Nursing Diagnoses: A Study of Cultural Relevance ELAINEM. GEISSLER,PHD, CTN, RN*
This study examines the adequacy/inadequacy of three nursing diagnoses with cuttural etiologies: (1) impaired verbal communlcatlon related to cultural differences; (2) impaired social interaction related to sociocultural dissonance; and (3) noncompliance related to patient value system. The research tool was admlnistered to the membership of the American Nurses Association Council on Cultural Diversity and the International Transcultural Nursing Society, with a response rate of N = 248 (42.2 per cent) from 43 states, the District of Columbia, and seven foreign countries. The tool Ilsted the North American Nursing Diagnosls Association (NANDA) defining characteristics and cuftural etiology for each diagnosis rated on a flve-point Llkert scale from “nearly always present” to “rarely present.” The subjects also wrote and ranked other defining characteristics they used to make the diagnosis in clinical practice. Percentage distribution results indicate no definlng characterlstlc meets the NANDA criteria for a major or mlnor defining characteristic. By collapsing categories, seven were acceptable only as minor defining characteristics. Respondents’ 113 suggestions for additional characterlstlcs were content analyzed. Themes for 12 categories were intuited and added to the lists. Based on respondents’ suggestlons, the definitions for each diagnosis were reworked, and new cultural-related factors were added. The cuRural adequacy/inadequacy of elements within these three dlagnoses was identified and provides the opportunity for greater selectivity in their clinical use. Additional suggestions from transcuftural nursing experts form a data base for future research to expand the use of the currently limited components of NANDA diagnoses wlth culturally diverse patients. (Index words: Cultural etiologies; North American Nursing Diagnosis Association; Nursing diagnoses; Transcultural nursing, inadequacy of) J Prof Nurs 8:301-307, 1992. Copyright 0 1992 by W.6. Saunders Company
T
HERE HAS BEEN little impact of the rapidly evolving transcultural nursing knowledge and
practice
base on the content
best, the Diagnosis
of nursing
1989 list of the North Association (NANDA)
diagnoses.
of Professsionul Nursing,
a few cultural
cultural
factors
that
defining
appear
related
to a given
nurses
have three options.
new taxonomy. as one that, ceptual
characteristics
to be antecedent
nursing
diagnosis.
and to or
It appears
that
The first is to develop
a
Jenny (1989) defines a good taxonomy
in addition
proves communication gaps,
to clarifying between
indicates
retrieval”
analysis
Jenny
techniques,
ally related categories
concepts,
nurses,
con-
and im-
(p. 83). Using
identified
“im-
identifies
needs for research,
proves information
concept
seven conceptu-
based on Orem’s self-care deli-
tits. She suggests that her new categories of health protection and health restoration are heavily influenced by cultural patterns and resources. Ignoring the cultural needs of patients the inadequacy
of the current
unfortunately,
a second
patients cultural
NANDA
option
because diagnoses
for nurses
caring
experiencing cultural needs. “Many nursing individuals are so frustrated
of is, for
transwith
NANDA’s list that they want to throw out the baby too,” wrote one respondant in this study. Leininger (1990) believes that “the NANDA diagnostic classificatory system needs to be reevaluated, reconsidered and refocused into transculturally relevant, meaningful, and useful transcultural perspectives” (p. 24). The study described here represents the third option: nated
(a) working
NANDA
the cultural
within
classification
adequacy
the widely
system
or inadequacy
dissemi-
by examining of the current
defining characteristics for three nursing diagnoses; (b) offering expert suggestions for more culturally relevant defining characteristics; and (c) refining and expanding the current diagnostic definitions and related factors for further research and validation when they are applied
At
to cultural
etiologies. Methods
American Nursing nursing diagnoses
*Associate Professor of Nursing, University of Connecticut, Stow. Address correspondence and reprint requests to Dr Geissler: 20 Stone Pond, Tolland, CT 06084. Copyright 0 1992 by W.B. Saunders Company 0883-7223/92/0805-0011$03.00/0
Journal
contains
RESEARCHDESIGN Levin, Krainovitch, Bahrenburg, and Mitchell (1989) used the nurse-consensus quantitative research approach of Gordon and Sweeney (1979) and Fehring (1986) to determine the diagnostic content validity of six of the most frequently used nursing diagnoses to
Vol 8, No 5 (September-October),
1992: pp 301-307
301
ELAINE M. GEISSLER
302
determine
confidence
Each defining Likert-type
characteristic defining
fied by NANDA. Likert-type
characteristics
Vincent
However,
ended question,
allowing
used in making Vincent’s for this study
and
cent) in transcultural
characteris-
fice Coupon-Response
of ineffective
individ-
included
an open-
of clinical
spe-
to write in other criteria
they
in clinical
handling
and one
it allowed
for the write-in
of
perceived by transcultural nursing for culturally diverse patients. It
also identified the gaps and needs for research advocated by Jenny while providing statistical data on the usefulness
of the existing
NANDA
obtain
defining
and
nursing.
and
1 17 (47.8
A prepaid
International of their respective
per
US Post Of-
was included
packet so that foreign respondents
the postage
110
in
could
countries
with-
out charge. INSTRUMENT
Gordon
new characteristics experts as critical
of the
each non-US
patients,
Formal educational
that 148 (48.2 per cent) had one
practice.
model was the more appropriate because
indicated
or more courses in anthropology
a five-point
this diagnosis
(1985)
Sweeney (1979)
experience
and
her sample
diverse
already identi-
the defining
Vincent
cialists the opportunity
with culturally
per cent) had domestic
(44.9 per cent) had served abroad.
model
diagnosis
204 (83.3
only those ma-
used Gordon
scale to validate
ual coping.
In addition,
(1985)
nurse-validation
tics for the NANDA
cent).
experience
was rated on a five-point
scale. The study included
jor and minor Sweeney’s
levels in their use in practice.
charac-
teristics. The Gordon and Sweeney procedure “involves tabulating which defining characteristics listed for a diagnosis are present when the diagnosis is made in clinical practice” (p. 8). This nurse-consensus model can be used retrospectively based on the nurse remembering clinical encounters with patients and on the nurse’s accrued nursing knowledge. “The advantage of the retrospective model is the feasibility of sample of nurses” obtaining a large, representative
A five-point
rating scale with an alpha coefficient
.74 was developed defining
by Vincent
characteristics
(1985)
to validate
of the NANDA
nursing
of the
diag-
nosis labeled ineffective coping (individual). The author’s permission was secured to modify her instrument.
