Healthcare practitioners have a wide range of theoretical models to draw on in formulating clinical interventions, and nurses in particular have numerous grand theories that can help guide their practice in challenging settings. In an increasingly multicultural environment, a growing number of nursing theorists have also identified the need to deliver healthcare services that are transcultural in nature. In this regard, practitioners such as Madeleine Leininger advocate a transcultural nursing paradigm that provides nurses with a flexible framework in which to evaluate what may be different or similar among patients with respect to their special care needs and concerns. This paper presents a review of the relevant literature concerning a nursing leadership philosophy in general and the role that transcultural nursing, mentoring and the level of support provided by older colleagues can play in promoting improved healthcare outcomes and employee satisfaction in particular. A summary of the research and important findings are presented in the conclusion.
Review and Discussion
While every healthcare setting is unique and the leadership attributes that are needed to guide it through challenging times differs from place to place, one of the overarching elements of effective nursing leadership is the ability to accommodate the needs of different people, an element that may require an investment of personal time and effort outside the healthcare venue. For instance, the ability to accommodate people from different cultures in healthcare setting in culturally sensitive ways frequently requires the delivery of health related information in the language of specific cultural groups (Daley, Speedy, Jackson, Lambert & Lambert, 2005), a need that can reasonably be expected to require ongoing educational support and the investment of time and effort to achieve and sustain the requisite fluency in different languages demanded by changes in employment setting or clientele. In addition, healthcare practitioners must possess a wide range of knowledge that comprise a skill set concerning the cultural and religious aspects of their patients that involve significant life events such as birth or death, which also represent significant transcultural knowledge that needs to be known and understood by nurses and other healthcare practitioners and accommodated to the extent practicable and appropriate when formulating clinical interventions (Daly et al., 2005).
Because the United States and many other industrialized nations are becoming increasingly multicultural in demographic makeup, developing the skill set needed to respond to this diverse client base clearly requires a personal commitment, but the need is clear. In this regard, Madeleine Leininger wrote that, "Transcultural nursing is a growing and highly relevant area of study and practice today that has great relevance for nurses living and functioning in a multicultural world" (p. 37). Transcultural nursing frequently involves taking into account the different ways that other people have of knowing the world around them in ways that can facilitate treating people from diverse cultural backgrounds (Leininger & McFarland, 2002).
Transcultural nursing provides the framework needed that can allow nurses to think about what may be different or similar among people with regard to their special care needs and concerns (Daly et al., 2005). According to Daly and his colleagues, "As nurses discover the client's particular cultural beliefs and values, through research, they learn ways to provide culturally sensitive, compassionate, and competent care that is satisfying and meaningful to the client and congruent with their lifeway practices" (p. 308). In this context, values are considered to be standards that have eminent worth, meaning, and importance in individuals' lives that guide behavior (Leininger, 1995). Such culture values comprise the "powerful directive forces that give order and meaning to people's thinking, decisions, and actions" (Leininger, 1995, p. 37). In this regard, Jeffreys (2006) emphasizes that, "Culture values guide thinking, decisions, and actions within the student and/or nurse role, as well as other in aspects of their lives. Students, nurses, and other health professionals also hold numerous beliefs (ideas, convictions, philosophical opinions, or tenets) that are accepted as true without requiring evidence or proof" (p. 14). Unfortunately, in many cases, beliefs are frequently accepted as being truths without further analysis or reflection (Jeffreys, 2006). According to Daly et al., "This process of discovery of cultural knowledge, in addition to enabling nurses to develop deep understanding and appreciation for cultures, will allow nurses to develop insights about their own cultural background (self-awareness) and how to use such knowledge appropriately with clients, families, communities, and health care services" (2005, p. 309).
