "creating a caring 
environment in schools of nursing is critical not only for teaching nursing students how to 
care but also for developing cohesiveness among faculty and students" (2001, pp. 101, 
108). Therefore, in order for student nurses to care for themselves as well as their 
patients, it is necessary that they experience caring from their instructors while they are 
in school. 

Along with the act of caring, nursing students need to become of their own 
culture as well as those of their peers and the patients they care for. "One culture may 
not use care constructs (like touch) in the same way as another culture; (yet) as nurses 
become knowledgeable about these differences, they can use them in ways that are 
congruent with a client's cultural values and life ways for more effective caregiving" 
(Leininger, 1988, p. 18). Also in 1993 the NLN called for curricula innovations that paid 
"special attention to the multicultural, multiracial and growing diversity of both 
individual and family lifestyles" (p. 12). Therefore, care and culture go hand in hand in 
nursing and must be taught and practiced in order to be beneficial for all concerned. 

There are many innovative ways of teaching culture and care to student nurses, 
and much depends on how knowledgeable and sensitive the instructor is to culture, care 
and the pattern of interaction with students. The instructor needs to understand care and 
culture on a personal level before attempting to teach students how to care for patients of 
the non-dominant culture. By understanding one's culture, one can then identify 
similarities and differences in other cultures. The same is true of how one cares for 


others. It is imperative that one understands how to care before identifying how others 
care. Examining one's own biases and prejudices is necessary before understanding what 
care and culture mean to others. Consequently, one must look at where these biases are 
originating from and what impact they have had and have on one's life. Also it is 
necessary for one to identify if these behaviors can or should be changed and, if so, how 
to make positive adjustments that will lead to change that results in better patient care. 
Clearly adult learners need to be able to put aside their insecurities and prejudices in 
order to learn about culture and ways of caring. 

"The goal of any health profession program. . .is to professionalize the human 
capacity to care through the acquisition of knowledge and the skills needed to fulfill 
prescribed professional roles" (Roach, 1987, p. 8). The study of culture enhances ones 
ability to care. For as Chipman eloquently stated, "caring in nursing is not just an 
emotion, concern, or benevolent desire; it is the moral ideal whereby the end is 
protection, enhancement, and preservation of human dignity" (1991, pp. 171-172). 
Preservation of human dignity is a tenet of care and is essential for the well being of the 
patient as well as that of the nurse. Isaacs indicates that "it is not so much about learning 
a different culture; it is more about how nurses come to keep an open-mind" (2010, 0. 
19). This is not to say that nurses should not concern themselves with the study of 
culture; rather as Isaacs' point has to do with the importance of nurses' keeping open 
minds and being mindful of the patients as individuals, with all their uniqueness. Even 
the most educated and experienced nurse must remember to be present and remain 
unbiased when delivering care to patients so that all necessary information and 
communications take place toward accuracy in diagnosis and success in treatment In the 


end, a successful nurse respects and addresses others' cultures without prejudice in caring 
for each patient, in teaching each student, and in working thoughtfully among colleagues. 


Chapter III Methods 
Statement of the problem and context for research 

A qualitative study was undertaken to identify how baccalaureate student nurses 
who have not yet begun the clinical portion of their program perceive care and culture in 
American society. The information gathered from these nursing students was used to 
identify areas of care and culture requiring additional study in the education of nurses. 

My interest in care and culture has evolved over many years as a result of my rich 
nursing experience which includes military nursing in critical care areas on three 
continents, clinical practice in an internationally recognized specialty hospital, and 
nursing education and administration in various nursing programs. The knowledge 
gathered form the various experiences across education and practice in the nursing 
profession led me to identify the fact that too often nurses are not adequately prepared to 
care for patients from different cultures. 

In my quest to find answers to this contemporary problem I began a personal 
study of care and culture. This pursuit of knowledge brought me to the Transcultural 
Nursing Society and to the International Association of Human Caring which, in turn, 
gave me access to literature, seminars and classes in cutting-edge presentations on both 
culture and care. In studying culture, I was privileged fortunate enough to attend a 
transcultural nursing seminar in New York City where Madeleine Leininger a nurse 
anthropologist and the founder of transcultural nursing gave the keynote address on how 
important it is for nurses to deliver skilled care to culturally diverse patients. Later I 
attended a course on transcultural nursing at Kean University in New Jersey given by 
Larry Purnell, a renowned transcultural nurse researcher and educator, who affirmed the 


same goal. 

My study of care dates back to my entry-level nursing program at Catherine 
Laboure School of Nursing in Boston where one of my instructors was Sr. Simone 
Roach, a foremost authority on care. Later while I was pursuing a Master of Science in 
Nursing degree at the University of Massachusetts, Boston, my research partner and I 
replicated a study concerning caring interactions between students and faculty. Further 
studies in care involved courses at Boston College with Fr. John Shea and a recent 
seminar in Boston featuring Jean Watson, a prominent expert in care and nursing. 
Encountering these theorists on care and culture who speak to the importance of teaching 
nursing and medical professionals more specifically about care inspired me to explore the 
study of culture and care more deep. Consequently I developed the following 
investigation to learn student nurses' perceptions of care and culture toward learning 
about how care and culture can be taught more effectively in nursing programs. 
Information from the literature reviewed here and a response to Leininger's, Purnell's, 
and Watson's call for action on behalf of the profession and the patients it serves 
contextualized the problem addressed in this research. 
Instrument development 

In order to gather the information needed for this research, my doctoral committee 
and I decided that a qualitative questionnaire based on an extensive literature review of 
care, culture, and nursing education would be the best tool to utilize for a survey of 
nursing students. The committee members assisted me in narrowing the focus of the 
study and helped to refine the wording of the questions. Since the survey participants had 
not yet attended their first clinical nursing site and because of the possibility that some 


subjects would possibly identify a language other than English as their primary language, 
the committee and I decided to use common everyday English terminology in phrasing 
the research questions. 

The original number of 15 questions was reduced to 10 open-ended questions so 
that students would be able to give short answers and respond in their own voices. Since 
demographic information was also a necessary component for this study, a check off and 
direct style of questioning was used for this portion of the survey. The length of the 
survey was also considered because the researcher wanted to attract as many participants 
as possible to the instrumentation area without infringing on the students' free time. For 
that reason, a decision was made to make use of a two-sided sheet of paper that could be 
completed in 15 minutes or less. 

In the demographics section of the survey, students were asked to identify the 
following: gender, age range, country of origin, date of arrival in the United States, ethnic 
background, nationality, primary language and other languages spoken, where they were 
educated, highest level of study, and whether they had prior nursing experience, what 
type of experience, and where this experience took place. Ten short answer questions 
followed. The first three asked the participants to define care, where and how they 
learned about care, who taught them care and how this person influenced them. The next 
three questions asked the surveyed to define culture, how they learned about culture, 
who taught them culture and how that individual influenced them. Questions seven 
through ten requested that the student nurses think about how they would respond in 
culturally sensitive situations involving patient care. Question seven asked them to 
describe what they thought nurses needed to know about care and culture in order to 


perform their job. In question eight, the surveyed were requested to list some 
considerations that a nurse would make when determining the care of a patient from a 
different background than the caregiver. The next question asked the students where 
culture specific information could be obtained for a patient. The final query asked the 
participants to determine how a cultural conflict with a patient could be resolved. 
Participants and data collection 

The qualitative study was undertaken with a group of first year declared nursing 
students enrolled in a baccalaureate degree program at Curry College in Milton, 
Massachusetts. Internal Review Board (IRB) approval was obtained from both Lesley 
University and Curry College (See Appendices A and B). The survey was conducted in 
the spring of 2009 on a day when approximately 90 students would be on campus for 
their nursing uniform fittings. On the date in question, this researcher arrived at the 
nursing department and was instructed to proceed to the college's Nursing Resource 
Center (NRC) where the uniform fittings were taking place. The researcher was assigned 
a classroom suite next to the NRC. Leaflets inviting the above-mentioned students to 
participate in the survey were hung by the elevators and outside the uniform fitting area. 