The NANDA
nursing
diagnosis,
the existing
NANDA etiology relating specifically to culture, and the NANDA defining characteristics were listed. Subjects
were asked to retrospectively
rate each defin-
ing characteristic as “nearly always present” (in 80 per cent to 100 per cent of clients), “frequently present” (60 per cent to 79 per cent), “sometimes present” (40 per cent to 59 per cent), “seldom present” (20 per cent to 39 per cent), and “rarely present” (0 per cent to 19 per cent). The “other” item on the list asked the respondent to write in and rate any other behaviors exhibited under each diagnosis.
(p. 7). RESEARCH
QUESTIONS
SAMPLE
1. Which The membership
lists of the International
Trans-
cultural Nursing Society and the American Nurses Association Council on Cultural Diversity in Nursing Practice comprised the sample. Because a subject could hold membership in both organizations, duplicate names on one list were eliminated resulting in 580 potential subjects. The response rate was N = 245 (42.2 per cent), corrected to 46.1 per cent by eliminating from the total the questionnaires that could not be delivered by mail. Responses were received from 43 states and the District of Columbia, and 16 responses from seven foreign countries (Canada, Philippines, Sweden, Pakistan, Saudi Arabia, Israel, and Malawi) are included in the sample. Respondents’ job titles were grouped as educators in either academic or service positions (148 or 53.9 per cent), practitioners (8 1 or 37.0 per cent), students (11 or 5.0 per cent), retired or not working in nursing (4 or 1.8 per cent), and unable to classify (5 or 2.3 per
of the
current
NANDA
defining
characteristics identify the culturally relevant behaviors in the selected nursing diagnoses: a. impaired verbal communication related to cultural differences, b. impaired social interaction related ciocultural dissonance, and c. noncompliance related to patient
to sovalue
system. 2. What additions are needed in the diagnostic definition, defining characteristics, and related factors to identify patients’ culturally relevant problems and needs?
Results ANALYSIS
OF CURRENT
DEFINING CHARACTERISTICS
According to NANDA policy a defining characteristic is major if it is present 80 per cent to 100 per
CULTURALRELEVANCE OF NURSINGDIAGNOSES
cent of the time and minor
if it is present
to 79 per cent of the time under The first diagnosis
reported
when it is specifically
differences.
The NANDA
is, “The state decreased guage
in human
com-
to cultural
experiences
to use or understand
interaction”
(NANDA,
of the
The second dissonance.
a
lan-
1989, p.
49).
of the
current official nursing diagnoses reflects the inability to respond to cultural needs of patients.
1 fit the
NANDA criteria for either major or minor defining characteristics. When the categories “nearly always present” and “frequently present” are collapsed, defining characteristics numbers 1, 2, and 5 meet the criteria of a minor defining characteristic for the diagnosis when it is related to cultural differences and restricted dominant
to the patient being unable to speak the (nurses’) language. The remaining defining
characteristics, ceptable. entation,
numbers
Number support
characteristic
TABLE 1.
3, 4, 6, 7, and 8, are unac-
7, dyspnea, and number 8, disorian argument for exclusion of this
for use with culturally
diverse patients
Impaired Verbal Communication
diagnosis
when
of social exchange”
“rarely
studied
to sociocultural
definition
for this diagnosis
under impaired
dissonance.
None
official
to respond
of the defining
social interaction
for inclusion
characteristics
categories
1989,p. 50).
also reflects the inability
criteria
in an quality
of the current
needs of patients.
the NANDA minor
participates
or ineffective
(NANDA,
characteristics
cultural
is impaired
it is related
2 the inadequacy
diagnoses
meet
as either
major or
when they are related
to socio-
When
are collapsed
data from
for numbers
the first
noncompliance,
when
two
1 and 2, they are
acceptable as minor defining characteristics. The same result is obtained in the third diagnosis,
in Table
nursing
or excessive quantity
to cultural
None of the response percentages
under
is, “The state in which an individual insufficient
nursing
the inadequacy
percentages
The NANDA
In Table
Ia.
high
social interaction
for this diagnosis
an individual
ability
verbal
because present. ”
diagnosis.
related
definition
in which
or absent
50 per cent
a given
is impaired
munication
303
it is related
nursing to the
patients’ value systems. Respondents’ negative reactions to this particular diagnosis and its definition are reported elsewhere (Geissler, in press) NANDA defines this nursing diagnosis as, “A person’s informed decision not to adhere to a therapeutic recommendation” (NANDA, 1989,p. 67). Numbers 1 and 5 collapse into acceptable minor defining characteristics when related to patients’ value systems.
Because the number
ond defining
characteristic,
of responses objective
to the sec-
tests,
was low
(N = 155), the data were not used. Many respondents indicated that they did not understand the characteristic
and did not respond.
Higher
percents
are
Related to Cultural Differences
Nearly Always Present
(Collapsed Percent)
Frequently Present
Sometimes Present
Unable to speak dominant language
22.8
66.1
43.3
23.7
4.5
5.8
Speaks or verbalizes with difficulty
20.4
65.3
44.9
24.0
4.9
5.8
Does not or cannot speak
6.7
5.4
18.4
26.5
43.1
Stuttering, slurring, difficulty forming words or sentences
4.1
11.4
20.0
26.4
38.2
38.4
27.7
8.9
8.5 18.9
Official NANDA Behaviors
Difficulty expressing thought verbally
16.5
54.9
Seldom Present
(Collapsed Percent)
Rarely Present
Inappropriate verbalization
6.0
20.7
37.8
16.6
Dyspnea
0.5
4.5
8.5
26.0
86.5
60.5
Disorientation
0.9
5.4
17.9
25.9
75.9
50.0
ELAINE M. GEISSLER
304 TABLE
2.
