PD HINDUJA COLLEGE OF NURSING

SEMINAR ON

“TRANSCULTURAL NURSING”

Submitted to- Submitted by-

Mrs. Savita Raut Reshma S R
Lecturer 1st Year M.sc Nursing
PD Hinduja College of Nursing PD Hinduja College of Nursing

Date of submission:29/04/2021
AIM AND OBJECTIVES
Aim: At the end of the seminar, the student will acquire knowledge regarding transcultural
nursing and implement in nursing education and practice.

Objectives: The student will:

 Define transcultural nursing
 Enumerate terminologies in transcultural nursing
 Underline the importance of transcultural nursing
 Narrate the theory of transcultural nursing
 Explain the transcultural nursing models
 Enlist the standards of transcultural nursing
 Recognises nurse’s role in providing culturally sensitive care

INTRODUCTION
Transcultural Nursing is a specialty within nursing focused on the comparative study and
analysis of different cultures and sub- cultures. Various groups are examined with respect to
their caring behaviour, nursing care, health and illness values, beliefs and patterns of
behaviour. When caring for a patient from a culture different from your own, you need to be
aware of and respect his cultural preferences and beliefs; otherwise, he may consider you
insensitive and indifferent, possibly even incompetent. But beware of assuming that all
members of any one culture act and behave in the same way; in other words, don't stereotype
people.

DEFINITION OF TRANSCULTURAL NURSING

“It is a substantive area of study and practice that focuses on the comparative cultural values
of caring, the beliefs and practices of individuals or groups of similar or different cultures”
- Madeleine Leininger, The pioneer of transcultural nursing-1995

TERMINOLOGIES IN TRANSCULTURAL NURSING

Culture
- It’s the thoughts, communications, actions, customs, beliefs, values, and institutions of
racial, ethnic, religious, or social group.
Microculture
- Microculture is a small culture group like gender, age, or religious belief.
Macro culture
- Macro culture is a large culture group like national, ethnic, or racial groups.
Subculture
-Composed of people who have distinct identity and yet are related to larger culture group.
-Shares ethnic origin or physical characteristics within larger cultural group.
-E.g.- occupational group- nurses, Societal groups- feminists.
Bicultural
-A person who has dual pattern of identification when crosses two cultures.
-E g: when a person’s father and mother from different counties, he will be influenced by
both cultures.
Diversity
-The fact or state of being different.
-Many factors account for diversity.
-E g: sex, age, ethnicity, socioeconomic status, education, religion.
-Diversity not only between two culture groups but also within cultural group.
Race
-Often used interchangeably with culture and ethnicity.
-Race should not be interpreted as being primarily biological or genetic in reference. Race
and ethnicity may be thought of in terms of social and cultural characteristics as well as
ancestry.
-E g: white/black/African/American, Indian, Chinese, Asian, Korean.
-There is not scientific merit to concept of race, whereby social meaning perceived physical
differences resulting in inequality.
-There is only one race called: human race.
Ethnicity
-It’s interchangeably used with race.
-It’s the relationship between individuals who believe that they have distinctive
characteristics that make them in a group.
-Ethnicity changes may shift over time. Migration and intermarriage show that people move
into another ethnic group.
Religion
-System of beliefs, practices, and ethical values about divine or superhuman power worshiped
as the creators and rulers of the universe.
Ethnocentrism
-It’s the belief in the superiority of one’s own culture and lifestyle.
Nationality
-It refers to the country where one has membership, which may be through birth, through
inheritance of parents or through naturalisation.
Prejudice
-It’s the preconceived judgement that is not based on sufficient knowledge. It may be
favourable or unfavourable. Unfavourable prejudices may lead to stereotyping and
discriminatory behaviour toward group of people.
Generalisations
-Statements about common cultural pattern. Generalisations may not hold true at the
individual level.
Discrimination
-Refers to differential and negative treatment of individuals on the bais of their races,
ethnicity, or gender.
Stereotyping
-Making assumption that an individual reflects all characteristics associated with being a
member in a group. Stereotyping serves barrier to communication and understanding and
propagates discriminatory behaviour.
Acculturation
-Occurs when people incorporate traits from another culture.
Assimilation
-Process by which an individual develops new cultural identity.
Cultural values
-The individual's desirable or preferred way of acting or knowing something that is sustained
over a period and which governs actions or decisions.

Culturally diverse nursing care

-An optimal mode of health care delivery; it refers to the variability of nursing approaches
needed to provide culturally appropriate care that incorporates an individual’s cultural values,
beliefs, and practices including sensitivity to the environment from which the individual
comes and to which the individual may ultimately return.
IMPORTANCE OF TRANSCULTURAL NURSING
The aim of transcultural nursing is;
 To give culturally congruent nursing care
 T provide culture specific and universal nursing care practices for the health and well-
being of people or to aid them in facing adverse human conditions, illness, or death in
culturally meaningful ways
Transcultural Nursing is a comparative study of cultures to understand similarities (culture
universal) and differences(culture-specific) across human group. Its importance lies on the
cultural changes

 There is a marked increase in the migration of people within and between countries
world-wide.
 There has been a rise in multicultural identifies, with people expecting their cultural
belief, values, and lifeways to be understood and respected by nurses and other health
care providers.
 The increased use of health care technology sometimes conflicts with cultural values
of clients.
 World-wide there are cultural conflicts, clashes, and violence that have an impact
health care as more cultures interact with one another.
 There was an increase in legal suits resulting from cultural conflict, negligence,
ignorance, and imposition of health care practices.
 There is an increase in the number of people travelling and working in many different
parts of the world.
 There has been a rise in feminism and gender issues, with new demands on health
care systems to meet the needs of woman and children
 There has been an increased demand for community and culture-based health care
services in diverse environmental contexts.

THE THEORY OF TRANSCULTURAL NURSING

Madeleine Leininger, a nurse, anthropologist , put he views on transcultural nursing in 1991
published her book culture care diversity and universality: a theory of nursing, Leininger
states that care is the essence of nursing and the dominant, distinctive , and unifying feature
of nursing. Leininger produced the sunrise model to depict her theory of cultural care
diversity and universality. This model emphasizes that the health and care are influenced by
elements of social structure and the technology, religious and philosophical factors, economic
factors, social system and culture, political and legal factors, economic factors, and
educational factors. for nurse to assist people of diverse cultures, Leininger presents three
interventional models through her ‘cultural care diversity and universality theory’ i.e.
a) Culture acre preservation and maintenance
b) Culture care accommodation, and recognition
c) Culture care restructuring and repatterning
Leininger states that her theory is the only one focussed un-equity of culture care, examining
what is universal among cultures and what varies.
This theory attempts to provide culturally congruent nursing care through “cognitively based
assistive, supportive, facilitative, or enabling acts or decisions that are mostly tailor-made to
fit with the individual, group’s, or institution’s cultural values, beliefs, and lifeways.”