After their uniform fittings, students who wanted to participate in the survey were 
directed to report to the researcher's location. As students entered, they were introduced 
to the researcher who sat at a desk in the ante room. The purpose of the survey was 
explained and those who wished to participate were given a letter of introduction, an 
informed consent form to sign and the two-sided survey (See Appendices C, D and E). 
The students were advised that the researcher would be available to answer any of their 
questions. The participating nursing students next entered the adjoining classroom where 


they were able to complete the survey in private. Upon completion the participants were 
directed to place their consent forms and surveys face down in a designated collection 
box. The researcher thanked the surveyed students and gave each of them a letter 
containing the researcher's contact information. Forty eight students approached the 
researcher and inquired about the survey. All 48 students took copies of the survey; 
however, only 45 completed it. The three other students who took a copy of the survey 
said that they would return it at a later time but they never did. Thus the participants who 
completed the survey represent approximately 50% of the nursing class. 


Chapter IV Findings 

A mixed method study incorporating quantitative and qualitative research was 
attempted. The demographic section of the project was quantifiable; however, the data 
were too skewed for statistical analysis. Consequently, the responses to the questions 
were analyzed qualitatively. 

The sample consisted of 45 declared nursing students who completed a two-sided 
form with demographic data and 10 short answer questions relating to care and culture. 
The majority of the students were female (41) while 4 were males. The age range was as 
follows: 38 females and 3 males were under 25 years of age, 2 females and 1 male were 
between 26 and 35 years of age, and 1 female was between 36 and 45 years old. 

The country of origin for the majority of students was the United States (39). 
Other countries included 1 student each from Ireland, Romania and Haiti. Three 
students did not specify a country of origin. Fifteen ethnic backgrounds were identified, 
however, some students listed between 2 and 4 ethnicities. Seven subjects did not list 
an ethnic background while Caucasian was listed as a primary or secondary ethnicity by 
12 of the participants. (See Figurel) 


Ethnic Background 



2% 2% 2% 3 o /o 

3% 2% 


□ American Indian BArmenian 

□ Canadian 

□ English 

■ French 

□ French Canadian ■ German 

□ Greek 

■ Haitian 

■ Irish 

□ Italian □ Japanese 

■ Polish 

■ Portuguese 

■ Scottish 

■ Caucasian □ None Specified 

Figure 1. Ethnic backgrounds of participants 

Fourteen different nationalities were identified with American (9) and Irish (9) 
comprising the majority. Three students listed 2 or 3 nationalities while 1 
participant listed Black and 2 listed White. Of those surveyed, 17 did not answer 
the question. 

The entire group spoke English and 1 respondent listed French and 
Haitian Creole as primary languages. Other languages spoken included Greek (1), 
Japanese (1), Portuguese (1), and Spanish (3). (See Table 1) 

Table 1 . Languages spoken besides English 

Greek (1) 

Haitian Creole (1) 

Japanese (1) 

Portuguese (1) 

Spanish (3) 


Only 1 student self-identified as being educated in Ireland while 4 stated they 
Held a Bachelor's degree outside of nursing. Eleven of the surveyed specified having 
some nursing experience. The experiences comprised Certified Nursing Assistant (CNA) 
(6), and 1 each for ski patroller, student internship, and job shadow. The 6 CNAs worked 
in hospital and nursing home settings. 

The 10 qualitative questions were examined and analyzed for recurring themes. 
The questions were then separated and categorized according to care, culture, what nurses 
need to know in their job, considerations to be mindful of when caring for patients of a 
different culture, obtaining culture specific information for a patient, and how to resolve a 
conflict with a patient of a different culture. The findings for each question follow. 
Question 1. What is your definition of care? 

Defining care took on various formats from helping, comforting and respecting 
others to empathy, love and compassion. Taking care of the patient both physically (12) 
and emotionally (16) was deemed important for the surveyed students. The physical 
element of care was referred to by such answers as helping someone achieve wellness, 
making the person feel better, doing whatever it takes to make a patient comfortable, and 
making sure they were well treated. Respect, being considerate, and courteous were 
specified as important elements in caring. On a more profound level, compassion, love, 
being there for someone, nurturing, and empathy were brought forth thus revealing a 
deeper understanding of what is considered to be care. As one respondent stated, 
"care is being there for someone else". (See Table 2) for the responses, followed by 
number of participants who wrote the response. 


Table 2. Participants' responses to definition of care 

Helping someone get better (18) 

Emotional support (1) 

Love and respect for another person (5) 
Attending to someone (4) 

Providing empathy (1) 

Emotionally and physically improve someone's state (1) 
Directing your abilities to another individual (1) 

Taking care of someone (4) 

Make a person feel comfortable (12) 

Having the heart to help someone (1) 

Do what is best for the well-being of the patient (1) 

Showing affection (1) 

Providing someone with what they need (2) 

Assist anyone in need in a comforting manner (1) 

Being considerate of others (1) 

Being courteous (1) 

Better an individual's quality of life (1) 

An emotional attachment to someone (1) 

Treating people well (1) 

Giving someone the time and effort to make them feel better (1) 

Helping people in healthy ways (1) 

Compassion (1) 

Understanding (1) 

Ensuring the patient is free of pain and safe (10 

Taking care of people to the best of your ability (1) 

Concern (1) 

Having sympathy for someone (1) 

Being there for someone else (1) 

Care was further identified as being an emotion (12) or function (18). Function 
comprised the physical tasks done by nurses when giving care to patients. These tasks 
included helping, comfort, attention and concern Emotion was the act of love, empathy, 
compassion, and emotional attachment. Affection, consideration, courtesy, respect, and 
being there overlapped both categories. (See Figure 2 and Table 3) 


40% - 
35% - 
30% - 
25% - 
20% - 
1 5% - 
1 0% - 
5% - 

Definition of Care 


Emotion Function Both 


2. Partic 

ipants' def 

inition of care 

Table 3. Participants' dej 

finitions of care by category 

Physical Care 

♦ Helping 

♦ Comfort 

♦ Attention 

♦ Concern 

Emotional Care 

♦ Love 

♦♦♦ Empathy 

♦ Emotional Attachment 

♦ Compassion 

Both Emotional and 

♦ Affection 

Physical Care 

♦ Consideration 

♦ Courtesy 

*l* Respect 

♦♦♦ Being There 

Question 2. Where and how did you learn about care? 

The surveyed students stated that they learned care at home, in school, and 


through life experiences. Twenty eight of the surveyed identified parents and other family 
members such as grandparents, aunts and uncles as the people most instrumental in 
assisting them to learn about care. Teachers, friends and nurses (1 each) provided 
influence in learning about care. One's life experiences (7) were also included as a way 
for learning about care. 
Question 3. Who taught you about care and how did that individual influence you ? 

The students' definitions for care included beliefs, background, traditions, 
identity, values, heritage, shared thoughts and actions, and views on the world. As in the 
previous response, the students indicated that they were taught care at home by their 
parents (38) especially their mothers. Yet again, teachers (1) and other people (3) were 
identified as the outside influence in how care was taught. 
Question 4. What is your definition of culture? 