Impaired
Social
Interaction
Official NANDA Behaviors Verbalized or observed situations
discomfort
Related
Dysfunctional interaction and/or others
Dissonance Frequently Present
Nearly Always Present
[Collapsed Percent)
Sometimes Present
Seldom Present
Rarely Present
29.5
65.6
36
1
23 3
71
40
22.9
58 3
35 4
26 9
94
54
77
33 0
38 5
11 8
91
59
158
32.4
27 0
189
in social
Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history Observed use of unsuccessful interaction behaviors
to Sociocultural
social
with peers, family,
recorded in Table 3 under the center point of the scale, “sometimes present, ” rather than with the other two diagnoses. The NANDA results for the first research question-which of the current NANDA defining char-
were 22, and for the third diagnosis,
noncompliance,
there were 43. Because the instrument design fixed the write-ins within the rating scale for each diagno-
acteristics identify the culturally relevant behaviors for the selected nursing diagnoses?-are summarized
sis, researcher subjectivity was partially controlled for relating the message to the characteristics of the prespecified diagnosis. Themes were sorted into similar content categories, and titles for the categories were
in Table 4. Because the NANDA percentage criteria for inclusion of a diagnostic behavior are stringent,
intuited and became the new defining characteristic. A second certified transcultural nurse repeated the
the percentages
content
were lowered for the remainder
of this
study. Subsequent inclusion of new suggestions as a major defining characteristic was set at or above 50 per cent and as a minor defining characteristic between 25 per cent and 49 per cent.
analysis
process,
Discussion
113 new defining
characteristics written by respondents were content analyzed. For the first diagnosis, impaired verbal communication, 48 additions were submitted; for the impaired social interaction, there second diagnosis, TABLE
3.
Noncompliance
Related
Official NANDA Behaviors Behavior indicative Objective
of failure to adhere
tests*
Evidence of development complications
of
Evidence of exacerbation
of symptoms
Failure to keep appointments Failure to progress “Not included
in study.
synthesized
related factors based on the specific suggestions from the respondents were incorporated into the revisions.
CULTURAL ADDITIONS TO NURSING DIAGNOSES
In the second step of this study,
and the results
the work of both researchers. Changes, additions, and deletions in the definitions of the diagnoses and in the
to Patient
The defining characteristics meeting the NANDA criteria that the transcultural nurses in the sample considered present in their culturally diverse patients, the NANDA
Value System
defining
(Health
Beliefs,
characteristics Cultural
based
on less
Influences)
Nearly Always Present
(Collapsed Percent)
Frequently Present
Sometimes Present
Seldom Present
Rarely Present
21 7
67 4
45.7
25 3
63
09
5.7
32 3
38 2
158
70
38
29 7
50.0
137
28
7.0
31 9
46 0
103
47
47 0
28.8
9!
23
35.9
42.6
1’ 5
4.8
12.8 5.3
59.8
CULTURAL RELEVANCE OF NURSING DIAGNOSES
TABLE
4.
305
Acceptable Defining Characteristics Based on NANDA Criteria
bal communication fluent
Impaired verbal communication related to cultural differences Unable to speak dominant language Speaks or verbalized with difficulty Difficulty expressing thought verbally Impaired social interaction related to sociocultural dissonance Verbalized or observed discomfort in social situations Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history Noncompliance related to patient value system Behavior indicative of failure to adhere Failure to keep appointments
criteria,
and the new suggestions
are pre-
when
in their own languages
ability
to communicate
NANDA
defining
iological
both
understanding,
verbally.
characteristics
within
variance.
They
the context
cultural
which
are
of cultural-language exclusively
yet the nonverbal
are critical to mutual
may have nothing
pathophys-
and inappropriately
differences,
every culture
existing
to speak,
are now directed
verbal communication
not the
The
address
causes of the inability
irrelevant
are adequately
(Table 5). The problem
is one of the barriers to mutual
inant stringent
skills
toward related
to
expressions
understanding
to do with knowledge
of and
of the dom-
language.
Cultural
expression
communi-
cation,
dents gave of clinical behaviors their patients are indented after the newly added defining
exhibit charac-
language. Several respondants advised that the related factors be separated into differences in language and differences in cultural expression. Differences in language refer to language barriers alone, and differences in cultural expression are a much broader etiology
teristics. The diagnostic definitions have been reworded and related factors added to reflect the suggestions offered. Neither nurse nor patient TABLE 5.
experience
impaired
ver-
Impaired Verbal Communication Related to Cultural Differences (Revised)
Definition: The state in which an individual is unable to speak and understand the dominant language of the health care delivery system when the barrier is not secondary to physical or psychological disorders Defining characteristics Unable to speak dominant language (NANDA) Speaks or verbalizes with difficulty (NANDA) Difficulty expressing thought verbally (NANDA) Evidences anxiety when trying to verbalize in dominant language Too fearful or embarrassed to participate Hesitancy in sharing cultural information Regresses under stress, even if speaks the dominant language Gives responses nurse wants to hear Responding the way the client thinks the nurse would want him or her to respond Expresses perceived values of health care practitioner rather than own values and beliefs Lack of congruence between nonverbal and verbal communication Nonverbal responses not consistent with dominant culture Aberrant patterns of eye, body contact, personal space, and body language when verbalizing Nods head in agreement to questions while eyes do not reflect understanding Needs interpreter Requires use of interpreter to meet basic needs Cannot understand health cafe provider Lack of appropriate interpreter available Related factors Difference in language Difference in cultural expression
involving
TABLE
6.