In 1991, Leininger presented her "Theory of Culture Care Diversity and Universality" that set forth the primary constructs of culture and care that included describing, explaining, and predicting nursing similarities and differences in ways that helped inform care and caring in human cultures. According to Daly et al. (2005), "Leininger used world view, social structure, language, ethnohistory, environmental context, and the generic (folk) and professional systems to provide a comprehensive and holistic view of influences in culture care and well-being" (p. 309). The three modes of nursing decisions and actions (culture care preservation and/or maintenance, culture care accommodation and/or negotiation, and culture care repatterning and/or restructuring) explicated by Leininger and others describe the different ways that nurses can provide culturally congruent or culturally competent care depending on the clinical setting and practitioner capabilities (Leininger, 1991; Leininger & McFarland, 2002; Daly et al., 2005). These capabilities, of course, will differ from place to place and time to place, making the leadership attributes that are best suited to facilitate the delivery of high quality healthcare services a dynamic process but the mandate is clear. Nursing leaders must take the initiative in identifying resources within the existing human resources that can be shared among colleagues. For instance, Wilson and Sanner (2010) emphasize that, "Currently 30% of those seen in health care settings are of diverse ethnicity, yet only 12% of the current nursing workforce is diverse" (p. 145). Less convincing is the assertion by Wilson and Sanner that, "It is estimated that by 2020, nearly one-half of the population of the U.S. will be a mixture of various ethnic groups. Therefore, the challenge for nursing and health care providers is to prepare a workforce that mirrors the faces and values of those who seek care" (p. 145). This assertion suggests that it is only possible to provide high-quality healthcare services in a culturally diverse setting by creating a one-to-one representation in the nursing workforce for every geographical setting which may not be feasible. Transcultural nursing concepts, though, provide practitioners with a nursing philosophy that includes the domain of knowledge that is needed to guide transcultural nursing practice in a wide range of settings (Leininger & McFarland, 2002). Properly understood and applied, transcultural nursing as explicated by Leininger and others can help facilitate the delivery of high-quality healthcare services provided practitioners make the effort to understand the different cultures they routinely encounter in the workplace. This investment of personal time and effort can help avoid ethnocentristic approaches that can adversely affect the therapeutic relationship. For instance, Leininger and McFarland report that, "Cultural imposition practices, which often stem from cultural ignorance, cultural blindness, ethnocentrism, and biases, remain a major and unrecognized problem in nursing. Cultural imposition is defined as the tendency of an individual or group to impose their beliefs, values, and patterns of behaviour upon another culture for varied reasons" (Leininger & McFarland, 2002, p. 37). Leininger and others state that cultural imposition practices between nurses and clients can be witnessed in healthcare settings wherein nurses believe their views are "the right, best, and most therapeutic professional ways, and that the client's views are strange, bizarre, and not desirable for their health" (Leininger & McFarland, 2002, p. 37).
Based on a review of the literature and previous studies of self-efficacy and its effect on transcultural nursing, Jeffreys (2006) concluded that:
1. The learning of transcultural nursing skills is influenced by self-efficacy perceptions (confidence);
2. The performance of transcultural nursing skill competencies is directly influenced by the adequate learning of such skills and by transcultural self-efficacy perceptions;
3. The performance of culturally congruent nursing skills is influenced by self-efficacy perceptions and by formalized educational exposure to transcultural nursing care concepts and skills throughout the educational experience;
4. All students and nurses (irrespective of age, ethnicity, gender, sexual orientation, lifestyle, religion, socioeconomic status, geographic location, or race) require formalized educational experiences to meet culture care needs of diverse individuals;
5. The most comprehensive learning involves the integration of cognitive, practical, and affective dimensions;
6. Learning in the cognitive, practical, and affective dimensions is paradoxically distinct yet interrelated;
7. Learners are most confident about their attitudes (affective dimension) and least confident about their transcultural nursing knowledge (cognitive dimension);
8. Novice learners will have lower self-efficacy perceptions than advanced learners;
9. Inefficacious individuals are at risk for decreased motivation, lack of commitment, and/or avoidance of cultural considerations when planning and implementing nursing care;
10. Supremely efficacious (overly confident) individuals are at risk for inadequate preparation in learning the transcultural nursing skills necessary to provide culturally congruent care; and,