Leininger’s theory’s main focus is for nursing care to fit with or have beneficial meaning and
health outcomes for people of different or similar cultural backgrounds. With these, she has
developed the Sunrise Model in a logical order to demonstrate the interrelationships of the
concepts in her theory of Culture Care Diversity and Universality.

Transcultural Nursing Theory is discussed further below,

Description
The Transcultural Nursing Theory first appeared in Leininger’s Culture Care Diversity and
Universality, published in 1991, but it was developed in the 1950s. The theory was further
developed in her book Transcultural Nursing, which was published in 1995. In the third
edition of Transcultural Nursing, published in 2002, the theory-based research and the
Transcultural theory application are explained.

Major Concepts of the Transcultural Nursing Theory

The following are the major concepts and their definitions in Madeleine Leininger’s
Transcultural Nursing Theory.

Transcultural Nursing
Transcultural nursing is defined as a learned subfield or branch of nursing that focuses upon
the comparative study and analysis of cultures concerning nursing and health-illness caring
practices, beliefs, and values to provide meaningful and efficacious nursing care services to
their cultural values and health-illness context.

Ethno-nursing
This is the study of nursing care beliefs, values, and practices as cognitively perceived and
known by a designated culture through their direct experience, beliefs, and value system
(Leininger, 1979).

Nursing
Nursing is defined as a learned humanistic and scientific profession and discipline which is
focused on human care phenomena and activities to assist, support, facilitate, or enable
individuals or groups to maintain or regain their well-being (or health) in culturally
meaningful and beneficial ways, or to help people face handicaps or death.

Professional Nursing Care (Caring)

Professional nursing care (caring) is defined as formal and cognitively learned professional
care knowledge and practice skills obtained through educational institutions that are used to
provide assistive, supportive, enabling, or facilitative acts to or for another individual or
group to improve a human health condition (or well-being), disability, lifeway, or to work
with dying clients.

Cultural Congruent (Nursing) Care

Cultural congruent (nursing) care is defined as those cognitively based assistive, supportive,
facilitative, or enabling acts or decisions that are tailor-made to fit with the individual, group,
or institutional, cultural values, beliefs, and lifeways to provide or support meaningful,
beneficial, and satisfying health care, or well-being services.

Health
It is a state of well-being that is culturally defined, valued, and practiced. It reflects
individuals’ (or groups) ‘ ability to perform their daily role activities in culturally expressed,
beneficial, and patterned lifeways.

Human Beings
Such are believed to be caring and capable of being concerned about others’ needs, well-
being, and survival. Leininger also indicates that nursing as a caring science should focus
beyond traditional nurse-patient interactions and dyads to include families, groups,
communities, total cultures, and institutions.

Society and Environment

Leininger did not define these terms; she speaks instead of worldview, social structure, and
environmental context.

Worldview
Worldview is how people look at the world, or the universe, and form a “picture or value
stance” about the world and their lives.

Cultural and Social Structure Dimensions

Cultural and social structure dimensions are defined as involving the dynamic patterns and
features of interrelated structural and organizational factors of a particular culture (subculture
or society) which includes religious, kinship (social), political (and legal), economic,
educational, technological, and cultural values, ethnohistorical factors, and how these factors
may be interrelated and function to influence human behavior in different environmental
contexts.

Environmental Context
Environmental context is the totality of an event, situation, or particular experience that gives
meaning to human expressions, interpretations, and social interactions in particular physical,
ecological, socio-political, and/or cultural settings.

Culture
Culture is learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular
group that guides their thinking, decisions, and actions in patterned ways.

Culture Care
Culture care is defined as the subjectively and objectively learned and transmitted values,
beliefs, and patterned lifeways that assist, support, facilitate, or enable another individual or
group to maintain their well-being, health, improve their human condition lifeway, or deal
with illness, handicaps or death.

Culture Care Diversity

Culture care diversity indicates the variabilities and/or differences in meanings, patterns,
values, lifeways, or symbols of care within or between collectives related to assistive,
supportive, or enabling human care expressions.

Culture Care Universality

Culture care universality indicates the common, similar, or dominant uniform care meanings,
patterns, values, lifeways, or symbols manifest among many cultures and reflect assistive,
supportive, facilitative, or enabling ways to help people. (Leininger, 1991)

Sub-concepts
The following are the sub-concepts of the Transcultural Nursing Theory of Madeleine
Leininger and their definitions:

Generic (Folk or Lay) Care Systems

Generic (folk or lay) care systems are culturally learned and transmitted, indigenous (or
traditional), folk (home-based) knowledge and skills used to provide assistive, supportive,
enabling, or facilitative acts toward or for another individual, group, or institution with
evident or anticipated needs to ameliorate or improve a human life way, health condition (or
well-being), or to deal with handicaps and death situations.

Emic
Knowledge gained from direct experience or directly from those who have experienced it. It
is generic or folk knowledge.

Professional Care Systems

Professional care systems are defined as formally taught, learned, and transmitted
professional care, health, illness, wellness, and related knowledge and practice skills that
prevail in professional institutions, usually with multidisciplinary personnel to serve
consumers.

Etic
The knowledge that describes the professional perspective. It is professional care knowledge.

Ethnohistory
Ethnohistory includes those past facts, events, instances, experiences of individuals, groups,
cultures, and instructions that are primarily people-centered (ethno) and describe, explain,
and interpret human lifeways within particular cultural contexts over short or long periods of
time.

Care as a noun
Care as a noun is defined as those abstract and concrete phenomena related to assisting,
supporting, or enabling experiences or behaviors toward or for others with evident or
anticipated needs to ameliorate or improve a human condition or lifeway.

Care as verb
Care as a verb is defined as actions and activities directed toward assisting, supporting, or
enabling another individual or group with evident or anticipated needs to ameliorate or
improve a human condition or lifeway or face death.

