AbstrActOne of the biggest challenges in nursing educati.docx

AbstrAct
One of the biggest challenges in
nursing education is to develop cul-
turally sensitive graduates. Although
theory and lecture are appropriate to
introduce cultural issues, the applica-
tion of those skills is limited by the
kinds of clinical experiences and pa-
tient populations students may treat.
Literary works are a rich source of
information for nursing. This assign-
ment was created to sensitize the
students to the influence of cultural
diversity. Students were assigned to
read one novel from an approved list
and answer the questions posed on
the Cultural Discovery worksheet.
The only direction that was given re-
garding novel selection was that the
novel had to represent a culture other
than the student’s own. The focus
was to expose students to a different
culture. Classroom discussion, based
on worksheet answers, followed. The
assignment’s good, bad, and ugly out-
comes are discussed. Suggestions for
adaptation of this assignment to an
online format are also provided.
T
he United States is home to

one of the most ethnically and
culturally heterogeneous popu-
lations in the world. There are more
than 150 ethnic groups (U.S. Census
Bureau, 2006) and 430 recognized
tribes of Native Americans in the
United States (Redish & Lewis, 2007),
all with their own diverse practices
and beliefs. Culture and ethnicity of-
ten determine the clients’ perception
of health and illness. This includes
kinds of acceptable treatment, type
of follow up permitted, and who will
make health care decisions. As a cul-
ture defines health and illness, it also
defines health care and treatment
practices. Cultural values determine,
in part, how patients will behave.
The provision of culturally compe-
tent care is a dynamic process that
requires individuals to be aware of
their own values and beliefs, as well
as understand how these affect their
responses to those from cultures dif-
ferent from their own. Leininger
(1991) defined culture as the learned,
shared, and transmitted values, be-
liefs, norms, and life practices of a
particular group that guide their
thinking, decisions, and actions in
patterned ways. Cultural competence
includes the attributes of caring, re-
spect, adaptation, honesty, appropri-
ate body language, and interest and

the ability to develop working rela-
tionships across lines of difference
(Galanti, 2004). This encompasses
self-awareness, cultural knowledge
about illness and health practices, in-
tercultural communication skills, and
behavioral flexibility (Strivastava,
2006). Even the concept of transcul-
tural nursing is relatively new in the
nursing literature. In fact, only in the
past 3 decades have nurses begun to
develop an appreciation for the need
to incorporate culturally appropriate
clinical approaches into the daily rou-
tine of client care (Giger & Davidhi-
zar, 1999). Educators strive to develop
students into sensitive practitioners,
and they are challenged regarding
how to best integrate cultural content
and experiences into the nursing cur-
riculum to develop improved cultural
competence.
In the 1990s, several frameworks
for incorporation of cultural concepts
into classroom and clinical experiences
were developed. One of these was de-
veloped by Campinha-Bacote (2003),
who believed that nurses should see
themselves in the process of becoming
culturally competent rather than be-
ing culturally competent. Campinha-
Bacote (2003) defined competence as:
a set of congruent behaviors, at-

titudes, and policies that come
together in a system, agency, or
amongst professionals and enables
that system, agency, or those profes-
sionals to work effectively in cross-
cultural situations. (p. 8)
Cultural competence involves sys-
tems, agencies, and providers with
the ability to respond to the unique
needs of populations whose cultures
are different from the dominant or
mainstream American culture.
Although nurses recognize the
need for culturally appropriate clini-
cal approaches, the literature on
the subject is sparse. Several nurs-
ing texts explore the issue in depth
(Galanti, 2004; Strivastava, 2006),
but there are also other ways to learn
about different cultures. Many learn-
Received: March 2, 2006
Accepted: October 20, 2008
Posted: June 26, 2009
Dr. Halloran is Professor, Nursing Depart-
ment, Western Connecticut State University,
Danbury, Connecticut.
Address correspondence to Laurel Hal-
loran, PhD, APRN, Professor, Nursing De-
partment, Western Connecticut State Univer-
sity, Danbury, CT 06810; e-mail: [email protected]
wcsu.edu.