The definition of culture involved heritage, beliefs, traditions, values, 
morals, code of ethics, language, and food. When answering the question reference was 
made to not only the heritage, beliefs and traditions of other cultures but also to those of 
the students responding to the survey. Food and family stories were indicated as a means 
of continuing family heritage and traditions. Combination (30) responses included 
morals, values and the code of ethics of a society were applied to groups of people 
sharing the same thoughts, ideas, actions, behaviors, and culture. These shared beliefs 
and ideas were also were part of the group's way of life and views on the world. One 
student mentioned that culture was "the piece of identity that defines who you are". 
Table 4 includes responses followed by the number of participants who chose that 
response. Table 5 shows responses by category. 


Table 4. Participants' definition of culture 

Beliefs (8) 

Background (12) 

Traditions (11) 

Ways people live by (1) 

Practices of society (5) 

Identity (1) 

Code of ethics (1) 

Way of living based on morals (1) 

Views of the world (1) 

Customs (1) 

One's place of origin (1) 

Norms (3) 

Behaviors (1) 

Shared ideas and practices of a group (1) 
Thoughts and actions (2) 

Heritage (3) 

Language (3) 

Religion (1) 

Table 5. Participants' responses to definition of culture 


♦♦♦ Background 

♦ Traditions 

♦♦♦ Place of Origin 

♦ Values 


♦♦♦ Views of the world 

♦♦♦ Behaviors 

♦♦♦ Norms 

♦♦♦ Ways people live by 

Both Heritage and 

♦ Identity 

♦♦♦ Practices of Society 

♦ Shared Ideas 

♦♦♦ Ideas and beliefs by a group 
♦♦♦ Peoples' thoughts and actions 

Question 5. Where and how did you learn about culture? 

The students stated that culture was learned at home (1 1), by teachers in school 
(19), and through life experiences (5). Traveling (1), television (2), and family 
traditions (1) were also identified as a way of learning about culture. (See Figure 3) 


How did you learn about culture? 

45% -, 










3~ _ = 


Teacher Life Experience Combination Not Specified 

igure 3. How participants learned about culture 

Question 6. Who taught you about culture and how did that individual influence you ? 

Again as with care, students indicated that they were taught about culture by their 

parents (9) and teachers (11). Life experiences, friends of other ethnic cultures and travel 

were also cited by 1 student each. 

Question 7. What do nurses need to know about care and culture in order to perform 
their job? 

Many tasks were listed for nurses to know in order to perform their jobs 

effectively. The responsibilities mentioned were basically procedures and treatments that 

nurses do routinely when caring for patients. Included tasks were safety, caring, 

comfort, gentleness, and giving treatments that are appropriate. Students also addressed 

the issue of being non-judgmental, accepting and being sensitive to other cultures when 

caring for patients. Being aware of the patient's culture, race and religion were indicated 


as being helpful to the nurse in providing culture sensitive care. What's more, the 
surveyed mentioned that people care differently, each person is unique, and everyone 
needs to be cared for and treated individually (1 each). In addition nurses needed to 
respect the patient's culture by having knowledge of that culture. When planning care the 
following elements such as beliefs and wishes were included. Table 6 lists the responses, 
followed by the number of participants who wrote that response. 
Table 6. Participants' perceptions of what nurses need to know in order to do their job 

People care differently (2) 

Understand and relate to patients (4) 

Accept each individual in order to provide care (1) 

How people like to be treated (1) 

Make people feel safe and comfortable (2) 

Nurses need to know that their job is to care and not judge (4) 

Unbiased opinion (2) 

Understand a patient's culture (1) 

Each person is unique and has a different background (1) 

Relate to the patient's culture (1) 

Sensitivity (3) 

Sympathy (1) 

Care is equal for every patient (1) 

Be open-minded (2) 

People have strong beliefs (1) 

Consideration (1) 

Respect differences (1) 

Everyone needs to be cared for (1) 

Be gentle and heart warming (2) 

Do everything necessary to help others (1) 

Do not violate cultural beliefs and wishes (1) 

Question 8. What are some considerations you as a nurse would make when determining 
the care of someone whose ethnic background is different from yours? 

Participants wrote a range of responses. The following were included: respect is 

of importance when considering the care of a patient from another culture, the nurse must 

consider that the patient's values, beliefs, and language may differ from those of the 

dominant culture, the patient's religion, likes and dislikes, limitations, use of medicine 


and personal needs should be regarded when planning how care will be delivered. Being 
considerate, open-minded, and treating everyone as an individual were again noted in the 
responses. Also cited was the fact that the patient is relying on the nurse for care and 
wants to be treated in the same manner as someone from the dominant culture. The 
responses are listed in Table 7, followed by the number of participants who wrote that 


Table 7. Participants' considerations for nursing 
Do what they want (4) 

Ask the patient about cultural traditions (1) 
Get to know the patient's likes (1) 

Understanding (1) 

Respect (6) 

Values may be different (1) 

Ask questions (1) 

Try to relate to the patient's culture (1) 

Consideration (2) 

Open-minded (1) 

Know the patient's limitations (1) 

Language (2) 

Be unbiased (1) 

Religion (2) 

Treat everyone equally (4) 

Provide proficient care (1) 

Beliefs (5) 

Study and research (2) 

Make the patient comfortable (5) 

Treat them as individuals (2) 

Be mindful that everyone needs care (1) 

Make sure that the patient understands (1) 

Nursing considerations in patient care were also categorized as being patient 
centered, nurse centered and both. (See Table 8) 


Table 8. Nursing considerations in patient care 


♦♦♦ Do what the patient wants 
♦♦♦ Get to know the patient' s likes 
♦♦♦ Know the patient's limitations 
♦♦♦ Make them feel comfortable 
♦♦♦ Treat them as individuals 


♦♦♦ Be understanding 

♦♦♦ Patient's values may be different 

♦> Ask questions 

♦♦♦ Be open minded 

♦> Study and research 

♦♦♦ Try to relate to the patient' s culture 


Patient and 

♦♦♦ Ask the patient about their cultural 

♦♦♦ Be considerate 
♦♦♦ Provide proficient care 
♦> Language 
♦♦♦ Religion 
♦♦♦ Respect 
♦♦♦ Treat everyone equally 

Question 9. How would you obtain culture specific information for your patient? 

Obtaining culture specific information incorporated numerous suggestions such as 
asking the patient and the family, consulting with staff members who have cared for the 
patient, reading the medical records, listening to the patient, doing research, and forming 
a relationship with the patient. Other responses included learning about the culture, doing 
research, and utilizing the internet. The responses are listed in Table 9, followed by the 
number of participants who wrote the response while Table 10 shows the ways the 
respondents anticipate gaining information. 


Table 9. Participants' suggestions for obtaining cultural specific information 
Ask the patient (32) 

Ask the family (9) 

Internet (10) 

Research (7) 

Ask others (4) 

Inquire about cultural preferences (2) 

Check the patient's chart (8) 

Speak with people who have cared for the patient (2) 

opccus. wiui jjcujjic wnu nave i^aicu iui uic 

Speak with people of the same culture (1) 

Listen to the patient (2) 

Read (1) 

Learn the culture (1) 

Become personal with the patient (1) 

Form a relationship with the patient(l) 

Write down information (2) 

Table 10. Categorical results for participants' suggested 
ways of obtaining cultural specific information 

Task Oriented 

♦♦♦ Check the patient' s chart 
♦♦♦ Listen to the patient 
♦ Read 
♦♦♦ Write down information 


♦ Ask the patient 
♦> Ask the Family 
♦> Ask others 
♦♦♦ Inquire about cultural 

♦♦♦ Speak with others who have 

cared for the patient 
♦♦♦ Speak with someone of the same 


Both Task 
Oriented and 

♦♦♦ Internet 

♦♦♦ Research 

♦♦♦ Learn the culture 

Question 10 How would you resolve a cultural conflict when caring for your patient? 