Culture Shock
Culture shock may result when an outsider attempts to comprehend or adapt effectively to a
different cultural group. The outsider is likely to experience feelings of discomfort and
helplessness and some degree of disorientation because of the differences in cultural values,
beliefs, and practices. Culture shock may lead to anger and can be reduced by seeking
knowledge of the culture before encountering that culture.

Cultural Imposition
Cultural imposition refers to the outsider’s efforts, both subtle and not so subtle, to impose
their own cultural values, beliefs, behaviours upon an individual, family, or group from
another culture. (Leininger, 1978)

Leininger’s Culture Care Theory attempts to provide culturally congruent nursing care
through “cognitively based assistive, supportive, facilitative, or enabling acts or decisions that
are mostly tailor-made to fit with individual, group’s, or institution’s cultural values, beliefs,
and lifeways.”
“Together the nurse and the client creatively design a new or different care lifestyle for the
health or well-being of the client. This mode requires the use of both generic and professional
knowledge and ways to fit such diverse ideas into nursing care actions and goals. Care
knowledge and skill are often repatterned for the best interest of the clients.
The theory’s culturological assessment provides a holistic, comprehensive overview of the
client’s background. The assessment addresses the following:
 Communication and language
 Gender considerations
 Sexual orientation
 Ability and disability
 Occupation
 Age
 Socioeconomic status
 Interpersonal relationships
 Appearance
 Address
 Use of space
 Foods and meal preparation and related lifeways
The Sunshine Model is Leininger’s visual aid to the Culture Care Theory.
TRANSCULTURAL NURSING MODELS

Transcultural nursing models provide nurses with the foundation required for gaining
knowledge about different cultures during healthcare delivery. The models are under
continual development and they guide nursing practice all over the world. Hence, this paper
focuses on the four particularly significant models.

1)Sunrise Model of Madeleine Leininger’s Theory

In Leininger’s nursing theory, it was stated that the nurse would help the client move towards
improvement of their health practice or condition. This statement would be of great difficulty
for the nurse because instilling new ideas in a different culture might present an intrusive
intent for the “insiders.” Culture is a strong set of practices developed over generations that
would make it difficult to penetrate.

Because of the intrusive nature, resistance from the “insiders” might impose a risk to the
nurse’s safety, especially for cultures with highly taboo practices.

Cultural knowledge plays a vital role for nurses on how to deal with the patients. To start, it
helps nurses to be aware of how the patient’s culture and faith system provide resources for
their experiences with illness, suffering, and even death. It helps nurses understand and
respect the diversity that is often present in a nurse’s patient load. It also helps strengthen a
nurse’s commitment to nursing based on nurse-patient relationships and emphasizing the
whole person rather than viewing the patient as simply a set of symptoms or illness. Finally,
using cultural knowledge to treat a patient also helps a nurse be open-minded to treatments
that can be considered non-traditional, such as spiritually based therapies like meditation.
Nowadays, nurses must be sensitive to their patients’ cultural backgrounds when creating a
nursing plan. This is especially important since so many people’s culture is so integral in who
they are as individuals, and it is that culture that can greatly affect their health and their
reactions to treatments and care. With these, awareness of the differences allows the nurse to
design culture-specific nursing interventions.
Leininger’s model makes the following assumptions:
 Care is the essence of nursing and a distinct, dominant, and unifying focus.

 Caring is essential for well-being, health, healing, growth, and to face death.

 Culture care is the broadest holistic means by which a nurse can know, explain,
interpret, and predict nursing care phenomena to guide nursing care practices.
  Nursing is a transcultural, humanistic, and scientific care discipline and profession
with the central purpose to serve human beings worldwide.

 Caring is essential to curing and healing. There can be no curing without caring.

 Culture care concepts, meanings, expressions, patterns, processes, and structural

forms of care are different and similar among all cultures of the world.

 Every human culture has lay care knowledge and practices and usually some
professional care knowledge and practices which vary transculturally.

 Culture care values, beliefs, and practices are influenced in the context of a culture.
They tend to be embedded in such things as worldview, language, spirituality,
kinship, politics and economics, education, technology, and environment.

 Beneficial, healthy, and satisfying culturally based nursing care contributes to the
well-being of individuals, families, and communities within their environmental
context.
 Culturally congruent nursing care can only happen when the patient, family, or
community values, expressions, or patterns are known and used appropriately, and in
meaningful ways by the nurse with the people.

 Culture care differences and similarities between the nurse and patient exist in any
human culture worldwide.

 Clients who experience nursing care that fails to be reasonably congruent with their
beliefs, values, and caring lifeways will show signs of cultural conflicts,
noncompliance, stresses and ethical or moral concerns.

 The qualitative paradigm provides new ways of knowing and different ways to
discover the epistemic and ontological dimensions of human care.
Giger and Davidhizar Transcultural Assessment Model

This model emphasizes the importance of considering every person as unique in his or her
culture. According to Giger and Davidhizar, there are six dimensions common to every
culture:
i Communication iv Time
ii Space v Environmental control
iii Social organization vi Biological variation
i.Communication
The first dimension is communication, which is the holistic process of human interaction and
conduct. The use and preservation of communication takes several forms - verbal, nonverbal,
and written - and differs in terms of expression, language and dialect, voice tone and volume,
context, emotional implication, facial expression, gestures, and body language. Language can
become a barrier to quality healthcare due to simple misunderstandings and failure to
communicate as intended.
ii. Space
The second dimension is space, which is the distance maintained between interacting
individuals; this "personal space" differs according to individuals' cultural backgrounds. The
concept of space involves three other behavioural patterns: attachment with objects in the
environment, body posture, and movement in the setting. It is important to observe tact and to
avoid overstepping boundaries with respect to these aspects of interaction, because doing so
can cause patients unnecessary anxiety.
iii. Social organization
The third dimension is social organization, which is how certain cultures group themselves in
accordance with family, beliefs, and duties. This dimension requires nurses to remain aware
that patient conduct can be influenced by factors like sexual orientation, acknowledgement
and utilization of titles, and decision-making regulations. An awareness of this dimension can
help nurses avoid being perceived as being derogatory or disrespectful.
iv. Time
The fourth dimension is time, which is similar to social organization in terms of influence.
Time is subdivided into whether the group is clock-oriented, like most Westerners, or socially
oriented. The clock-oriented group is fixated on time itself, and individuals with this
orientation seek to keep appointments so as not to be seen as ill-mannered or offensive. The
behaviour of socially oriented groups emphasizes the here and now. Such individuals
understand time as a flexible spectrum defined by the duration of activities; an activity does
not begin until the preceding event has ended.
v. Environmental control
The fifth dimension is environmental control, which implicates how the person perceives
society and its internal and external factors, such as beliefs and understandings regarding how
illness occurs, how it should be treated, and how health is uplifted and maintained.
vi. Biological orientation
The sixth and last dimension is biological orientation. Races vary biologically due to
differences in DNA, and some races are more prone to certain diseases than others. Other
notable elements of this model are a deeper understanding of pain tolerance and deficiencies
and predilections in nutrition.
Purnell model for cultural competence
The Purnell model focuses on providing a foundation for understanding the various attributes
of a different culture, allowing nurses to adequately view patient attributes, such as
incitement, experiences, and notions about healthcare and illness.
This model is presented in a diagram with parallel circles that represent aspects of global
society as well as the community, family, and person.
The Purnell model includes twelve domains:
i Culture and heritage vii Nutrition
ii Communication viii Pregnancy
iii Family roles and Organization ix Death rituals
iv Workforce issues x Spirituality
v Bio-cultural ecology xi Healthcare practices
vi High-risk behaviours xii Healthcare professionals
i. Culture and heritage