doi:10.3928/01484834-20090610-07
Teaching Transcultural Nursing Through Literature
Laurel Halloran, PhD, APRN
E D U C A T I O N A L I N N O v A T I O N S
September 2009, Vol. 48, No. 9 523
ing strategies have been documented
in the literature to aid students in de-
veloping an understanding of caring
for clients from diverse groups (Un-
derwood, 2006). Simulation games,
values clarification, exercises, and
consciousness-raising groups have
helped students study the affective
components of cultures differing from
their own. Clinical strategies, such as
service-learning experiences (Bentley
& Ellison, 2007), community-based
clinics (Sensenig, 2007), and care of
homeless populations (Hunt & Swig-
gum, 2007), have been used to help
students to become more culturally
sensitive. One thing educators can
agree on is that one of the biggest
challenges nurse educators face is de-
veloping culturally sensitive gradu-
ates.
Although theory and lecture are
appropriate to introduce cultural is-

sues, faculty are limited in the ap-
plication of those skills by the kinds
of clinical experiences and patient
populations students treat. Literary
works are a rich source of informa-
tion for nursing (Bartol, 1986; Pat-
erson & Zderad, 1988; Smith, 1996;
Younger, 1990). Through a story, in
the thoughts and words of a sensitive
and skilled writer, nurses may intui-
tively understand a patient’s respons-
es and experiences (Younger, 1990).
A story enables nurses to become ac-
quainted with issues that are outside
of their personal experiences. In ad-
dition, it entails no obligations on the
part of the reader. Readers can grow
in knowledge, understanding, and
compassion without the pressure to
say or do the appropriate thing. Sto-
ries have appeal because they cap-
ture interest and attention, enable
recall of details by association, and
bring facts to life by putting them in
personal scenarios. They are espe-
cially effective in teaching because
they allow all students to operate
from the shared or common informa-
tion. That information then serves as
a basis for identifying the problem,
clarifying values, selecting relevant
information, setting priorities, and
developing an action plan (Cassidy,
1996). This vicarious experience may
bridge gaps in the personal experi-

ences of nurses. Literature helps to
dispel the false notion of one single
monolithic culture. Literary reflec-
tion can help nurses hear the stories
of those they hope to help and heal
(Bartol & Richardson, 1998).
Novels can be especially complex
in their in-depth treatment of issues,
concerns, and customs. Although the
possibility exists that the cultural
depiction is stereotypical, the explo-
ration of the subject allows for dia-
loguing. The worst question regard-
ing different cultures is the one that
is not asked. Narratives can be open
to multiple interpretations and allow
the teacher and students to explore
textual and wider professional issues
from a variety of critical perspec-
tives.
Faculty should be aware of several
issues related to assigning a novel
reading to nursing students. It can be
an immensely unpopular assignment.
Novels are not seen as immediately
useful or relevant readings in nursing
education. They do not have nursing
in the title, they do not have detailed
instructions that tell the reader how
to do things, their meanings are not
transparently obvious, and they are
not listed in bullet points. They are
often highly ambiguous and have
no immediacy of application. This is

risky territory for both students and
faculty. There is no right answer.
There are no lectures or clinical ob-
jectives. Students may balk at what
they consider to be “a silly reading as-
signment.” However, written literary
works can serve to expand students’
capacity for compassion and empathy,
equip them to live in the current so-
ciety, and expand their perception of
self and the world in which they live.
Literature can serve to develop imagi-
nation and satisfy curiosity in a safe
environment (Stowe & Igo, 1996). Ac-
cording to van Manen, 1990):
Through a good novel, we are
given the chance of living through
an experience that provides us with
the opportunity of gaining insight
into certain aspects of the human
condition. The stories transcend
the particularity of the plots which
makes them subject to thematic
analysis and criticism. (p. 15)
This assignment was created with
the intention to sensitize students
to the influence of cultural diversity.
Our stories connect us. The simplic-
ity and immediacy of the storytelling
tradition offers a powerful tool that
facilitates a deeper understanding
of self and others within ethical and
cultural contexts. We strive to devel-
op sensitive, caring nurses who are

aware of personal cultural character-
istics and stereotypes. Because many
nursing students are Caucasian
women with little exposure to other
cultures, understanding appropriate
approaches to a person’s culture re-
quires techniques. These techniques
can be developed by knowledge of
diverse cultures, knowing how to be
culturally sensitive, and being aware
of personal cultural characteristics
and stereotypes (Giger & Davidhi-
zar, 1999). Our goal was to develop
a culturally sensitive practitioner
with skills in respect, patience, sin-
cerity, acceptance, appreciation, and
tolerance. The objective of this as-
signment was to explore and to open
dialogues. By exploring different cul-
tures through literature, we exposed
students to different ways of think-
ing, acting, and reacting. In this way,
we could open the channels of com-
munication and explore new ways of
thinking. It allowed exposure to am-
biguities of practice.
the climate
Two or three classes were dedi-
cated to the discussion of the novels,
culture, and implications for nursing
care. It was critical to set up a climate
that facilitated learning and sharing.
Knowles (1980) stated that the criti-
cal role of the teacher is to create a