is different
nonverbal
respon-
5 through
which
includes
7). Examples
sented below (Tables
different
values,
than understanding
beliefs,
customs,
verbal
and non-
Impaired Social Interaction Related to Sociocultural Dissonance (Revised)
Definition: The state in which an individual is observed to have or verbally expresses conflict in social exchange with members of the dominant culture or with members of own cultural group Defining characteristics Verbalized or observed discomfort in social situations (NANDA) Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history (NANDA) Verbalized or observed personal choice to retain traditional system(s) Clings to own people Personal choice to retain cultural ways or live away from Anglo culture Decreased verbalization as culturally appropriate response to dissonance Verbalized or observed avoidance of interaction with dominant culture Ineffective communication Nonverbal communication patterns conflict with dominant culture Subtle sense of humor either not perceived or understood by others Caretaker misreads data Reaction to altered cultural environment Perception of inhospitable environment Family discord related to various levels of enculturation within one group Related factors Relocation or dislocation from cultural group Fear of expressing cultural beliefs Level of enculturation Unacceptable behavior
ELAINE M. GEISSLER
TABLE
7. Noncompliance/Nonadherence Related to Patient Value System (Revised)
Definition: A value conflict in which a person uses own rules of compliance (adherence) that differ from the dominant culture. Defining characteristics Behavior indicative of failure to adhere (NANDA) Failure to keep appointments (NANDA) Verbalized or observed personal choice to retain traditional system(s) Evidence of use of traditional cultural healers, medicines, or health rituals instead of prescribed therapeutic regimen Expressed disagreement with suggested treatment, eg, it is unnecessary, ineffective, or conflicts with folk beliefs and practices Limited interaction with dominant health care system Farlure to ask for assistance of health care workers Delay in health care-seeking behaviors Distrust of the western medical model Denies noncompliance Denial of noncompliance Gives impression of agreement but does not adhere Incompatibility between patient and provider cultures Use of both traditional and nontraditional health practices Verbalizes incompatibility Views time with varying degrees of importance Inappropriate application of information Behavior indicative of lack of understanding of treatment Inappropriate application of information to own life value system Related factors Values time with varying degrees of importance Distrust of dominant medical model Fear of harm Conflicting beliefs about the cause of illness Conflicting beliefs about the cure of rllness Health values conflict with professional regimen Use of traditional medical model
verbal mannerisms
between
the caregiver
and the pa-
tient. A few nurses objected to the use of the word impaired in this diagnosis (Table 6) and preferred changing it to altered. They felt social dysfunction is relative and culturally defined and only makes sense within an identified cultural context. Skill with humor requires a high level of fluency and cultural understanding. Subtleties
of humor
are one of the very last things
learned within one’s own culture. The reason for involuntary dislocation or voluntary relocation from the patient’s original cuitural group emerged as a critical factor for social interaction. It must be identified to differentiate between political refugees and immigrants or migrants with or without immediate access to family and cultural support systems. In the same way, unacceptable behavior must be identified as unacceptable to the patient’s own cultural group, to the dominant culture, or to both. Enculturation refers to the process by which indi-
viduals
learn
their
risk of losing
group’s
culture.
their cultural
identity
school contacts
with the dominant
with members
at a variety
public Families
of levels of enculturation
adoption
and social patterns
of the dominant
for a diagnosis
are at
through culture.
and acculturation-the didates
Children
of the cultural
of altered
group--are family
traits can-
social inter-
action. Inclusion definition nition
of “an informed presented
choice” in the NANDA
a major problem
for noncompliance
(Table
gued the ethics of people being want when
it is an informed
with
the defi-
7). Respondents
ar-
able to do what they choice.
They
preferred
term nonadherence over noncompli-
the less value-laden ance.
The original
NANDA-related
factors are so broad
that it would be close to impossible to plan care around them. The newly suggested related factors are somewhat
more specific for the culturally
diverse pa-
tient’s etiology, and each should result in a different set of nursing interventions. For example, some patients seem to disappear
from medical
care for periods
of time, but they may have returned to folk healers because of dissatisfaction with the results of western medical care. Or, they may be using both western and folk systems simultaneously. Determination of relevant related factors requires more assertive assessment than is typically found that despite
practiced. a lengthy
Mexican-American
subjects
Shellenberger ( 1988) interview schedule, her failed
to tell her about
folk remedies they used. She realized the data were missing and returned to her subjects to ask why. They said that
they
never
thought
that
an Anglo
nurse
would be interested in hearing about them. Stereotypes work both ways, and members of the AngloSaxon culture are stereotyped as only being interested in scientific western medicine.
Conclusion The suggestions nursing
offered by experts
for strengthening
in transcultural
these diagnoses
when they
are applied to a cultural etiology are reported here so that others may build on them. Problems with the new suggestions must be resolved before they are used in clinical practice with culturally diverse patients. For example, the defining characteristic, verbalized or observed choice to retain traditional system(s), is not mutually exclusive to just one diagnosis and may not be a defining characteristic at all, but it holds potential for development as a nursing diagnosis. The suggestions from which the defining characteristic of in-
307
CULTURAL RELEVANCE OF NURSING DIAGNOSES
effective communication problem
ethnocentrically
not the patient. were achieved. elements
evolved can be perceived
within
three diagnoses
The
located initial
The cultural
within
purposes adequacy
the current
NANDA
was identified
more selective
in their
use in their
diverse
patients. experts
the nurse,
of this study or inadequacy
future research to expand culturally
relevant
defining
the now limited characteristics
number
of
and related
factors.
of
data for these
Acknowledgment
so that nurses may be
with culturally
fered by transcultural
as a
clinical
practice
The suggestions form a data
of-
base for
The author wishes to express gratitude to Marga Coler, EdD, CS, CTN, RN, for her assistance with the content analysis conducted during this study.
References Fehring, R. (1986). Validating diagnostic labels: Standardized methodology. In M. Hurley (Ed.), Classification of nursing diagnosis: St. Louis: Mosby.
Proceedings
of the sixth conference.
Geissler, E. M. (199 1). Transcultural nursing ing diagnoses. Nursing & H&th Care, 12(4), 203.
and nurs190-192,
Gordon, M., & Sweeney, M. A. (1979). Methodological problems and issues in identifying and standardizing nursing diagnoses. Advances in Nursing Science, 2(l), l- 15. Jenny, J. (1989). Classifying nursing diagnoses: A selfcare approach. Nursing & Health Care, 10(2), 83-88. Leininger, cerns related
M. M. (1990). Issues, questions, and conto the nursing diagnosis cultural movement
from a transcultural nursing perspective. Journal of Transcultwal Nursing, 2(l), 23-32. Levin, R. F., Krainovitch, B. C., Bahrenburg, E., & Mitchell, C. A. (1989). Diagnostic content validity of nursing diagnoses. Image, 21 (l), 40-44. North American Nursing Diagnosis Association. (1989). Taxonomy revised 1989-With officiar diagnostic urtego&s. St. Louis: Author. Shellenberger, J. M. (1988). A practice model for culturally appropriate nursing care in a primary health care setting for Mexican-American persons (Doctoral dissertation, University of Texas at Austin, 1987). Dissertation Abstracts International. 49, 695B. Vincent, K. G. (1985). The validation of a nursing diagnosis. Nursing Clinics of North America, 20(4), 632-640.