The first domain is culture and heritage, which includes the country of derivation, the
geographical influence of the original and present home, political affairs, economics,
educational status, and profession.
ii. Communication
The second domain comprises important notions relevant to communication, such as primary
language and dialects, circumstantial effectiveness and convenience of the language,
paralinguistic differences, and nonverbal communication.
iii. Family roles and organization
The third domain, family roles and organization, involves who heads the household in terms
of gender and age. The organization of the family is affected by goals and priorities,
developmental tasks, social status, and alternative lifestyles.
iv. Workforce issues
The fourth domain is workforce issues, including acculturation, autonomy, and the presence
of language barriers.
v. Bio-cultural ecology
The fifth domain includes factors of bio-cultural ecology, which encompass observable
differences with respect to ethnic and racial origins, like skin color and other physical
variations.
vi. High-risk behaviours
The sixth domain is such as using tobacco, alcohol, or recreational drugs. This domain also
includes physical activity and levels of safety or precautions taken.
vii. Nutrition
The seventh domain is nutrition. Depending on their place of origin, individuals or groups are
accustomed to certain foods and draw meaning from the foods they eat. Food consumption
associated with certain rituals may affect health. Some ethnic groups suffer from certain
nutritional limitations and deficiencies.
viii. Pregnancy
The eighth domain is pregnancy. Pregnancy is viewed differently because there are a myriad
of beliefs accompanying this life phase. The act of birthing and the postpartum period involve
certain practices that need to be taken into consideration when dealing with a particular
ethno-cultural group.
ix. Rituals
The ninth domain is death rituals. Perceptions of death differ from culture to culture in terms
of how death is accepted, what rituals are performed, and how one should behave following a
death.
x. Spirituality
The tenth domain is spirituality, which includes religious practice, use of prayer, individual
strength, the meaning of life, and how spirituality relates to health.
xi. Healthcare practices
The eleventh domain reflects healthcare practices. This domain includes the responsibility for
health and the barriers that must be overcome to achieve successful health outcomes.
Healthcare practices include traditional practices, magical religious practices, chronic-disease
treatment and rehabilitation, mental-health practices, and the roles of the sick.
xii. Healthcare professionals
The twelfth and final domain, healthcare professionals, involves the perceptions and roles of
traditional and folk healthcare practices.

Campinha-Bacote Model of Cultural Competence in Healthcare Delivery

Campinha-Bacote first developed her model, known as "cultural competency in the delivery
of healthcare services," in 1998, revising it in 2002. The model considers cultural competence
not as a consequence brought about by certain factors, but as a process.
To achieve cultural competence, a nurse must undertake a process of developing the capacity
to deliver efficient and high-quality care, a process that encompasses five components.
i Cultural awareness iv Cultural encounter
ii Cultural skill v cultural desire
iii Cultural knowledge
i. Cultural awareness
The first involves cultural awareness, a process in which healthcare professionals consciously
acknowledge their own cultural backgrounds, which helps them avoid biases toward other
cultures.
ii. Cultural skill
The second component is cultural skill, defined as the ability to obtain the necessary
information from patients via culturally appropriate conduct and physical assessment.
iii. Cultural knowledge
The third component is cultural knowledge, a process in which healthcare professionals open
their minds to understand variations in cultural and ethnic traits as they relate to patient
attitudes toward illness and health.
iv. Cultural encounter
The fourth component is cultural encounter during which stereotyping is avoided through the
interaction between healthcare professionals and members of different cultures. During this
process, overreliance on conventional views is discouraged.
v. Cultural desire
The fifth and last component is cultural desire, which is the driving force for becoming
educated, skilled, competent, and aware of culture; it also presumes a willingness to have
transcultural interactions.

STANDARDS OF TRANSCULTURAL NURSING

A task force of the Expert Panel for Global Nursing and Health of the American Academy of
Nursing, along with members of the Transcultural Nursing Society, has developed a set of
standards for cultural competence in nursing practice. The aim of this project was to define
standards that can be universally applied by nurses around the world in the areas of clinical
practice, research, education, and administration, especially by nurses involved in direct
patient care.

Standards Description
1. Social Justice
Professional nurses shall promote social justice for
all. The applied principles of social justice guide
nurses' decisions related to the patient, family,
community. and other healthcare professionals.
Nurses will develop leadership skills to advocate
for socially just policies.

2. Critical Reflection Nurses shall engage in critical reflection of their

own values, beliefs, and cultural heritage in order
to have an awareness of how these qualities and
 issues can impact culturally congruent nursing
care.
3. Transcultural Nursing Knowledge nurses shall gain an understanding of perspectives
traditions, values. practices. and family systems of
culturally diverse individuals, families,
communities and populations they care for. as well
as a knowledge of the complex variables that
affect the achievement of health and well-being.
4.Cross Cultural Practice

Nurses shall utilize cross cultural knowledge and

culturally sensitive skills in implementing
culturally congruent nursing care.
5. Healthcare Systems and Organizations Healthcare organizations should provide the
structure and resources necessary to evaluate and
meet the cultural and language needs of their
diverse clients.

