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.

The 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: halloranl@ wcsu.edu.

doi:10.3928/01484834-20090610-07

Teaching Transcultural Nursing Through Literature Laurel Halloran, PhD, APRN

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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

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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

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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.

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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.

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September 2009, Vol. 48, No. 9 527

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)

references American Nurses Association. (2005). Code

of ethics for nurses. Retrieved June 7, 2007, from http://nursingworld.org/ ethics/code/protected_nwcoe813.htm

Bartol, G.M. (1986). Using the humanities in nursing education. Nurse Educator, 11, 21-23.

Bartol, G.M., & Richardson, L. (1998). Us- ing literature to create cultural com- petence. Image: Journal of Nursing Scholarship, 30, 75-79.

Bentley, R., & Ellison, K.J. (2007). Increas- ing cultural competence in nursing through international service-learning experiences. Nurse Educator, 32, 207- 211.

Bucher, L., Klemm, P., & Adepoju, J. (1996). Fostering cultural competence: A multicultural care plan. Journal of Nursing Education, 35, 334-336.

Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services: A culturally compe- tent model of care (4th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associ- ates.

Cassidy, v.R. (1996). Literary works as

case studies for teaching human exper- imentation ethics. Journal of Nursing Education, 35, 142-144.

Galanti, G.-A. (2004). Caring for patients from different cultures (3rd ed.). Phila- delphia: University of Pennsylvania Press.

Giger, J.N., & Davidhizar, R.E. (1999). Transcultural nursing: Assessment & intervention (3rd ed.). St. Louis, MO: Mosby.

Hunt, R.J., & Swiggum, P. (2007). Being in another world: Transcultural student experiences using service learning with families who are homeless. Journal of Transcultural Nursing, 18, 167-174.

Knowles, M.S. (1980). The modern prac- tice of adult education: From pedagogy to andragogy (2nd ed.). New York: Cam- bridge Books.

Leininger, M.M. (1991). Culture care di- versity and universality: A theory of nursing. New York: National League for Nursing Press.

Paterson, J., & Zderad, L. (1988). Human- istic nursing. New York: Wiley.

Redish, L., & Lewis, O. (2007). American Indian FAQs for kids: Information on Native Americans. Retrieved June 7, 2007, from www.native-languages.org/ kidfaq.htm

Sensenig, J.A. (2007). Learning through teaching: Empowering students and culturally diverse patients at a community-based nursing care center. Journal of Nursing Education, 46, 373- 379.

Smith, M.A. (1996). The use of poetry to test nursing knowledge. Nurse Educa- tor, 21(5), 20-22.

Stowe, A.C., & Igo, L.C. (1996). Learning from literature: Novels, plays, short stories, and poems in nursing educa- tion. Nurse Educator, 21(5), 16-19.

Strivastava, R. (2006). The healthcare professional’s guide to clinical cultural competence. St. Louis, MO: Mosby.

Underwood, S.M. (2006). Culture, diver- sity, and health: Responding to the queries of inquisitive minds. Journal of Nursing Education, 45, 281-286.

U.S. Census Bureau. (2006). United States Census 2000. Retrieved June 7, 2007, from http://www.census.gov/main/ www/cen2000.html

van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy (2nd ed.). Albany: State University of New York Press.

Younger, J.B. (1990). Literary works as a mode of knowing. Image: Journal of Nursing Scholarship, 22, 39-43.

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