Participants stated that they would resolve a cultural conflict, by communicating 
with the patient and the patient's family, employing respect doing what patient wants, 
and utilizing compromise. Knowing the culture and why there may be a conflict was 


thought to be helpful. One respondent out of 45 wanted the physician to speak to the 
patient while another would employ the services of an interpreter to help with the 
resolution of a conflict. The responses are listed in Table 11, followed by the number of 

participants who wrote the response. 

Table 11. Participants' suggestions for resolving conflict with a patient 
Do what the patient wants (2) 

Make the patient happy (1) 
Serve them (1) 

Respect their thoughts, beliefs, and needs (2) 

Put the patient first (1) 

Speak to the patient (4) 

Accommodate their differences (1) 

Know the patient's culture (1) 

Ask the patient why there is a conflict (1) 

Explain possible resolutions (1) 

Listen to the patient (1) 

Find an alternative plan (1) 

Respect the patient's wishes (2) 

Find the problem and correct it (1) 

Apologize (1) 

Do what is culturally appropriate (1) 
Do what is best for the patient (1) 

Try to understand the patient's point of view (1) 

Make the patient feel comfortable (5) 

Respect their culture (1) 

Compromise (1) 

Have an interpreter (1) 

Be open-minded (1) 

Remember that the patient is important (1) 

Learn about their culture (1) 

Incorporate the patient's cultural beliefs in the care plan (1) 
Put cultural differences aside (1) 

Communication (1) 

Try to agree (1) 

Explain to the patient that the treatment will help get better (1) 
Have the doctor speak with the patient (1) 



Various themes emerged from the responses provided by the sample group. 
For the question defining care, the themes of emotion and function were identified. 
Emotion (16) was recognized as love, support, and compassion while function (12) was 
indicated as comfort, helping others, ensuring patient safety, and taking care of people. 
As far as where the sample group learned about care, the themes that appeared were life 
experience (7) education (1) or another person (28). Eight students stated that they 
learned care from two sources while one student did not answer the question. The 
question on who taught them care the surveyed recognized family members (38), teachers 
(1) and other people (3) as instrumental in this area. Three students indicated that a 
combination of people were involved in teaching them about care. (See Figure 4) 

40% -, 

Definition of Care 

1 5% 4 


0% 4 




'igure 4. Definition of care 


Beliefs, traditions, and background were the themes identified for the definition of 
culture. Thirty of respondents gave a combination of beliefs, traditions, and background 
for their definition of culture. Four students did not answer the question. The question 
regarding where the surveyed students learned about culture indicated family, teachers 
and life experience as influential in this area. A combination of these responses was 
identified by numerous students. Four students did not answer this question. Parents 
and teachers were among those who taught culture to the sampled students. A 
combination of parents, teachers and other people were also listed. Six respondents did 
not answer the question. 

According to those surveyed, nurses need to be respectful and patient centered 
and recognize the patient's cultural traditions when caring for patients. Patient 
considerations were identified as patient focused (12) or other (33) focused. When it 
came to obtaining culture specific information for patients, the respondents listed asking 
the patient, talking with the family, referring to other sources such as books or other 
people, and using the internet. For the resolution of a cultural conflict the respondents 
were patient focused, nurse focused, and other focused. Seven of the surveyed did not 
answer the question. 

In addition to the above responses, 36 students employed the word care 
in their answers and 40 indicated the term culture in their responses. The use of the 
term family relevance was included by 11 of the surveyed students. Overall, the survey 
responses were found to be patient focused (26), nurse focused (9) while no one 
mentioned family focus in their answers. (See Table 12) 


Table 12. Themes of definition of care 

Physical Care 

♦♦♦ Helping 
♦♦♦ Comfort 
♦♦♦ Attention 
♦♦♦ Concern 

Emotional Care 

♦♦♦ Love 
♦♦♦ Empathy 
♦♦♦ Emotional 

♦♦♦ Compassion 

Both Emotional and 
Physical Care 

♦♦♦ Affection 
♦♦♦ Consideration 
♦♦♦ Courtesy 
♦♦♦ Respect 
♦♦♦ Being There 


Chapter V Discussion 

This chapter presents an overview and analysis of the findings of the research 
study. The presentation is based on the results as reported in Chapter IV, Findings, and 
draws comparisons between the results and the literature presented in Chapter II. This 
chapter also includes limitations of the study and implications for future research, nursing 
education and curriculum development, and nursing practice. 
Discussion, analysis and interpretation of findings 

The general finding of this study points to the need for improving the education of 
student nurses prior to placing them in clinical settings so that they enter the "direct-care 
arena" with a greater understanding about the essential relationship of care and culture 
and the importance of recognizing patients' language and cultural considerations in all 
aspects of nursing practice. 

The sample was made up of 41 female and 4 male respondents who are nursing 
students in a small, private New England college. The disproportionate sample of females 
who responded to the survey corresponds with the fact that nursing continues to be a 
female dominated profession. The inclusion of four male respondents was considered 
important in collection of data for this study for it assisted the researcher in comparing 
the variables between both sexes. Males as well as females were concerned about care 
and culture and gave similar definitions for these terms. The family influence especially 
from the mother was evident in how the surveyed learned and were taught about care and 
culture. What nurses needed to know and what considerations they needed to employ 
when caring for patients was also comparable between females and males. Similarly, 


obtaining information and resolving a conflict showed little differences in response. 
Thus, the findings of this study indicate that both males and females who enter nursing 
appear to share common background characteristics and perceptions. 
Care and caring 

Students frequently confused the phenomenon of care with the action of caring. 
Care is a profound experience involved in improving someone's life and involves 
putting another person before oneself. This unselfish act does not require anything in 
return. On the other hand, "caring involves the activities directed towards assisting a 
person" (Leininger and McFarland, 2003, p.47). Included in caring were the show of 
affection, love, and being considerate of another. These activities were identified as a 
way of caring for a patient by providing comfort. One student replied that care came from 
unconditional love; while another respondent stated that caring is one of the stronger gifts 
a person can have and involves being there for someone else. These definitions of care 
are profound and involve love and caring, the basis for empathy. The physical context of 
providing care was an important element for some of these students as they defined the 
term functionally, including provision of safety, nutrition, and assistance with 

Many of the respondents identified respect as a right of every person. 
Approximately one third also indicated that nurses should recognize and respect a 
patient's beliefs, values, religion, language, and customs with an open mind. A few 
referred to treating others as one would want to be treated and pointed this out as a basis 
for respect. Other students were concerned with being sensitive and not offending the 


patient and the patient's culture and that being non-judgmental was a way of showing 
respect for others. Only a minority indicated realization that treating patients with respect, 
regardless of their cultural heritage or practices, is intertwined with care. 

Providing comfort was seen as an important element when administering patient 
care. The activities of bathing, bed making, nutrition, and ambulation were identified as 
important elements in providing the basic elements of comfort and safety. However, what 
makes these activities important in caring is the manner in which the duties are carried 
out by the nurse. The nurse's demeanor sets the tone for how comfort and therefore care 
are to be delivered to the patient. The demands on nurses to attend to the needs of 
multiple patients make it more challenging to attend to their personal needs; especially 
when rushed and feeling under pressure, student nurses may forget that the patient needs 
attention to language and communication in order for nursing to be effective. 
Doing what the patient wants 

Doing what the patient wants may not be in the patient's best interest. For 
instance, the patient might be requesting to smoke inside the hospital or to have an 
intravenous which is necessary for fluid intake or medication administration removed. In 
this scenario, the nurse would need to explain that smoking is not allowed in hospitals 
because of safety concerns for patients, visitors and staff. The continuation of the 
intravenous solution might be considered a nuisance by the patient; however, with the 
proper explanation from the nurse, the patient may understand more fully both the 
purpose and the importance of administering the intravenous solution and thus come to 
realize that the inconvenience is necessary. Nurses need to be cognizant of the fact that 


what the patient requests might be a detriment in the healing process. 