positive climate in which students
feel accepted, respected, and sup-
ported. Teachers must engage their
entire personality, how they think,
what they know, how they know it,
and how and why they feel certain
ways. Enthusiasm, caring, and the
ability to listen is critical. Classes
began with the question “Who here
wants to be a good nurse?” A general
discussion regarding how and why
culture might influence success with
EDUCATIONAL INNOvATIONS
524 Journal of Nursing Education
patients followed. Sharing personal
feelings toward the importance of the
topic and the assignment was helpful.
I usually started the class segment by
commenting:
In the several years that I have
used this assignment I have always
come away from it having learned
something that I didn’t know be-
fore. This will be an exploration for
all of us. We need to be open to what
we will learn.
In this manner, faculty and students
share in the learning experience. It
becomes a common ground on which

relationships and practice patterns
can be formed. It is critically impor-
tant to impart that just as patients
are all to be treated with respect, so
are students and faculty. The climate
developed was one of a safe classroom
in which individuals could share their
thoughts and feelings without evalu-
ation or disdain.
the Assignment
Students were assigned to read one
novel from an approved list (table 1)
and answer the questions posed on the
Cultural Discovery worksheet (table 2).
Trial and error proved that the class
was better served choosing only 3 to 4
books that addressed a selected group
of cultures, rather than choosing from
the entire list. This made discussion
more manageable. I also found that
a short turnaround (i.e., 2 weeks) and
TablE 1
list of Novels
Novel Culture
Allende, I. (1985). House of spirits. New York: Knopf. Chilean
woman’s perspective in the Central and South
American tradition of mystical literature
Alverez, J. (1992). How the Garcia girls lost their accent. New
York:

Plume.
Dominican American sisters’ story
Brown, R.M. (1977). Rubyfruit jungle. New York: Bantam
Books. Coming-of-age story of a lesbian
Garcia, C. (1992). Dreaming in Cuba. New York: Ballantine
Books. A family torn apart by the Cuban revolution
Gutterman, D. (1994). Snow falling on cedars. New York:
Harcourt Brace. Japanese American during World War II
Hillerman, T. (1973). Dance hall of the dead. New York: Harper
& Row. Mystery exploring the Navajo culture with a Navajo
policeman protagonist
Hillerman, T. (1988). A thief of time. New York: Harper &
Row. Mystery exploring the Navajo culture with a Navajo
policeman protagonist
McMillan, T. (1987). Mama. New York: Washington Square
Press. Black American women’s perspective on life in the 20th
century
McMillan, T. (1992). Disappearing acts. New York: Viking.
Black American women’s perspective on life in the 20th
century
McMillan, T. (1992). Waiting to exhale. New York: Viking.
Black American women’s perspective on life in the 20th
century
McMillan, T. (1997). How Stella got her groove back. New
York: Viking. Black American women’s perspective on life in
the 20th

century
Morrison, T. (1972). The bluest eye. New York: Washington
Square Press. A year in the life of a young Black girl coping
with the
controversial themes of racism, incest, and molestation
Morrison, T. (1977). Song of Solomon. New York: Knopf. A
Black family’s struggle through many generations
Morrison, T. (1987). Beloved. New York: Knopf. The burden of
slavery seen through the eyes of a slave woman
Morrison, T. (1992). Jazz. New York: Knopf. The urban and
cultural renaissance of the jazz age, set in
1920s Harlem
Morrison, T. (1992). Tar baby. New York: Knopf. Exploration
of a love affair of two Black people from
different worlds
Santiago, E. (1993). When I was Puerto Rican. Reading, MA:
Addison
Wesley.
Autobiography of a young girl’s journey from a remote
village in Puerto Rico to New York City and eventual
acceptance into the city’s High School of Performing Arts
Tan, A. (1991). Joy luck club. New York: Vintage Books.
Chinese-American perspective
Urchida, Y. (1987). Picture bride. Flagstaff, AZ: Northland.
Japanese woman’s arranged marriage
Villeserior, V. (1991). Rain of gold. Houston, TX: Arte Publico.