6. Patient Advocacy and Empowerment Nurses shall recognize the effect of healthcare
policies, delivery systems, and resources on their
patient populations, and shall empower and
advocate for their patients as indicated. Nurses
shall advocate for the inclusion of their patient's
cultural beliefs and practices in all dimensions of
their healthcare.
7. Multicultural Workforce Nurses shall be activists in the global effort to
ensure a more multicultural workforce in
healthcare settings.
8. Education and Training Nurses shall be educationally prepared to promote
and provide culturally congruent health care.
Knowledge and skills necessary for assuring that
nursing care is culturally congruent shall be
included in global health care agendas that
mandate formal education and clinical training, as
well as required ongoing, continuing education for
all practicing nurses
9. Cross Cultural Communication Nurses shall use effective, culturally competent,
communication with clients that takes into
consideration the client's verbal and nonverbal
language. cultural values and context. and unique
healthcare needs and perceptions.

10. Cross Cultural Leadership nurses shall have the ability to influence
individuals, groups and systems to achieve
outcomes of culturally competent care for diverse
populations.
11. Policy Development Nurses shall have the knowledge and skills to
work with public and private organizations.
professional associations and communities to
establish policies and standards for comprehensive
 implementation and evaluation of culturally
competent

12. Evidence-Based Practice and Research Nurses shall base their practice on inter,'entöns
that have been systematically tested and shown to
be the most effective for the culturally diverse
populations that they serve, In areas where there is
a lack of evidence of efficacy, nurse researchers
shall investigate and test interventions that may be
the most effective in reducing the racial and ethnic
inequalities in health outcomes.

NURSES ROLE
Health Beliefs and Practices
Three views of health beliefs include magico-religious, scientific, and holistic. In the
magico-religious health belief view, health and illness are controlled by supernatural
forces.
The client may believe that illness is the result of "being bad" or opposing the
creator(s)' will. Getting well is also viewed as dependent on the will of the creator(s). The
client may make statements such as "If it is God's will, I will recover" or "What did I do
wrong to be punished with cancer?" Some cultures believe that magic can cause illness.
Some people view illness as possession by an evil spirit.
Although these beliefs are not supported by empirical evidence, clients who hold
these beliefs may in fact become ill as a result. Such illnesses may require magical
treatments in addition to scientific treatments. For example, a man who experiences
headaches after being told that a spell has been placed on him may recover only if the spell
is removed by the culture's healer, and he may, in fact, not need a scientific intervention.
The scientific or biomedical health belief is based on the belief that life is controlled
by physical and biochemical processes that can be manipulated by humans. The client with
this view will believe that illness is caused by germs, viruses, bacteria, or a breakdown of
the body. This client will expect a pill, treatment, or surgery to cure health problems.
The holistic health belief holds that the forces of nature must be maintained in balance
or harmony. Human life is one aspect at of nature that must be in harmony with the rest of
nature. When the natural balance or harmony is disturbed, illness results. The medicine
wheel is an ancient symbol used by Native Americans of North and South America to
express many concepts. For health and wellness, the medicine wheel teaches the four aspects
of the individual 's nature: the physical, the mental, the emotional, and the spiritual. The four
dimensions must be in balance to be healthy. The medicine wheel can also be used to
express the individual's relationship with the environment as a dimension of wellness.
The concept of yin and yang (in the Chinese culture) and the hot-cold theory of illness in
many cultures (such as Middle Eastern, Spanish, and Asian) are examples of holistic health
beliefs. a Chinese client has a yin illness or a "cold" illness such as cancer, the treatment
may include a yang or "hot" food (e.g., hot tea).
 What is considered hot or cold varies considerably across cultures. many cultures, the
mother who has just delivered a baby is offered warm or hot foods and kept warm with
blankets because childbirth is seen as a "cold" condition. To reduce a fever, conventional
scientific thought recommends cooling the body. The primary care provider may order
liquids for the client and cool compresses to be applied to the forehead, the axillae, or the
groin. In contrast, many cultures believe that the best way to treat a fever is to increase
elimination of toxins through sweat baths. Clients from these cultures may want to cover up
with several blankets, take hot baths, and drink hot beverages.
Sociocultural forces, such as politics, economics, geography, religion, and the predominant
health care system, influence the client's health status and health care behaviour. For
example, people who have limited access to scientific health care can turn to folk medicine or
folk healing. Folk medicine is defined as those beliefs and practices relating to illness
prevention and healing that derive from cultural traditions rather than from modern
medicine's scientific base. Many persons have special teas or "cures" (such as chicken soup)
used by older family members to prevent or treat colds, fevers, indigestion, and other
common health problems. Folk medicine is thought to be more humanistic than biomedical
health care. The consultation and treatment take place in the community of the recipient,
frequently in the home of the healer. It may be less expensive than scientific or biomedical
care. The healer often prepares the treatments, for example, herbs to be ingested, poultices to
be applied, or charms or amulets to be worn. A frequent component of treatment is some
ritual practice on the part of the healer or the client to cause healing to occur. Because folk
healing is more culturally based than traditional Western health care, it is often more
comfortable and less frightening for the client.
It is important for the nurse to obtain information about folk or family healing practices that
may have been used before or while the client used Western medical treatment. Often
clients are reluctant to disclose the use of home remedies with health care professionals for
fear of being laughed at or rebuked.
Treatments once considered to be folk treatments, including acupuncture, therapeutic touch,
and massage, are now being investigated for their therapeutic effect. The National Centre
for Complementary and Alternative Medicine at the National Institutes of Health provides
uptodate information on this line of research

Family Patterns
The family is considered the basic unit of society; however, the concept of family is complex
and influenced by personal and social values.

The value placed on children and older adults within society is culturally derived. In some
culture children are not punished physically. They are directed to avoid harm or injury. In
some cultures, older adults are believed to be the wiser in cultures they are treated
respectfully. In some cultures, older adults are not allowed to live independently, they will be
with their married son.
Culture gender role behaviour also may affect nurse-client relationship. In some country,
male dominates, and women have every little status. They won’t accept same nurse care
provider but follow the same instructions given by male nurse. Male superiority is machismo.
The women are expected to maintain home and raise children. The women need to consult
her husband before making decision about her or her children’s medical treatment.

Cultural family values may also dictate the extend of family members in the involvement of
care.in some culture only nuclear and joint family members participate in care. But in some
cultures, the community wishes to participate in care.
Some cultural groups are very reluctant to disclose personal information.
Naming system is also different from culture to culture E.g.: Sikhs have personal name
following title Singh, Kaur for women
In central America, if Louisa Vicario marries carols Gonzales, her name changes to Louisa
Vicario de Gonzales. Where de means belonging to.