This study examines the adequacy/inadequacy of three nursing diagnoses with cuttural etiologies: (1) impaired verbal communlcatlon related to cultural differences; (2) impaired social interaction related to sociocultural dissonance; and (3) noncompliance related to patient value system. The research tool was admlnistered to the membership of the American Nurses Association Council on Cultural Diversity and the International Transcultural Nursing Society, with a response rate of N = 248 (42.2 per cent) from 43 states, the District of Columbia, and seven foreign countries. The tool Ilsted the North American Nursing Diagnosls Association (NANDA) defining characteristics and cuftural etiology for each diagnosis rated on a flve-point Llkert scale from “nearly always present” to “rarely present.” The subjects also wrote and ranked other defining characteristics they used to make the diagnosis in clinical practice. Percentage distribution results indicate no definlng characterlstlc meets the NANDA criteria for a major or mlnor defining characteristic. By collapsing categories, seven were acceptable only as minor defining characteristics. Respondents’ 113 suggestions for additional characterlstlcs were content analyzed. Themes for 12 categories were intuited and added to the lists. Based on respondents’ suggestlons, the definitions for each diagnosis were reworked, and new cultural-related factors were added. The cuRural adequacy/inadequacy of elements within these three dlagnoses was identified and provides the opportunity for greater selectivity in their clinical use. Additional suggestions from transcuftural nursing experts form a data base for future research to expand the use of the currently limited components of NANDA diagnoses wlth culturally diverse patients. (Index words: Cultural etiologies; North American Nursing Diagnosis Association; Nursing diagnoses; Transcultural nursing, inadequacy of) J Prof Nurs 8:301-307, 1992. Copyright 0 1992 by W.6. Saunders Company
T
HERE HAS BEEN little impact of the rapidly evolving transcultural nursing knowledge and
practice
base on the content
best, the Diagnosis
of nursing
1989 list of the North Association (NANDA)
diagnoses.
of Professsionul Nursing,
a few cultural
cultural
factors
that
defining
appear
related
to a given
nurses
have three options.
new taxonomy. as one that, ceptual
characteristics
to be antecedent
nursing
diagnosis.
and to or
It appears
that
The first is to develop
a
Jenny (1989) defines a good taxonomy
in addition
proves communication gaps,
to clarifying between
indicates
retrieval”
analysis
Jenny
techniques,
ally related categories
concepts,
nurses,
con-
and im-
(p. 83). Using
identified
“im-
identifies
needs for research,
proves information
concept
seven conceptu-
based on Orem’s self-care deli-
tits. She suggests that her new categories of health protection and health restoration are heavily influenced by cultural patterns and resources. Ignoring the cultural needs of patients the inadequacy
of the current
unfortunately,
a second
patients cultural
NANDA
option
because diagnoses
for nurses
caring
experiencing cultural needs. “Many nursing individuals are so frustrated
of is, for
transwith
NANDA’s list that they want to throw out the baby too,” wrote one respondant in this study. Leininger (1990) believes that “the NANDA diagnostic classificatory system needs to be reevaluated, reconsidered and refocused into transculturally relevant, meaningful, and useful transcultural perspectives” (p. 24). The study described here represents the third option: nated
(a) working
NANDA
the cultural
within
classification
adequacy
the widely
system
or inadequacy
dissemi-
by examining of the current
defining characteristics for three nursing diagnoses; (b) offering expert suggestions for more culturally relevant defining characteristics; and (c) refining and expanding the current diagnostic definitions and related factors for further research and validation when they are applied
At
to cultural
etiologies. Methods
American Nursing nursing diagnoses
*Associate Professor of Nursing, University of Connecticut, Stow. Address correspondence and reprint requests to Dr Geissler: 20 Stone Pond, Tolland, CT 06084. Copyright 0 1992 by W.B. Saunders Company 0883-7223/92/0805-0011$03.00/0
Journal
contains
RESEARCHDESIGN Levin, Krainovitch, Bahrenburg, and Mitchell (1989) used the nurse-consensus quantitative research approach of Gordon and Sweeney (1979) and Fehring (1986) to determine the diagnostic content validity of six of the most frequently used nursing diagnoses to
Vol 8, No 5 (September-October),
1992: pp 301-307
301
ELAINE M. GEISSLER
302
determine
confidence
Each defining Likert-type
characteristic defining
fied by NANDA. Likert-type
characteristics
Vincent
However,
ended question,
allowing
used in making Vincent’s for this study
and
cent) in transcultural
characteris-
fice Coupon-Response
of ineffective
individ-
included
an open-
of clinical
spe-
to write in other criteria
they
in clinical
handling
and one
it allowed
for the write-in
of
perceived by transcultural nursing for culturally diverse patients. It
also identified the gaps and needs for research advocated by Jenny while providing statistical data on the usefulness
of the existing
NANDA
obtain
defining
and
nursing.
and
1 17 (47.8
A prepaid
International of their respective
per
US Post Of-
was included
packet so that foreign respondents
the postage
110
in
could
countries
with-
out charge. INSTRUMENT
Gordon
new characteristics experts as critical
of the
each non-US
patients,
Formal educational
that 148 (48.2 per cent) had one
practice.
model was the more appropriate because
indicated
or more courses in anthropology
a five-point
this diagnosis
(1985)
Sweeney (1979)
experience
and
her sample
diverse
already identi-
the defining
Vincent
cialists the opportunity
with culturally
per cent) had domestic
(44.9 per cent) had served abroad.
model
diagnosis
204 (83.3
only those ma-
used Gordon
scale to validate
ual coping.
In addition,
(1985)
nurse-validation
tics for the NANDA
cent).
experience
was rated on a five-point
scale. The study included
jor and minor Sweeney’s
levels in their use in practice.
charac-
teristics. The Gordon and Sweeney procedure “involves tabulating which defining characteristics listed for a diagnosis are present when the diagnosis is made in clinical practice” (p. 8). This nurse-consensus model can be used retrospectively based on the nurse remembering clinical encounters with patients and on the nurse’s accrued nursing knowledge. “The advantage of the retrospective model is the feasibility of sample of nurses” obtaining a large, representative
A five-point
rating scale with an alpha coefficient
.74 was developed defining
by Vincent
characteristics
(1985)
to validate
of the NANDA
nursing
of the
diag-
nosis labeled ineffective coping (individual). The author’s permission was secured to modify her instrument.