Asking the patient or family about culturally specific preferences is necessary in 
order for the nurse to plan appropriate care for the patient. Although asking is an 
important beginning, it is not enough particularly if there is a conflict in the belief 
systems. This simple act shows that the nurse respects and is sensitive to the patient's 
needs and culture and is willing to incorporate the patient's cultural preferences in the 
plan of care whenever possible. However, unless the nurse is culturally competent he/she 
may not include or understand the patient's preferences. Culture is an essential part of 
one's identity so it is important for student nurses to be open-minded and non- 
judgmental. While some students identified an understanding of culture, e.g., as the ideas 
and values collectively believed by a group of individuals and spoke of accepting people 
for who they are even if different from one's self, the fact is that many of the respondents 
did not do so and, furthermore, did not relate culture to the provision of care. 
Ethnicity, race and nationality 

The terms race, ethnicity and nationality were used interchangeably by the 
surveyed students. According to Purnell and Paulanka (1998, p. 3) and Leininger and 
McFarland (2002, p. 49), ethnicity refers to a group of people who share a common 
background based on national origin while race and nationality are the primary 
characteristics of how people view their culture. Although race refers to color of skin, 
nationality refers to national origin. Hall speaks to the issue of cultural variables (1990, p. 
3). These variables are related to culture differences but they are not how culture is 
defined. When caring for a patient it is important that the nurse not pre -judge the 


customs, characteristics, and values of the patient. For in so doing the nurse is imposing 
the biases and prejudices of the dominant culture on the patient. Only a handful of student 
nurses indicated this understanding and drew a connection that the actions by the nurse 
that are unfamiliar or unacceptable to a patient's culture can lead to distrust and, 
consequently impede nursing care 

Knowing what languages a patient speaks is essential to the nurse. It is extremely 
important that the patient understand what the nurse and medical staff are saying, what 
the treatment plan incorporates, and how the patient will manage the treatment protocol 
and promote wellness at home. Narayan states that "difficulties stemming from words' 
nuances are magnified when the patient's primary language is different from the nurse's" 
(2010, p. 41). This emphasizes the fact that when a patient does not speak English, a 
licensed interpreter is needed. An interpreter is someone who has a degree of dual 
language proficiency in both the languages spoken by the patient and the nurse. A 
competent interpreter can assist the staff in conveying this important information to the 
patient and family. Using family members as interpreters is helpful in certain minor 
situations such as what foods the patient likes to eat and inquiring about the use of the 
bathroom; but any discussion of the patient's medical history and treatment procedures 
should be done with the use of a qualified medical interpreter. 

According to the Civil Rights Act of 1964, persons with Limited English 
Proficiency (LEP) are entitled to receive the services of a qualified medical interpreter 
(Partridge and Proano, 2010, p.77) The medical interpreter is a person who has received 
training in medical terminology and is thus able to convey specific information about the 


patient's condition and treatment with accuracy and sufficient detail that the patient and 
family can listen and ask questions to gain understanding about what is involved in the 
patient's situation. 

Additionally, it is important to honor the patient's rights. It is imperative for 
nursing students to learn upfront that if they ask a family member to perform the task of 
interpretation, the nurse is violating the patient' s privacy. Under no circumstances 
should any duty of interpretation be performed by a child, not only because of 
developmental considerations but also since this activity can be ultra sensitive or 
embarrassing for both the child and the adult and impose a burden on both parties. 

Many ways of obtaining information were identified by the respondents; 
asking the patient and the family were foremost. However, it was a shock to realize that 
the complexity of communicating with a patient who does not speak English was not 
addressed by the respondents. Only one student responded that it was important to seek 
an interpreter! 

Responses to how student nurses would learn about cultural factors varies, 
showing that a filtering process for information accuracy is needed. Responses showed 
logic, e.g., speaking to someone of the same culture as the patient, asking assistance from 
another staff member who has cared for the patient, and reading books and journals as 
valued sources for the obtaining of information pertaining to the patient care. Other 
responses raise concern, as the use of the internet was selected by ten of the respondents. 
While general information about a particular culture or cultural practices may be 
available on the internet, the practice of drawing conclusions based on downloading 


information can be both helpful and harmful. Caution must be taken when using the 
internet since inappropriate/inaccurate information can be accessed. The use of an 
embassy web site for a specific country can be helpful since the site will provide an 
historical perspective and cultural background of the particular country. However, 
information on health care practices might be lacking. One student mentioned cultural 
immersion as a way of learning about a culture. This notion is admirable but is not 
advantageous when the required information is needed immediately. Few mentioned the 
need to learn about cultures most represented in the area in which the nurse works. 
Patient Needs and Considerations 

Some of the traits identified by the surveyed students as necessary for nurses to 
know include acceptance, showing respect, being sensitive to the patient's culture, and 
being open-minded. Respect is a resounding attribute for these respondents because if a 
nurse can respect a patient, the patient may feel more comfortable with the care being 
tended. Accepting the patient's culture is also a show of respect for the patient, while 
being sensitive to the patient's needs is a way of providing comfort and safety to the 
patient. Again, it is important to note that approximately half of the students did not 
indicate a relationship between culture and nursing practice, and only one acknowledged 
the importance of seeking an interpreter for patient communication. 
Conflict resolution 

Reaching a compromise with a patient was mentioned as a way to help resolve a 
conflict. The amount or the type of compromise was not mentioned and neither was how 
compromising is beneficial to the patient. Speaking nicely was one method identified as a 
way to help resolve a conflict because the tone of the nurse's voice can help diffuse the 


patient's anger. Asking for help was deemed appropriate to lessen a serious conflict for it 
provided for the safety of both the patient and the nurse. The goal is to provide a 
culturally responsive resolution to the conflict. 

Intercultural communication appeared to be important when dealing with a 
conflict and the use of a person of the same culture was mentioned as a means of 
assisting in the resolution of a conflict. The use of an interpreter was recognized by one 
student as an asset in conflict resolution. The interpreter could assist by asking the patient 
what caused the conflict and what is needed to help resolve the incident because the 
patient may not know how to resolve the conflict. Since it is possible that a conflict has 
arisen because of misunderstanding the role of the interpreter may be critical in the 
process of resolution toward attending to the patient's needs. To quote Flores, "the 
provision of adequate language services results in optimal communication, patient 
satisfaction, outcomes, resource use, and patient safety" (2006, p. 2). 

The use of feedback was noted by one student as a solution in conflict resolution. 
As important as feedback is, nonessential points should be presented in debriefing after 
the incident is over. While debriefing, comments about what happened and how the 
situation could have been managed differently are important feedback, the priority for 
student nurses, and all nurses, is accuracy of information to promote patient 

Naivete was shown by two students who suggested that conflict resolution would 
not be necessary since there would be no conflict to resolve. Another student insisted on 
having the physician speak to the patient about a conflict. In this act, the nurse defers to 
the physician by removing him/herself from the obligation of assisting the patient through 


a difficult situation. This type of performance does little to promote nursing autonomy in 
patient care (Stokowski, 2010, p. 2). Still another student suggested telling the patient 
that the treatment being suggested would be beneficial. Nursing students need to learn 
that this statement could be misunderstood during a conflict to mean that the dominant 
culture decides the treatment modality and that the patient has to go along with the 
decision. In essence, this takes away the patient's right to decide how care and treatment 
are to be rendered, accepted and carried out after hospital discharge. 

Furthermore, it is not enough to say that learning a patient's culture is helpful in 
patient care; in fact it is essential for nurses and other healthcare professionals to be 
knowledgeable about culturally specific differences that may negatively impact care. 
Patient-centered focus in contrast to nurse-centered focus 

Most student responses indicated that the patient is the primary focal point in 
nursing practice, and that focusing on the patient is the essence of care. In fact for nurses, 
the patient is the most important entity in the hospital and nurses must do what is proper, 
appropriate, and culturally sensitive when caring for the patient. 