Communication style
Communication and culture are closely connected.
a)Verbal Communication
The most obvious cultural difference is in verbal communication: vocabulary,
grammatical structure, voice qualities, intonation, rhythm, speed, pronunciation, and
silence. In North America, the dominant language is English; however, immigrant groups
who speak English still encounter language differences because English words can have
different meanings in different English-speaking cultures.
Initiating verbal communication may be influenced by cultural values. The busy nurse
may want to complete nursing admission assessments quickly. The client, however, may be
offended when the nurse immediately asks personal questions. Discussing general topics
can convey that the nurse is interested and has time for the client. This enables the nurse to
develop a rapport with the client before progressing to discussion that is more personal.
Verbal communication becomes even more difficult when an interaction involves
people who speak different languages. Both clients and health professionals experience
frustration when they are unable to communicate verbally with each other.
For the client whose language is not the same as that of the health care provider, an
intermediary may be necessary. A translator converts written material (such as client
education pamphlets) from one language into another. Interpretation moves beyond
translation; an interpreter can translate the message expressed in a source language into its
equivalent in a target. Become aware of the individual expressions and colloquial words
used in specific regions and acknowledge them when using interpreting services.

b) Nonverbal Communication

To communicate effectively with culturally diverse clients, the nurse needs to be aware of
two aspects of nonverbal communication behaviours: what nonverbal behaviours mean to the
client and what specific nonverbal behaviours mean in the client's culture.
Nonverbal communication can include the use of silence, touch, eye movement, facial
expressions, and body posture. Some cultures are quite comfortable with long periods of
silence, whereas others consider it appropriate to speak before the other person has finished
talking. Many people value silence and view it as essential to understanding a person's needs
or use silence to preserve privacy. Some cultures view silence as a sign of respect, whereas to
other people silence may indicate agreement.
Touching involves learned behaviours that can have both positive and negative meanings.
In the American culture, a handshake is a recognized form of greeting that conveys strength.
In some European cultures, greetings include a kiss on one or both cheeks, In some societies,
touch is considered magical and because of the belief that the soul call leave the body on
physical contact
In some Asian cultures only, certain older people permitted touch the head of others, and
children are never patted head. Nurses should therefore touch a client's head only with
permission. Cultures dictate what forms of touch are appropriate for individuals of the same
and opposite gender. The nurse should watch interaction among clients and families for cues
to the appropriate degree of touch in that culture. The nurse can also assess the client's
response to touch when providing nursing care, for example, by noting the client's reaction to
the physical examination or the bath. The nurse should also inquire about clients' references,
and inform clients before touching them, and whenever possible proceed after obtaining
permission. For example, "I would like to check your pulse, and I will need to hold your
wrist. Is that okay?"
Facial expression can also vary between cultures. In some cultures, persons are more
likely to smile readily and use facial expressions to communicate feelings, whereas in
others, persons may use fewer facial expressions and may be less open in their response,
especially to strangers. Facial expressions can also convey a meaning opposite to what is
felt or understood.
Eye movement during communication has cultural foundations. In many Western
cultures, direct eye contact is regarded as important and generally shows that the other is
attentive and listening. It is assumed to convey self-confidence, openness, interest, and
honesty. Lack of eye contact may be interpreted as secretiveness, shyness, guilt, lack of
interest, or even a sign of mental illness. However, other cultures view direct eye contact as
impolite or an invasion of privacy. In the Honkong culture, for example, continuous direct
eye contact is considered rude, but intermittent eye contact is acceptable. The nurse must
consider the cultural context to avoid misinterpreting, avoid chance of eye contact.
Body posture and hand gestures are also culturally learned. For an example, offensive
the gesture V sign in means other victory cultures. in some cultures, thumbs up may mean
"right" or "great job"

Space Orientation

Space is a relative concept that includes the individual, the body, the surrounding
environment, and objects within that environment. The relationship between the individual's
own body and objects and persons within that space is learned and is influenced by culture.
For example, in nomadic societies, space is not owned; it is occupied temporarily until the
tribe moves on. In many Western societies people tend to be more territorial, as reflected in
phrases such as "This is my space" or "Get out of my space." Spatial distances may be
defined as the intimate zone, the personal zone, and the social and public zones. The size of
 these areas may vary with the specific culture. Nurses move through all three zones as they
provide care for clients. The nurse needs to be aware of the client's response to movement
toward the client. The client may physically withdraw or back away if the nurse is
perceived as being too close. The nurse will need to explain to the client why there is a need
to be close. To assess the lungs with a stethoscope, for example, the nurse needs to move
into the client's intimate space. The nurse should first explain the procedure and, when
possible, await permission to continue.
Clients who reside in long-term care facilities, or who are hospitalized for an extended
time, may want to personalize their space. They may want to arrange their room differently or
control the placement of objects on their bedside cabinet. The nurse should be responsive to
clients' needs to have some control over their space. When there are no medical
contraindications, clients should be permitted and encouraged to have objects of personal
significance. Having personal and cultural items in one's environment can increase self-
esteem by promoting not only one's individuality but also one's cultural identity.

Time Orientation
Time orientation refers to an individual's focus on the past, the present, or the future. Most
cultures include all three-time orientations, but one orientation is more likely to dominate.
The European-American focus on time tends to be directed to the future, emphasizing time
and schedules. Other cultures may have a different concept of time. African Americans are
Often generalizing as present oriented as well, with a focus on rent health status, rather than
the anticipation of what may happen in the future. Socioeconomic status may also influence
time orientation. The middle class is generally future oriented; however, lower socio-
economic classes ate generally present oriented because of the focus on daily survival, which
may not allow for the luxury of being able to plan for the future.

The culture of nursing and health care values Punctuality and is future oriented.
Appointments are scheduled and treatments are prescribed with time parameters (e.g.,
changing a dressing once a day). Medication orders include how often the medicine is to be
taken and when (e.g., digoxin 0.25 mg, once a day, in the morning). Nurses need to be aware
of the meaning of time for clients. When caring for clients who are "present oriented," it is
important to avoid fixed schedules. The nurse can offer a time range for activities and
treatments. For example, instead of telling the client to take digoxin every day at 10:00 AM,
the nurse might tell the client to take it every day in the morning or every day after getting
out of bed. The nurse may also consider telling the client that even if the client feels well,
they may still need to take their medication.