The NANDA
nursing
diagnosis,
the existing
NANDA etiology relating specifically to culture, and the NANDA defining characteristics were listed. Subjects
were asked to retrospectively
rate each defin-
ing characteristic as “nearly always present” (in 80 per cent to 100 per cent of clients), “frequently present” (60 per cent to 79 per cent), “sometimes present” (40 per cent to 59 per cent), “seldom present” (20 per cent to 39 per cent), and “rarely present” (0 per cent to 19 per cent). The “other” item on the list asked the respondent to write in and rate any other behaviors exhibited under each diagnosis.
(p. 7). RESEARCH
QUESTIONS
SAMPLE
1. Which The membership
lists of the International
Trans-
cultural Nursing Society and the American Nurses Association Council on Cultural Diversity in Nursing Practice comprised the sample. Because a subject could hold membership in both organizations, duplicate names on one list were eliminated resulting in 580 potential subjects. The response rate was N = 245 (42.2 per cent), corrected to 46.1 per cent by eliminating from the total the questionnaires that could not be delivered by mail. Responses were received from 43 states and the District of Columbia, and 16 responses from seven foreign countries (Canada, Philippines, Sweden, Pakistan, Saudi Arabia, Israel, and Malawi) are included in the sample. Respondents’ job titles were grouped as educators in either academic or service positions (148 or 53.9 per cent), practitioners (8 1 or 37.0 per cent), students (11 or 5.0 per cent), retired or not working in nursing (4 or 1.8 per cent), and unable to classify (5 or 2.3 per
of the
current
NANDA
defining
characteristics identify the culturally relevant behaviors in the selected nursing diagnoses: a. impaired verbal communication related to cultural differences, b. impaired social interaction related ciocultural dissonance, and c. noncompliance related to patient
to sovalue
system. 2. What additions are needed in the diagnostic definition, defining characteristics, and related factors to identify patients’ culturally relevant problems and needs?
Results ANALYSIS
OF CURRENT
DEFINING CHARACTERISTICS
According to NANDA policy a defining characteristic is major if it is present 80 per cent to 100 per
CULTURALRELEVANCE OF NURSINGDIAGNOSES
cent of the time and minor
if it is present
to 79 per cent of the time under The first diagnosis
reported
when it is specifically
differences.
The NANDA
is, “The state decreased guage
in human
com-
to cultural
experiences
to use or understand
interaction”
(NANDA,
of the
The second dissonance.
a
lan-
1989, p.
49).
of the
current official nursing diagnoses reflects the inability to respond to cultural needs of patients.
1 fit the
NANDA criteria for either major or minor defining characteristics. When the categories “nearly always present” and “frequently present” are collapsed, defining characteristics numbers 1, 2, and 5 meet the criteria of a minor defining characteristic for the diagnosis when it is related to cultural differences and restricted dominant
to the patient being unable to speak the (nurses’) language. The remaining defining
characteristics, ceptable. entation,
numbers
Number support
characteristic
TABLE 1.
3, 4, 6, 7, and 8, are unac-
7, dyspnea, and number 8, disorian argument for exclusion of this
for use with culturally
diverse patients
Impaired Verbal Communication
diagnosis
when
of social exchange”
“rarely
studied
to sociocultural
definition
for this diagnosis
under impaired
dissonance.
None
official
to respond
of the defining
social interaction
for inclusion
characteristics
categories
1989,p. 50).
also reflects the inability
criteria
in an quality
of the current
needs of patients.
the NANDA minor
participates
or ineffective
(NANDA,
characteristics
cultural
is impaired
it is related
2 the inadequacy
diagnoses
meet
as either
major or
when they are related
to socio-
When
are collapsed
data from
for numbers
the first
noncompliance,
when
two
1 and 2, they are
acceptable as minor defining characteristics. The same result is obtained in the third diagnosis,
in Table
nursing
or excessive quantity
to cultural
None of the response percentages
under
is, “The state in which an individual insufficient
nursing
the inadequacy
percentages
The NANDA
In Table
Ia.
high
social interaction
for this diagnosis
an individual
ability
verbal
because present. ”
diagnosis.
related
definition
in which
or absent
50 per cent
a given
is impaired
munication
303
it is related
nursing to the
patients’ value systems. Respondents’ negative reactions to this particular diagnosis and its definition are reported elsewhere (Geissler, in press) NANDA defines this nursing diagnosis as, “A person’s informed decision not to adhere to a therapeutic recommendation” (NANDA, 1989,p. 67). Numbers 1 and 5 collapse into acceptable minor defining characteristics when related to patients’ value systems.
Because the number
ond defining
characteristic,
of responses objective
to the sec-
tests,
was low
(N = 155), the data were not used. Many respondents indicated that they did not understand the characteristic
and did not respond.
Higher
percents
are
Related to Cultural Differences
Nearly Always Present
(Collapsed Percent)
Frequently Present
Sometimes Present
Unable to speak dominant language
22.8
66.1
43.3
23.7
4.5
5.8
Speaks or verbalizes with difficulty
20.4
65.3
44.9
24.0
4.9
5.8
Does not or cannot speak
6.7
5.4
18.4
26.5
43.1
Stuttering, slurring, difficulty forming words or sentences
4.1
11.4
20.0
26.4
38.2
38.4
27.7
8.9
8.5 18.9
Official NANDA Behaviors
Difficulty expressing thought verbally
16.5
54.9
Seldom Present
(Collapsed Percent)
Rarely Present
Inappropriate verbalization
6.0
20.7
37.8
16.6
Dyspnea
0.5
4.5
8.5
26.0
86.5
60.5
Disorientation
0.9
5.4
17.9
25.9
75.9
50.0
ELAINE M. GEISSLER
304 TABLE
2.