Some of the surveyed appeared more nurse-focused than patient-focused when 
answering the researcher's questions. Although the nurse is important, what the nurse 
does or does not do for the patient has a deep impact on how the patient perceives the 
care being received. While the profession of nursing requires informed, aware, and 
grounded practitioners, student nurses need to understand that their preparedness, self- 
understanding, and emotional maturity are expected in order that they can concentrate on 
the needs of the patient. 



The limitations of the study included: the use of a young group of students for the 
survey, a limited number of male respondents, and a small cultural diverse population. 
Unlike the community college setting where the average student is older and has prior 
work experience, the baccalaureate college student is for the most part a recent high 
school graduate with little to no work experience. Also, the diversity in the community or 
state college nursing programs is higher since these programs are perceived to be more 
affordable and to have higher admission rates than non public institutions. 

Another drawback was with the instrument itself. The use of a two-sided sheet of 
paper may have contributed to the fact that four of the forty five students did not answer 
the questions on the reverse side. The use of clearer instructions could possibly have 
prevented this situation. 

The researcher was able to capture 45 out of 90 possible candidates for the 
survey. Also a larger number of students may have completed the form if they had 
learned about the project prior to the day of the uniform fittings. 

Gathering information from the surveyed respondents indicated to the researcher 
that student nurses have a narrow field from which to gather information on care and 
culture and as an extension, how to implement culture- sensitive care to patients in the 
healthcare setting. As stated earlier, most students learned about and were taught care and 
culture at home or in school. Home provides the foundation for life and this narrow lens 
lends itself to imposing biases and prejudices, marginalizing those who are not like the 
dominant culture, and excluding those who do not "fit" into the dominant world view. 


Educators and schools/educational institutions were listed as contributors for the 
teaching and learning of care and culture. However, one needs to examine the type of 
school attended by the surveyed student to ascertain what influence this may have had on 
the student. It's good to keep in mind that a large inner city school is more diversified 
than a small town or private school. What is perhaps more relevant is that many people 
grow up attending school only with people of their own ethnic background, nationality 
and religion. This type of environment also limits exposure to other cultures and may 
lead students to bring in biases unwittingly that need to be addressed. 

Learning about care and cultural differences from books, videos, travel, and 
television, can be very subjective, because the author or the books and the media 
representatives of the videos and television programs more than likely incorporate their 
own biases into their works. Travel, on the other hand, exposes one to different cultures 
and traditions. Yet again one must be cognizant of the fact that tourists might not be 
introduced to the citizens of the area being visited and that often tours are staged for 
tourists. Additionally, travel costs money and takes time, and individuals and families 
may not have discretionary income to support it as a priority to take off from work or 
family responsibilities. 

The surveyed students made a noteworthy attempt at identifying what nurses need 
to know in order to perform their job and what considerations they need to be mindful of 
when giving care to persons of a different culture. Some of the caring aspects the students 
mentioned were basic tasks performed by nurses routinely. Getting to a deeper level of 
what care really is may not be possible for a student or beginning nurse since care is a 
profound phenomenon that might only be understood through experience. 


Understanding culture in-depth might not be achieved on the undergraduate level; 
therefore, further study is required. Being sensitized to another culture by immersion is 
the ideal method of learning about persons of diversity. While it is not possible to learn 
about each culture that one encounters, it is feasible to learn about the major cultures of 
the community in which the nurse lives and practices. One way for nursing students to 
gain knowledge of care and culture is through special courses dealing with these subject 
matters. This learning process can begin at the baccalaureate level and continue through 
graduate school and through professional development on the hospital sites, by attending 
classes and seminars given by qualified instructors, preferably with first person 
knowledge of the language and culture. However, it would be more advantageous for 
colleges of nursing to include a transcultural component in the first and second year of 
the liberal arts portion of the curriculum. This course should be taught prior to the student 
entering the clinical nursing courses. 

Internet usage was noted as a good way for obtaining culture specific information. 
Because a wealth of data can be found on the internet, one needs to be mindful that not 
everything one reads on the internet is accurate. In addition to the suggestions of using an 
embassy site's services, it is important for nursing education programs to look at the 
curriculum. Precise information pertaining to the care of a culturally diverse population 
would be found in articles and books that specialize in transcultural nursing. Students will 
benefit from learning the transcultural models designed by Leininger, Purnell, and Giger 
and Davidhizar. 

After reviewing the findings and realizing the lack of knowledge about culture, 
the researcher looked at the cultural content of eight basic popular nursing textbooks 


dating from 1999 to 2009. The books varied in size from 591 to 2368 pages. Despite the 
size of the text each of the eight books contained only one chapter on culture. It is 
interesting to note that these chapters were located at the beginning of the books where 
the content introducing students to the profession and practice of nursing are found. 
While such placement would seem advantageous, it is important to note further that each 
chapter was disproportionately slim in contrast to total book length and contained a low 
number, ranging from 10 to 25 pages of material on culture. Further of note is the fact 
that only three chapters were written by nurses who are experts in transcultural nursing. 
This situation indicates that student nurses are not being properly prepared to care 
proficiently for patients of diverse cultures. (See Appendix F for curriculum comparison 

Though student nurses at all entry levels to the profession are introduced to 
culture; it is only at the graduate level of education that some nurses immerse themselves 
more fully in the study of culture. This lack of cultural study is a disadvantage to both the 
nurse and the patient since neither is benefiting fully from the healthcare experience. 

As mentioned previously, conflict may arise out of cultural misunderstanding, and 
resolution of the conflict may require assistance from persons familiar with the patient' s 
culture, those who have cared for the patient previously, family members, and a qualified 
interpreter. The use of the interpreter, referred to by one of the 45 students who responded 
to the survey, indicates that students are not aware of the importance of interpreters. An 
important implication for this study is to teach nursing students about the need for 
interpreters in patient communication in the first year of study, before they enter a 
clinical setting. Student nurses must know that interpreters play a vital role in the 


healthcare setting for they are the preferred liaison between the patient and the nurse. 
Interpreters can assist both patients and nurses by dispelling myths and allaying concerns 
regarding hospital and home care. Using the interpreter assures the patient that the correct 
information will be conveyed and that patient confidentiality will be maintained. Student 
nurses need to understand that the use of interpreters is not a personal preference but 
rather a professional mandate. 

The Joint Commission, the accrediting body for hospitals in the United States, has 
required that "language access service options include bilingual staff, interpreters, and 
contact interpreter services" (2010, Standard RI.0 1.0 1.03). These language services are 
available for patient use free of charge at any time. Further having family members 
involved in interpreting does not insure that the patient or the nurse will receive the 
proper information necessary for the care of the patient. For instance, a family member 
might deliberately or inadvertently omit pertinent information, the patient might be 
uncomfortable in providing information that the family member may not aware of, and 
the family member might not understand the medical terminology that is being used. 
In studies by Chen (2009, p. 1) and Flores (2006, pp. 1-2) many physicians have opted 
not to use interpreters because of time constraints or because they feel that they are not 
needed unless serious matters are being discussed. The cost of using interpreters was also 
cited by Jacobs et al. (2004, p. 867) and Partridge and Proano (2010, p.77) who noted that 
the practice of not providing interpreters hinders the delivery of optimal healthcare and 
leads to serious medical errors. This practice is alarming since the patient is not receiving 
proper care. 