Mexican-American roots
Walker, A. (1992). The color purple. New York: Pocket Books.
The position of Black female life in the 1930s and racism
placement of the assignment early in
the semester facilitated completion,
with less craziness for the students. The
only direction that was given regarding
novel selection was that it had to repre-
sent a culture other than the students’
own. The focus was to expose students
to a different culture and to expand our
knowledge of other cultures. In this
manner, faculty avoid having a minor-
ity student speak for an entire ethnic
community. All students were expected
to explore a society and mores different
from their own, and to move outside of
their comfort zone. The Cultural Discov-
ery worksheets were returned during
the class discussion; however, students
were encouraged to keep a copy for their
reference. The students were instructed
to come to class ready to talk and to
share. Worksheets were graded as only
pass or fail. The worksheets were es-
sentially our method to prove that the
student had completed the reading and
the assignment. table 3 provides direc-

tion for adaptation of this assignment
for online classroom format.
the class Discussion
Class discussion followed the tem-
plate of the Cultural Discovery work-
sheet, with the exception of “describe
your own culture.” It was acknowl-
edged up front that student answers
gleaned from the novels might follow
more stereotypical than real cultural
practices. Faculty thought it was im-
portant to point out the stereotypes
to promote cultural sensitivity. The
purpose of this cultural encounter was
to encourage engagement in cross-
cultural interactions. The process al-
lowed for validation, negation, or mod-
ification of existing cultural knowledge
and also provided individuals with a
structurally specific knowledge base
from which they can develop cultur-
ally relevant interventions (Bucher,
Klemm, & Adepoju, 1996).
By acknowledging the stereotypes,
faculty were able to diffuse some of
the “but that is not how it is in the
real world” frustration of students
who did belong to minority groups.
We discussed and acknowledged the
difference between stereotypes and
cultural awareness. As a blonde, I
shared with them the all-blondes-

are-dumb stereotype to highlight the
difference! Along with acknowledging
the existence of stereotypes, we strove
to also identify the diversity within,
as well as among, groups. This was
demonstrated by asking the students
if they viewed things exactly as their
parents had, which pointed out that
diversity also existed within ethnic
groupings.
Cultural competence was iden-
tified as always occurring in an at-
mosphere of respect. Students were
encouraged to speak openly. They of-
ten added to each others’ comments.
Passages from the novels were used
to demonstrate the concepts. Scenar-
ios were analyzed through reflective
analysis. Class discussion focused on
the questions relating to the culture
that was the focus of the novel. Ques-
tions relating to the students’ biases,
stereotypes, and how they might
practice differently based on the in-
formation gleaned were left for more
private reflection. The students’ ex-
periences were also used as class
content. The faculty asked for exam-
ples from clinical or personal experi-
ence that either confirmed or denied
the information presented. Students
were encouraged during the discus-
sions to present different viewpoints
from their own personal and clinical

experiences. Although students were
encouraged to share, it was not a re-
quirement of the class. Faculty ini-
tially thought that requesting valida-
tion from personal experiences would
hinder discussion. However, this did
TablE 2
Cultural Discovery Worksheet
Briefly describe your own culture.
Briefly describe the culture identified in the novel.
Provide an overview of the identified group’s cultural attitudes,
values, and beliefs as they relate to health care.
Who makes the decisions?
How is health and wellness defined (i.e., physically,
emotionally, spiritually)?
How is beauty perceived?
Who has control over health (i.e., individual, family, doctor)?
What are the verbal and nonverbal communication patterns?
How is family and community perceived?
What did you learn regarding how the culture feels about health
and health care?
What did you learn about the culture that is not related to health
care?

What are the stereotypes? What may happen if you believed all
the stereotypes?
What do you think of the stereotypes now?
What are your own biases and prejudices toward other cultures?
How have they changed as a result of the reading and class
discussion?
To help with this assignment, you may write down passages
from the book to highlight your findings.
not prove to be true. Students were
able and happy to share experiences.
Many valid questions and concerns
regarding practicing with cultural
sensitivity arose from these shared
personal stories.
the Outcomes: the Good, the
bad, and the Ugly
Good
Students benefited greatly from this
experience. They learned to explore
another culture. Conversations about
stereotyping in health care were initi-
ated—a first step to becoming cultural-
ly sensitive. Students asked questions,

not only of their classmates, but also of
other students. One student posted a
question to the university community
asking for help from Hispanic students
to either confirm or deny what she dis-
covered regarding health practices in
her novel (How the Garcia Girls Lost
Their Accent [Alvarez, 1992]). She
received more than 50 responses. A
dialogue was started. Students shared
the following thoughts regarding the
assignment:
• It made me think “I wonder
how the patient is dealing with
this.”
• I’m much more aware now—
less “this is the way” and more “how
can we help.”
• I learned to ask who else beside
the patient needed to be educated.
• I learned that the most impor-
tant thing was to ask the question.
bad
Students complained about “anoth-
er reading assignment.” They thought
the novels gave a stereotypical view of
a culture. Often, they found it difficult
to answer all of the questions in the as-
sessment based on only the novel. In
the initial presentation of this assign-