Impaired
Social
Interaction
Official NANDA Behaviors Verbalized or observed situations
discomfort
Related
Dysfunctional interaction and/or others
Dissonance Frequently Present
Nearly Always Present
[Collapsed Percent)
Sometimes Present
Seldom Present
Rarely Present
29.5
65.6
36
1
23 3
71
40
22.9
58 3
35 4
26 9
94
54
77
33 0
38 5
11 8
91
59
158
32.4
27 0
189
in social
Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history Observed use of unsuccessful interaction behaviors
to Sociocultural
social
with peers, family,
recorded in Table 3 under the center point of the scale, “sometimes present, ” rather than with the other two diagnoses. The NANDA results for the first research question-which of the current NANDA defining char-
were 22, and for the third diagnosis,
noncompliance,
there were 43. Because the instrument design fixed the write-ins within the rating scale for each diagno-
acteristics identify the culturally relevant behaviors for the selected nursing diagnoses?-are summarized
sis, researcher subjectivity was partially controlled for relating the message to the characteristics of the prespecified diagnosis. Themes were sorted into similar content categories, and titles for the categories were
in Table 4. Because the NANDA percentage criteria for inclusion of a diagnostic behavior are stringent,
intuited and became the new defining characteristic. A second certified transcultural nurse repeated the
the percentages
content
were lowered for the remainder
of this
study. Subsequent inclusion of new suggestions as a major defining characteristic was set at or above 50 per cent and as a minor defining characteristic between 25 per cent and 49 per cent.
analysis
process,
Discussion
113 new defining
characteristics written by respondents were content analyzed. For the first diagnosis, impaired verbal communication, 48 additions were submitted; for the impaired social interaction, there second diagnosis, TABLE
3.
Noncompliance
Related
Official NANDA Behaviors Behavior indicative Objective
of failure to adhere
tests*
Evidence of development complications
of
Evidence of exacerbation
of symptoms
Failure to keep appointments Failure to progress “Not included
in study.
synthesized
related factors based on the specific suggestions from the respondents were incorporated into the revisions.
CULTURAL ADDITIONS TO NURSING DIAGNOSES
In the second step of this study,
and the results
the work of both researchers. Changes, additions, and deletions in the definitions of the diagnoses and in the
to Patient
The defining characteristics meeting the NANDA criteria that the transcultural nurses in the sample considered present in their culturally diverse patients, the NANDA
Value System
defining
(Health
Beliefs,
characteristics Cultural
based
on less
Influences)
Nearly Always Present
(Collapsed Percent)
Frequently Present
Sometimes Present
Seldom Present
Rarely Present
21 7
67 4
45.7
25 3
63
09
5.7
32 3
38 2
158
70
38
29 7
50.0
137
28
7.0
31 9
46 0
103
47
47 0
28.8
9!
23
35.9
42.6
1’ 5
4.8
12.8 5.3
59.8
CULTURAL RELEVANCE OF NURSING DIAGNOSES
TABLE
4.
305
Acceptable Defining Characteristics Based on NANDA Criteria
bal communication fluent
Impaired verbal communication related to cultural differences Unable to speak dominant language Speaks or verbalized with difficulty Difficulty expressing thought verbally Impaired social interaction related to sociocultural dissonance Verbalized or observed discomfort in social situations Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history Noncompliance related to patient value system Behavior indicative of failure to adhere Failure to keep appointments
criteria,
and the new suggestions
are pre-
when
in their own languages
ability
to communicate
NANDA
defining
iological
both
understanding,
verbally.
characteristics
within
variance.
They
the context
cultural
which
are
of cultural-language exclusively
yet the nonverbal
are critical to mutual
may have nothing
pathophys-
and inappropriately
differences,
every culture
existing
to speak,
are now directed
verbal communication
not the
The
address
causes of the inability
irrelevant
are adequately
(Table 5). The problem
is one of the barriers to mutual
inant stringent
skills
toward related
to
expressions
understanding
to do with knowledge
of and
of the dom-
language.
Cultural
expression
communi-
cation,
dents gave of clinical behaviors their patients are indented after the newly added defining
exhibit charac-
language. Several respondants advised that the related factors be separated into differences in language and differences in cultural expression. Differences in language refer to language barriers alone, and differences in cultural expression are a much broader etiology
teristics. The diagnostic definitions have been reworded and related factors added to reflect the suggestions offered. Neither nurse nor patient TABLE 5.
experience
impaired
ver-
Impaired Verbal Communication Related to Cultural Differences (Revised)
Definition: The state in which an individual is unable to speak and understand the dominant language of the health care delivery system when the barrier is not secondary to physical or psychological disorders Defining characteristics Unable to speak dominant language (NANDA) Speaks or verbalizes with difficulty (NANDA) Difficulty expressing thought verbally (NANDA) Evidences anxiety when trying to verbalize in dominant language Too fearful or embarrassed to participate Hesitancy in sharing cultural information Regresses under stress, even if speaks the dominant language Gives responses nurse wants to hear Responding the way the client thinks the nurse would want him or her to respond Expresses perceived values of health care practitioner rather than own values and beliefs Lack of congruence between nonverbal and verbal communication Nonverbal responses not consistent with dominant culture Aberrant patterns of eye, body contact, personal space, and body language when verbalizing Nods head in agreement to questions while eyes do not reflect understanding Needs interpreter Requires use of interpreter to meet basic needs Cannot understand health cafe provider Lack of appropriate interpreter available Related factors Difference in language Difference in cultural expression
involving
TABLE
6.