Patients entering the healthcare system need to be guaranteed of their right to 


privacy and to know that their cultural beliefs will be respected. Moreover, they need to 
have care that is given by culturally competent nurses. Therefore patients should be 
informed that The Joint Commission respects patient rights by accommodating "cultural 
and personal values, beliefs, and preferences" (2010, Standard RI.0 1.0 1.01). These values 
are to be honored unless they infringe on the rights or safety of others or the patient's 
practices are deemed to be therapeutically or medically contraindicated. Here again, a 
nurse who is knowledgeable of the patient's culture can plan care that will abide by this 
standard and render no harm. 

The importance of rendering culturally sensitive care cannot be understated. For 
as Leininger (1995, p. 20) stated that there "is the urgent need to prepare nurses in 
transcultural nursing in order to meet critical and worldwide needs to care for clients of 
diverse and similar cultures. The goal is to prepare culturally competent and responsible 
nurses." Fifteen years later the attainment of this goal continues to be important in the 
education of today's nurses. 


Chapter VI Conclusions 

This chapter summarizes the major conclusions and recommendations of this 
study. The results of this study indicate that family, school and friends have a profound 
effect on how culture and care are perceived by student nurses who have yet to be 
exposed to patient care. Students' familial influence can be both advantageous and 
detrimental depending on how one learns and was taught about care and culture because 
students bring their prejudices and biases to higher education and then to the clinical 
environment. Working with diverse patients can be very difficult at times for nurses who 
have not had training in transcultural nursing because a feeling of mistrust or a lack of 
understanding about the patient's culture can cloud patient care. This can be further 
exemplified in the clinical area of the hospital where a nurse cannot pick and chose a 
patient assignment and where a lack of appreciation can lead the nurse to label the patient 
as difficult. This occurrence could thus be based on how the patient is approached or 
whether the nurse is more sensitive to the patient's cultural needs. While other nurses 
who are more familiar with diverse patients may encounter less difficulty when dealing 
with patients of the non-dominant culture, student nurses may be experiencing other 
cultures for the first time. 

In order to perform in a multicultural environment, it is clear that nurses need to 
become competent in transcultural nursing. As presented in the literature, both Leininger 
(2002) and Purnell (2002) have developed in-depth theories in transcultural nursing 
which should be incorporated into baccalaureate nursing programs. Each has written a 
chapter in one of the textbooks listed on the chart in the appendices; however, their 
authorship only appears in two textbooks of all those listed. 


Faculty also needs to be adequately prepared in transcultural nursing in order to 
be able to assist their students to be caring and empathic toward people of different 
cultures. This endeavor involves curriculum changes and an alteration of attitude for 
faculty who may prefer the comfort of their familiar ways of teaching. 

Nursing is changing rapidly in the 21 st century. As indicated in the introduction, 
air travel, tourism, and immigration have changed the face of the patient seen at local as 
well as at metropolitan hospitals. Not only have the patients changed in appearance but so 
have the nurses and the medical staff who care for them. Nurses and doctors in the United 
States are no longer all native born or educated in the U.S. The new wave of immigrants 
also has brought medical and nursing personnel from every continent of the world. The 
complexity of factors makes it of utmost importance that nursing students study culture 
and care in their basic nursing programs. Students cannot be experts in every culture; 
however, they should know about basic care and culture, where to access information 
about a patient of a different culture, how to interact with the patient and the family, and 
how to let go of their biases and prejudices towards others. 
As Isaacs so aptly stated: 

We as nurses and others engaged in health care systems 

need to consider our own acculturation processes as we 

adapt to the changes happening in our society. Systemic 

approaches to cultural competency in health care need to 

be considered that enable nurses and other health care providers 

to be adaptive and resilient in a transnational nation. 

(2010, p.15) 


The best way to begin the transformation from a one-culture dominated way of 
caring for patients of diverse backgrounds is to educate the future nurses on the benefits 
of transcultural nursing. This alteration in nursing curricula should begin with first and 
second year while students are in the liberal arts portion of their education and before 
they enter their first clinical setting. This undertaking will require much time and effort 
on the part of faculty in order to accomplish the goal of caring for multicultural patients 
in hospitals and other healthcare settings. Nurses who are culturally competent will 
acknowledge the patients' beliefs, values, religion, cultural preferences, treatment 
modalities, receipt of information, proficiency of the English language, and how family 
involvement supports health. This is an enormous but necessary responsibility if nurses 
are to be accurate practitioners within a culturally sensitive and caring profession in this 

As previously stated, much has been written but little research has been done. In 
light of this, my study predominately supports the literature on care, culture, and nursing 
education and points to the need for more research. 

In ending I would liked to quote Elie Wiesel who spoke recently at my alma 
mater, Saint Louis University. In describing empathy he said, "Whatever you do in life, 
always think higher. Feel deeper. Be sensitive to each other — to each other's pain, to 
each other's joys and each other's fears" (2009). My vision holds the nursing profession 
to these standards, and this study is intended to help inform nurse educators of the 
importance of addressing care and culture in educating nurses of the future. 



Table 1 . Languages spoken besides English 93 

Table 2. Participants' responses to definition of care 95 

Table 3. Participants' definition of care by category 96 

Table 4. Participants' definition of culture 98 

Table 5. Participants' responses to definition of culture 98 
Table 6. Participants' perceptions of what nurses need to know 

in order to do their job 100 

Table 7. Participants' considerations for nursing 101 

Table 8. Nursing considerations for patient care 102 
Table 9. Participants' suggestions for obtaining cultural specific 

information 103 
Table lO.Categorical results for participants' suggested ways of 

obtaining cultural specific information 103 

Table 1 1. Participants' suggestions for resolving conflict with a patient 104 

Table 12 Themes of definition of care 107 



Figure 1 . Ethnic background of participants 93 

Figure 2. Participants' definition of care 96 

Figure 3. How participants' learned about care 99 

Figure 4. Definition of care 105 



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Appendix A 


Institutional Review Board 

29 Everett Street 
Cambridge, MA 02138 
Tel 617 349 8408 
Fax 617 349 8599 

Office of the Provost 

May 1, 2010 

To: Pauline R. Wright 

RE: Application for IRB Review: Nursing Students' Perceptions of Care and Culture: 
Implications for Practice 

IRB Number: 3608 

This memo is written on behalf of the Lesley University IRB to inform you that your 
application for approval has been granted following a review by the full board. Your 
project poses no more than minimal risk to participants. 

If at any point you decide to amend your project, e.g., modification in design or in the 
selection of subjects, you will need to file an amendment with the IRB and suspend 
further data collection until approval is renewed. 

If you experience any unexpected "adverse events" during your project you must inform 
the IRB as soon as possible, and suspend the project until the matter is resolved. 

Date of IRB Approval: 02.11.09 


Appendix B 

FW: Pauline Wright Page 1 of 1 

From: Anderson, Donald <> 
Subject: FW: Pauline Wright 

Date: Wed, 25 Mar 2009 11 :10 am 

Hi Pauline, 

Below is the official confirmation of the approval for your research. 

This is the only approval you will get in writing from the IRB at Curry College. 

Email me what your schedule looks like. We have this month to collect the data. 

Don Anderson, CMSRN. EdD 
Division of Nursing 

From: Steinberg, Bruce 
Sent: Fri 2/27/2009 12:21 PM 
To: Anderson, Donald 
Subject: RE: Pauline Wright 

Dear Do" 

The Curry College IRB has reviewed Pauline Wright's research plan and has approved her proposal for 
research with Curry College students. 

Sincerely yours, 

Bruce Steinberg, Ph. D 


Curry College IRB 

From: Anderson, Donald 

Sent: Wednesday, February 25, 2009 1:12 PM 

To: Steinberg, Bruce 

Subject: Pauline Wright 

HI Bruce, 

Could you email me official Curry IRB approval for the study to be done by Pauline Wright, the doctoral student I 
am working with from Lesley University? 