Nutritional Patterns
Most cultures have staple foods that are plentiful or readily accessible in the environment.
For example, the staple food of Asians is usually rice; and of Europeans it may be wheat
or pasta. Even clients who have been in the United States for several generations often
continue to eat the foods of their cultural homeland.
 The way food is prepared and served is also related to cultural practices. For example, in
the United States a traditional food served for the Thanksgiving holiday is stuffed turkey;
however, in different regions of the country the contents of the stuffing may vary. In
Southern states, the stuffing may be made of cornbread, in New England, of seasoned
bread and chestnuts.
The way in which staple foods are prepared also varies. For example, some Asian cultures
prefer steamed rice; others prefer boiled rice. Southern Asians from India prepare
unleavened bread from wheat flour rather than the leavened bread of European
Americans.
Food-related cultural behaviours can include whether to breast-feed or bottle-feed
infants, and when to introduce solid foods to them. Food can also be considered part of the
remedy for illness. Foods classified as "hot" foods or foods that are hot in temperature may
be used to treat illnesses that are classified as "cold" illnesses. For example, cornmeal (a
"hot" food) may be used to treat arthritis (a "cold" illness). Each cultural group defines
what it considers to be hot and cold entities.

Religious practice associated with specific cultures also affects diet. Some Roman
Catholics avoid meat on certain days such as Ash Wednesday and Good Friday, and some
Protestant faiths prohibit meat, tea, coffee, or alcohol. Both Orthodox Judaism and Islam
prohibit the ingestion of pork or pork product. Orthodox Jews observe kosher customs,
eating certain foods
Some Buddhists, Hindus, and Sikhs are strict vegetarians. The nurse must be sensitive to
such religious dietary practices.

Nursing Management
All phases of the nursing process are affected by the client's and the nurse's cultural values,
beliefs, and behaviours. As the client's culture and the nurse's culture come together in the
nurse-client relationship, a unique cultural environment is created that can improve or
impair the client's outcome. Self-awareness of personal biases can enable nurses to develop
modifying behaviours or (if they are unable to do so) to remove themselves from situations
where care may be compromised. Nurses can become more aware of their own culture
through values clarification, the nurse must also consider the cultural values dominant in the
health care setting because those, too, may influence the client's outcome.

Developing Self-Awareness
In learning how to provide culturally responsive care, the nurse must first understand his or
her own culture, beliefs, and assumptions. Many models have been documented in the
literature to deepen this self-exploration. Campinha-Bacote (2007) offers the asked
mnemonic model to develop cultural consciousness:

Awareness: Am I aware of my biases and prejudices, as well as racism and other "isms"?
Skill: Do 1 have the skill to conduct a cultural assessment in a sensitive manner?
Knowledge: Am I knowledgeable about the worldviews of diverse cultural and ethnic
groups?
Encounters: Do I seek face-to-face and other types of interactions with people who are
different from me?
Desire: Do 1 really "want" to become culturally competent? Other self-identity questions
may include the following (Tochiuk, 2010):

When did you first realize you were a member of your race/ethnicity? What did it mean to
you at that time?

How did your culture/race/ethnicity play a role in your childhood and/or adolescence?

What important events changed your relationship to race/ethnicity? What happened?

What significant people/relationships shaped the way you experience being a member of your
race/ethnicity?

How do you understand what it means to be a member of your race/ethnicity at this time in
your life?
Health-related questions may include:
How does your ethnic/racial group view health and illness?
What are the common healing practices in your ethnic/racial group?
What are examples of your family's traditional health and illness beliefs and practices?
Do they value stoic behaviour in relation to pain. or is it permissible to state that you are in
pain?

What beliefs do you hold about health care providers?

Conveying Cultural Sensitivity

The process of cultural assessment is important. How and when questions are asked requires
sensitivity and clinical judgment. The timing and phrasing of questions need to be adapted to
the individual. Timing is important in introducing questions. Sensitivity is needed in phrasing
questions. Trust must be established before clients can be expected to volunteer and shar
sensitive information. The nurse therefore needs to spend time with clients and convey a
genuine destiny to understand their values and beliefs.
Before conducting a cultural assessment, determine what language the client speaks and
the client's degree of fluency in the English language. It is also important to learn about the
client's communication patterns and space orientation. This is accomplished by observing
both verbal und nonverbal communications For example, does the client do the speaking or
asking to another? What nonverbal communication behaviours does the client (e.g., touching,
eye contact)?
It is vital for nurses to be culturally sensitive and to convey this sensitivity to clients,
support people. and other health care personnel.
Be authentic with people and be honest about your knowledge about their culture.
When you do not understand a person's actions, politely and respectfully seek information.
Use language that is culturally sensitive; for example, say 'gay, lesbian," or
"bisexual" rather than ' 'homosexual"; do not use "man" or "mankind" when
referring to a woman. Ask how the person self-identifies his or her race/ethnicity. A
person may have a preferred term, such as Latino rather than Hispanic. Make note of
client’s preferences.
Find out what the client thinks about his or her health problems, illness, and
treatments. Assess whether this information is congruent with the dominant health care
culture. If the beliefs and practices are incongruent, determine the impact on the client's
health.
Always ask about anything you do not understand to avoid making assumptions about the
client.Show respect for the client's values, beliefs, and practices, even if they differ from
your own or from those of the dominant culture. If you do not agree with them, it is
important to respect the client's right to hold these beliefs.
Show respect for the client's support people. In some cultures, men in the family make
decisions affecting the client, whereas in other cultures women make the decisions.