is different
nonverbal
respon-
5 through
which
includes
7). Examples
sented below (Tables
different
values,
than understanding
beliefs,
customs,
verbal
and non-
Impaired Social Interaction Related to Sociocultural Dissonance (Revised)
Definition: The state in which an individual is observed to have or verbally expresses conflict in social exchange with members of the dominant culture or with members of own cultural group Defining characteristics Verbalized or observed discomfort in social situations (NANDA) Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history (NANDA) Verbalized or observed personal choice to retain traditional system(s) Clings to own people Personal choice to retain cultural ways or live away from Anglo culture Decreased verbalization as culturally appropriate response to dissonance Verbalized or observed avoidance of interaction with dominant culture Ineffective communication Nonverbal communication patterns conflict with dominant culture Subtle sense of humor either not perceived or understood by others Caretaker misreads data Reaction to altered cultural environment Perception of inhospitable environment Family discord related to various levels of enculturation within one group Related factors Relocation or dislocation from cultural group Fear of expressing cultural beliefs Level of enculturation Unacceptable behavior
ELAINE M. GEISSLER
TABLE
7. Noncompliance/Nonadherence Related to Patient Value System (Revised)
Definition: A value conflict in which a person uses own rules of compliance (adherence) that differ from the dominant culture. Defining characteristics Behavior indicative of failure to adhere (NANDA) Failure to keep appointments (NANDA) Verbalized or observed personal choice to retain traditional system(s) Evidence of use of traditional cultural healers, medicines, or health rituals instead of prescribed therapeutic regimen Expressed disagreement with suggested treatment, eg, it is unnecessary, ineffective, or conflicts with folk beliefs and practices Limited interaction with dominant health care system Farlure to ask for assistance of health care workers Delay in health care-seeking behaviors Distrust of the western medical model Denies noncompliance Denial of noncompliance Gives impression of agreement but does not adhere Incompatibility between patient and provider cultures Use of both traditional and nontraditional health practices Verbalizes incompatibility Views time with varying degrees of importance Inappropriate application of information Behavior indicative of lack of understanding of treatment Inappropriate application of information to own life value system Related factors Values time with varying degrees of importance Distrust of dominant medical model Fear of harm Conflicting beliefs about the cause of illness Conflicting beliefs about the cure of rllness Health values conflict with professional regimen Use of traditional medical model
verbal mannerisms
between
the caregiver
and the pa-
tient. A few nurses objected to the use of the word impaired in this diagnosis (Table 6) and preferred changing it to altered. They felt social dysfunction is relative and culturally defined and only makes sense within an identified cultural context. Skill with humor requires a high level of fluency and cultural understanding. Subtleties
of humor
are one of the very last things
learned within one’s own culture. The reason for involuntary dislocation or voluntary relocation from the patient’s original cuitural group emerged as a critical factor for social interaction. It must be identified to differentiate between political refugees and immigrants or migrants with or without immediate access to family and cultural support systems. In the same way, unacceptable behavior must be identified as unacceptable to the patient’s own cultural group, to the dominant culture, or to both. Enculturation refers to the process by which indi-
viduals
learn
their
risk of losing
group’s
culture.
their cultural
identity
school contacts
with the dominant
with members
at a variety
public Families
of levels of enculturation
adoption
and social patterns
of the dominant
for a diagnosis
are at
through culture.
and acculturation-the didates
Children
of the cultural
of altered
group--are family
traits can-
social inter-
action. Inclusion definition nition
of “an informed presented
choice” in the NANDA
a major problem
for noncompliance
(Table
gued the ethics of people being want when
it is an informed
with
the defi-
7). Respondents
ar-
able to do what they choice.
They
preferred
term nonadherence over noncompli-
the less value-laden ance.
The original
NANDA-related
factors are so broad
that it would be close to impossible to plan care around them. The newly suggested related factors are somewhat
more specific for the culturally
diverse pa-
tient’s etiology, and each should result in a different set of nursing interventions. For example, some patients seem to disappear
from medical
care for periods
of time, but they may have returned to folk healers because of dissatisfaction with the results of western medical care. Or, they may be using both western and folk systems simultaneously. Determination of relevant related factors requires more assertive assessment than is typically found that despite
practiced. a lengthy
Mexican-American
subjects
Shellenberger ( 1988) interview schedule, her failed
to tell her about
folk remedies they used. She realized the data were missing and returned to her subjects to ask why. They said that
they
never
thought
that
an Anglo
nurse
would be interested in hearing about them. Stereotypes work both ways, and members of the AngloSaxon culture are stereotyped as only being interested in scientific western medicine.
Conclusion The suggestions nursing
offered by experts
for strengthening
in transcultural
these diagnoses
when they
are applied to a cultural etiology are reported here so that others may build on them. Problems with the new suggestions must be resolved before they are used in clinical practice with culturally diverse patients. For example, the defining characteristic, verbalized or observed choice to retain traditional system(s), is not mutually exclusive to just one diagnosis and may not be a defining characteristic at all, but it holds potential for development as a nursing diagnosis. The suggestions from which the defining characteristic of in-
307
CULTURAL RELEVANCE OF NURSING DIAGNOSES
effective communication problem
ethnocentrically
not the patient. were achieved. elements
evolved can be perceived
within
three diagnoses
The
located initial
The cultural
within
purposes adequacy
the current
NANDA
was identified
more selective
in their
use in their
diverse
patients. experts
the nurse,
of this study or inadequacy
future research to expand culturally
relevant
defining
the now limited characteristics
number
of
and related
factors.
of
data for these
Acknowledgment
so that nurses may be
with culturally
fered by transcultural
as a
clinical
practice
The suggestions form a data
of-
base for
The author wishes to express gratitude to Marga Coler, EdD, CS, CTN, RN, for her assistance with the content analysis conducted during this study.
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Gordon, M., & Sweeney, M. A. (1979). Methodological problems and issues in identifying and standardizing nursing diagnoses. Advances in Nursing Science, 2(l), l- 15. Jenny, J. (1989). Classifying nursing diagnoses: A selfcare approach. Nursing & Health Care, 10(2), 83-88. Leininger, cerns related
M. M. (1990). Issues, questions, and conto the nursing diagnosis cultural movement
from a transcultural nursing perspective. Journal of Transcultwal Nursing, 2(l), 23-32. Levin, R. F., Krainovitch, B. C., Bahrenburg, E., & Mitchell, C. A. (1989). Diagnostic content validity of nursing diagnoses. Image, 21 (l), 40-44. North American Nursing Diagnosis Association. (1989). Taxonomy revised 1989-With officiar diagnostic urtego&s. St. Louis: Author. Shellenberger, J. M. (1988). A practice model for culturally appropriate nursing care in a primary health care setting for Mexican-American persons (Doctoral dissertation, University of Texas at Austin, 1987). Dissertation Abstracts International. 49, 695B. Vincent, K. G. (1985). The validation of a nursing diagnosis. Nursing Clinics of North America, 20(4), 632-640.