Don Anderson, CMSRN, EdD 
Division of Nursing 
617.333.2336 69/aol/en-us/mail/PrintMessage.aspx 3/26/2009 


Appendix C 

Pauline R. Wright RN, MS, MEd 

Pitoune 1 7 @ aol . com 


April 2, 2009 

Dear Potential Study Participant, 

I would like to invite you to participate in my Lesley University doctoral 
research project. This is a study in how care and culture relate to nursing practice 
in a multicultural healthcare environment. Your participation will allow me the 
opportunity to gain the information I need to help improve nursing education. 

I will gladly answer any questions you may have. My contact information 
is above. Please read and sign the Informed Consent form below. 


Pauline R. Wright RN, MS, MEd 
Doctoral Student 
Lesley University 
Cambridge, MA 


Appendix D 

Informed Consent 

Title: Nursing Students' Perceptions of Care and Culture: 
Implications for Practice 

Investigator: Pauline Wright RN,MS,MEd,(Doctoral Student) 
Sponsor: There is no sponsor for this research. 

Description and Purpose: A qualitative study will be undertaken whereby open- 
ended questions on care and culture will be posed to undergraduate declared 
nursing students. These questions are intended to explore the students' thoughts 
and beliefs about care and culture and how knowledge of care and culture can 
enhance their nursing practice in a multi-cultural society. 

Procedure: Demographics regarding age, gender, race, ethnic background, 
nationality, country of birth, languages spoken, and educational background will 
be collected. The students will be asked questions regarding their thoughts and 
beliefs about care and culture, where and how they learned about care and culture, 
how this knowledge will enhance their nursing practice, and what resources they 
can use to enhance their knowledge of care and culture. 

Risks: There are no risks involved in this research. 

Confidentiality: You have the right to remain anonymous. Your records will be 
kept private and confidential to the extent allowed by law. Numeric identifiers 
will be used on study records rather than your initials. Your initials and other facts 
that may identify you will not appear when this study is presented or the results 
are published. 

Right to Withdraw: Your participation in this study is entirely voluntary, and you 
may withdraw from the study at anytime even after signing this consent. 

Compensation: There is no compensation provided in this study. 

Signatures and Names 
Investigator's Signature: 

Date Investigator's Signature Print Name 

I am 18 years of age or older. The nature and purpose of this research have been 
satisfactorily explained to me and I agree to become a participant in the study as 
described above. I understand that I am free to discontinue participation at any 
time if I choose, and that the investigator will gladly answer any questions that 
arise during the course of the research. 


Subject's Signature: 

Date Subject's Signature Print Name 

Nursing Students' Perceptions of Care and Culture: 
Implications for Practice 


Appendix E 

Instructions for Completing Survey 

This is a questionnaire to learn about your perceptions of care and culture as they 
relate to nursing. There are no right or wrong answers, so please respond to each 
question as thoroughly as possible according to your own knowledge and 
opinions. Please know that your responses will be kept confidential, so you may 
answer as much or as little as you like. 

Feel free to use either a pen or a pencil when responding. 

When you have completed the survey, please put your responses in the designated 


Gender F— M— 

Age range Below 25— 26-35— 36- 45— over 45— 

Country of Origin Date of arrival in US 

Ethnic Background Nationality 

Primary Language Languages Spoken 

US Educated Yes— No— 
If no, where were you educated? 

Highest level of education and area of study: 

Prior nursing experience Yes— No— 
If yes, what type and where 

What is your definition of care? (Describe what you mean by care) 

Where and how did you learn about care? 

Who taught you about care, and how did that individual influence you? 
What is your definition of culture? (Describe what you mean by culture) 

Where and how did you learn about culture? 

Who taught you about culture, and how did that individual influence you? 

What do nurses need to know about care and culture in order to perform their job? 

What are some considerations you as a nurse would make when determining the 
care of someone whose ethnic background is different from yours? 

How would you obtain culture specific information for your patient? 

How would you resolve a cultural conflict when caring for your patient? 

Thank you so much for taking the time to fill out this survey. 

Best wishes in your nursing program! 


Appendix F 





Chapter Title 



Medical - Surgical Nursing 
Across the Health Care 

Donna D. 
Ignatavicius, M. 

Workman, Mary 


W. B. Saunders Company 


Medical/Surgical Nursing: 
Concepts and Clinical Practice 

Wilma J. Phipps, 
Judith K. Sands, 
Jane F. Macek 

Cultural Care 

Mosby Inc. 


Textbook of Basic Nursing 

Caroline Bunker 
Rosdahl, Mary 
T. Kowalski 


Lippincott Williams and 


Nursing and Contemporary 
Society: Issues, Trends, and 
Transition to Practice 

Linda Haynes, 
Teresa Boese, 
Howard Butcher 

Diversity in 
Health Care* 

Pearson Prentice Hall 


Fundamentals of Nursing 

Patricia A. 
Anne Griffin 

Culture and 

Mosby Inc. 


Foundations in Nursing 

Elaine Oden 

Culture and 



Mosby Inc. 


Fundamentals in Nursing 

Carol Taylor, 
Carol Lillis, 
Pamela Lynch 


Lippincott Williams and 


Brunner and Suddarth's 
Textbook of Medical Surgical 

Suszanne C. 
Brenda G. Bare, 
Janice Hikle, 
Kerry H. 

Perspectives in 



Lippincott Williams and 

Student quotes on care 

Appendix G 

Care is the ability to emotionally and physically improve someone's state 

Care is having the heart and wanting to help someone 

Care is taking your abilities, love, and instinct and directing them at another individual 

Care is a learned thing 

Care is helping someone in need 

(I was taught) Care by my mother who influenced me by setting prime examples in my 


Care is having an emotional attachment to someone and providing (them) with a 

comforting or nurturing environment 

(My parents) Influenced me to treat other people kindly and respectfully 

(Care is to) Give someone the time and effort of making them feel better to the best of 

your ability 

My mother and aunts showed me that care comes from unconditional love 

(My parents taught me) To treat people the way you want to be treated and have empathy 

for them 

My mother taught me to care for others as I want to be cared for, kindly and respectfully 

Care is taking care of people to the best of (your) ability 

(Care is) Being there for someone else, to protect someone, to give them a helping hand, 
and thinking of someone else's best needs before your own 

Care is being there for someone else and putting forth your best efforts to help them. My 
parents raised me to be kind and loving towards others. They taught me that being caring 

is one of the stronger gifts a person can have 

My mother taught me to care about others and always help others. This inspired me to be 
a kind and caring person 

Student quotes on culture 

(Culture is a) Group of people with generally the same beliefs and background 

(Culture) Is what we live by and are influenced by 

(Culture consists of) Shared ideas, beliefs, and practices of a common group 

Culture is the ideas or values collectively behind a group of individuals 

Culture is a set of beliefs (and) moral ways of a particular people 

My teachers taught me about other people and how they may be different but to accept 
them nonetheless 

What nurses need to know in order to do their job 

Nurses need to know that everyone is different and that sometimes people of different 
cultures need different care 

Care is equal for every patient 

Nurses need to be able to) Treat people appropriately and (realizing that) knowing culture 
can help them do that 


Patient considerations 

Finding the best way to put the patient first in everything 

(Nurses) Need to make sure (that they) treat them correctly and take into consideration 

cultural differences 

Shoot for the highest and most proficient level of care no matter race or ethnicity 

© All rights reserved. No part of this dissertation may be reproduced or used in any form 
or by any means, electronic or mechanical, including photocopying, recording, or by 
information storage and retrieval system without permission in writing. For information 
address: Pauline R. Wright, pitoune 1 7 @ aol . com (1 Emerson Place, Apt. 5Q, Boston, MA 
02114, May 19, 2010).