Make a concerted effort to obtain the client's trust, but do not be surprised if it develops
slowly or not at all. A cultural assessment may take time and may need to extend over
several meetings.
Assessing
In creating a plan of care that is culturally responsive, many assessment tools are available.
The tools are a way of interviewing and facilitating communication with clients and their
families and may be used in any setting. Listen actively with empathy to the client's
perception of the problem.Explain what you think you heard/ask for clarification.
The Heritage Assessment Interview depicts the questions to ask when conducting a
heritage assessment. It is designed to enhance the process in order to determine if clients
are identifying with their traditional cultural heritage (heritage consistent) or if they have
acculturated into the dominant culture of the modern society in which they reside (heritage
inconsistent). The tool may be used in any setting and both facilitates conversation and
helps in the planning of cultural care. Once a conversation begins and the person describes
aspects of cultural heritage, it becomes possible to develop an understanding of the person's
unique health and illness beliefs, practices, and cultural needs. For example, you
may discover that the individual participates in ethnic cultural events and social groups,
such as religious festivals or national holidays, sometimes with singing, dancing, and
costumes or that the client's childhood development occurred in the person's country of
origin or in an immigrant community in the United States. For example, the person was
 raised in a specific ethnic neighbourhood, such as an Italian, African American, Hispanic,
or Jewish one, in a given part of a city and was exposed only to the culture, language,
foods, and customs of that particular group. There are infinite examples of cultural
influences on the client's health. Diagnosing
The nursing diagnoses developed by NANDA International are focused on nursing care
provided in the United States and are based on European-centric cultural beliefs. It is
essential to expand the understanding of the nursing practice to include cultural beliefs of
other cultures. Nurses must provide appropriate care to clients of any culture. This is
accomplished through developing cultural sensitivity and considering how a client's culture
influences his or her responses to health conditions, much as the nurse considers how a
client's age or gender influences a nursing diagnosis, plan, and delivery of nursing care.
Planning
Cultural competence in nursing involves delivering care that integrates the mind, the body,
the spirit, and the cultural values of the individual. The AACN (2008) defines cultural
competence as the attitudes, knowledge, and skills necessary for providing quality care to
diverse populations. Becoming culturally competent is an ongoing process in which an
individual or organization develops along a continuum until diversity is accepted as a norm
and the nurse has acquired greater understanding and capacity in a diverse environment.
Several steps are involved in the process that leads to the development of cultural
competency. The knowledge and skills necessary to incorporate cultural care into standard
nursing require the acquisition of a broad base of knowledge about different cultures and
social structures.

The following are examples of the necessary steps:

1. Become aware of one's own cultural heritage
2. Become aware of the client's heritage and health traditions as described by the client.
3. Become aware of adaptations the client made to live in Other culture. During this part
of the interview, a nurse can also identify the client's preferences in health practices
diet, hygiene, and so on.
4. Form a nursing plan with the client that incorporates his or her cultural beliefs
regarding the maintenance, protection, and restoration of health. In this way, cultural
values, practices, and beliefs can be incorporated with the necessary nursing care.

As a component of the planning phase of the nursing process the nurse "develops an
individualized plan in partnership With the person, family and others considering the
person's characteristics or situation, including but not limited to, values, beliefs, spiritual
and health practices, preferences, choices developmental level, coping style, culture and

environment and available technology" (American Nurses Association [ANA]

Implementing
The implementation of cultural nursing care includes
 (a) cultural preservation and maintenance
(b) cultural accommodation and negotiation.
Cultural preservation may involve the use of cultural health care practices, such as
giving herbal tea, chicken soup, or "hot" foods to the ill client. Accommodation of the
client's viewpoint and negotiating appropriate care requires expert communication skills,
such as responding empathetically, validating information, and effectively summarizing
content. Negotiation is a collaborative process. It acknowledges that the nurse—client
relationship is reciprocal and that different views exist of health, illness, and treatment. The
nurse attempts to bridge the gap between the nurse's scientific and the client's cultural
perspectives. During the negotiation process, the client's views are explored and
acknowledged. Relevant scientific information is then provided. If the client's views reveal
that certain behaviours would not affect the client's condition adversely, then they are
incorporated in planning care. If the client's views can lead to harmful behaviour or
outcomes, then an attempt is made to educate the client on the scientific view.
It must be determined precisely how the client is managing he illness, what practices
could be harmful, and which practices can be safely combined. For example, reducing
dosages f an antihypertensive medication or replacing insulin therapy with herbal
measures may be detrimental. Some herbal remedies are synergistic with modern
medicines and others are agonistic; therefore, it is necessary to fully inform the client you
the possible outcomes. Consider these examples of Potential conflicts between cultural
beliefs or practices and the Dominant American health care system:
Native americans are not ready to cut out weight. Jehovas witness not ready to receive
blood transfusions.Sikhs do not cut hair.
When a client chooses to follow only cultural practices and declines all prescribed
medical or nursing interventions, the nurse and client must adjust the client goals.
Monitoring the client' s condition to identify changes in health and to recognize
impending crises before they become irreversible may be all that is realistically
achievable. At a time of crisis, the opportunity may arise to renegotiate care.
Providing culturally responsive care can be challenging. It requires discovery of the
meaning of the client' s behaviour, flexibility, creativity, and knowledge to adapt nursing
interventions. An effort must be made to learn from each experience.

Evaluating
In evaluating nursing care that incorporates the client' s cultural perspectives, the actual client
outcomes are compared with the goals and expected outcomes established following
comprehensive assessment that includes cultural sensitivity. However, if the outcomes are not
achieved, the nurse should be especially careful to consider whether the client's belief system
has been adequately included as an influencing factor.

RESEARCH ARTICLE-2
The development of communication skills and the teacher's performance in the nursing
student's perspective

-Karime Rodrigues Emilio de Oliveira et al. Rev Esc Enferm USP. 2016 Jun.

Abstract

Objective: To understand experiences in the development of communication skills and the

teacher's role in this teaching-learning process under the perspective of undergraduate nursing
students by considering two types of curriculum organization.

Method: Descriptive study with a qualitative approach conducted in two public schools
located in São Paulo state, Brazil. Data were collected by means of self-completed forms
from 81 students in the second and fourth years of the undergraduate program. Results were
analysed in light of Content Analysis.
Results: Results showed that the development of such skills is related to: students' individual
characteristics, patients' characteristics, those of the health-disease process, the health-care
team's profile and the theoretical knowledge acquired on communication in health-care
provision and nursing. The teacher's role was perceived as one that supports and encourages
interactions with patients and health-care teams by teaching and providing orientation about
interpersonal communication.

Conclusions: Students identify and value the importance of their teachers' performance in the
development and acquisition of communication skills. Additionally, students who experience
active teaching-learning methodologies acknowledge the teacher as essential to provide
opportunities for students to express their knowledge and thoughts.

CONCLUSION
Teachers who are skilled at communication, classroom management and appropriate
discipline techniques create a positive learning environment. Although being well versed in
your subject area is important, being able to communicate necessary skills and concepts in a
way student can understand is crucial. Teachers develop skills over time through best
practices shared by other teachers, continuing education and classroom experience. Teachers
who can use both verbal and non-verbal communication help students understand what is
expected of them and help build their confidence in learning

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