ment, the students were instructed to
read any of the books on the list. Al-
though fascinating, this made class dis-
cussion days chaotic as students were
not operating from a common base of
material. Originally, this assignment
was scheduled for later in the semes-
ter. The students were so stressed at
the end of the semester that reading a
novel, even one that had been assigned
for class, was seen as a frivolous waste
of time and energy. They also found it
difficult to not have a “right answer.”
An inordinate amount of faculty time
was spent re-explaining the goals of the
assignment. Students were uncomfort-
able with the inability to regurgitate
the right answers.
Ugly
A surprising ugly factor was that
some students had great difficulty
with the reading level of the novels
chosen and it took them a great deal
longer than anticipated to complete
the assignment. These students were
referred to academic advising to re-
ceive help with their skills. Some stu-
dents really believed the stereotypes
that were presented. Although they
were respectful of other students in
class, one student was heard to say:
There must be a truth in there

somewhere or else why would there
be so many obese Puerto Ricans?
It was difficult to educate some
students and promote cultural sen-
sitivity when their thoughts were
so ingrained. Initially, students at-
tempted to rely heavily on what fel-
low students who were minorities
said about the cultural exploration
questions and less on either actually
doing the reading or thinking criti-
cally about what they had read. They
did not understand the implications
of their behavior (e.g., “What did I
do wrong?”) until they were asked to
answer the question “What is the cul-
ture’s view of beauty?” and to speak
for all Caucasian Americans. A light
bulb went on: “I see, just because we
look the same doesn’t mean we all
think the same.” Some students were
forced to face the self-knowledge that
they held deep-seated prejudices and
feelings regarding ethnic minori-
TablE 3
adaptation of the assignment to an Online Format: Synchronous
Chat from 7 to 9 p.m. on October 1, 2008
Read Julia Alverez’s How the Garcia Girls Lost Their Accent by
September 28, 2008. Log on to [WebCT site] and enter the
Discussions page at 7 p.m. on October 1, 2008. We will spend
our class time discussing the novel. Be prepared to discuss the
following questions:

Who makes the health care decisions in the family?
Who has control over health (i.e., individual, family, doctor)?
What are the verbal and nonverbal communication patterns?
How is health and wellness defined?
What did you learn regarding how the culture feels about
health care?
What are the stereotypes?
What might happen if you believed all the stereotypes?
What do you think of the stereotypes now?
To help with this assignment, you may write down passages
from the book to highlight your thoughts.
All students are expected to participate in the discussion.
Grade is 10% of the total course grade and pass or fail.
ties. Acknowledgement that we were
identifying stereotypes in addition
to cultural norms was startling for
some students. Two students real-
ized that nursing was not a career for

them and dropped out of the program
after completing this assignment. As
faculty and nurses, we did not toler-
ate racism. All statements regarding
a culture were made with respect. It
was emphasized that nurses are ex-
pected to care for all patients without
regard to race, culture, gender, reli-
gion, sexual preference, or ethnicity,
according to the Code of Ethics for
Nurses (American Nurses Associa-
tion, 2005). As stated in the Code of
Ethics (American Nurses Associa-
tion, 2005):
The nurse also recognizes that
health care is provided to culturally
diverse populations in this coun-
try…. In providing care, the nurse
should avoid imposition of the nurs-
es’ own cultural values upon others.
The nurse should affirm human
dignity and show respect for values
and practices associated with dif-
ferent cultures and use appropri-
ate approaches to care that reflect
awareness and sensitivity. (Section
8.2, ¶ 2)
conclusion
It was important to close the loop
of this assignment by relating new
understandings and insights to the
students’ own clinical or practice ex-
periences. That was accomplished by

asking the question: “What might you
do differently now?” Faculty learned
many things by participating in this
assignment. Above all, we learned
that there is no quick fix with cultural
competence; it is a process. Cultural
knowledge involves seeking informa-
tion about other world views to oper-
ate from an informed base for thera-
peutic intervention. The recognition
of similarities and differences is a first
step. The development of competent,
sensitive, and compassionate profes-
sional nurses is a major challenge for
the nursing profession. Human re-
sponses to life predicaments are com-
plex and difficult to know; yet the es-
sence of nursing is dependent on that
knowledge. Novels can help students
to bridge gaps in their experiences of
life, without its costs. We are fortu-
nate in the proliferation of novels that
have been popularly successful and
are also rich in cultural commentary.
According to Younger (1990):
Good books can be a gift of wis-
dom to our students—the experi-
ence of life without its costs. In us-
ing literary metaphors, the stories
we hope to understand are our own.
We and our patients are the char-
acters, but the consequences belong
to the “others.” The goal is compas-
sion, without the personal experi-

ence of suffering, through linking
ourselves in the timeless experience
of others. (p. 42)
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