Portal de Periódicos da CAPES

Cultural Aspects of Pain in Childbearing Women

1996; Elsevier BV; Volume: 25; Issue: 1 Linguagem: Inglês

10.1111/j.1552-6909.1996.tb02515.x

1552-6909

Sandy E. Weber,

Nursing Roles and Practices

As the American population increases in ethnic diversity, nurses must prepare to care for women from various cultures. The American Nurses Association has stated that a is vital at all levels of nursing. Culture is known to affect the patient's perception of pain and the nurse's inference of pain in the patient. Pain is expected in childbirth, and nurses should learn how culture influences individual women in their expression of pain. Because each woman is unique, nurses must combine information about culture with clinical assessment of the patient to provide culturally sensitive care. JOGNN, 25, 67–72; 1996. As the American population increases in ethnic diversity, nurses must prepare to care for women from various cultures. The American Nurses Association has stated that a is vital at all levels of nursing. Culture is known to affect the patient's perception of pain and the nurse's inference of pain in the patient. Pain is expected in childbirth, and nurses should learn how culture influences individual women in their expression of pain. Because each woman is unique, nurses must combine information about culture with clinical assessment of the patient to provide culturally sensitive care. JOGNN, 25, 67–72; 1996. The face of American society is changing: from white to multicolored; from European-American to African- and Asian-American; from one that is almost exclusively of the Judeo-Christian tradition to one that encompasses Islam, Hinduism, Buddhism, and other religious traditions. Always an immigrant society, the United States and Canada are home to a myriad of racial, ethnic, socioeconomic groups. This splendid diversity can be the root cause of culture clashes, which can result in escalation of bigotry and hatred. By learning about other cultures and understanding how they coincide with and differ from their own, nurses can set the stage for tolerance and sensitivity in health care settings. Inevitably, the obstetric population reflects the multiethnic character of our society. Childbirth is a unique moment in life. Steeped in cultural traditions and fraught with danger and pain, it is both a crisis and a blessed event. A critical element in the care of the obstetric patient is the recognition and treatment of pain and discomfort. Understanding how culture mediates pain is important for the clinician. As we each encounter women and families of other cultures in our practices, we must prepare to care for them. An underlying knowledge of various cultures can help the nurse to understand and anticipate some behaviors, thereby increasing preparedness to provide quality health care. This article explores the current understanding of how ethnicity and culture affect the perception and expression of pain and discomfort, especially as applied to childbirth and the perinatal period. Important concepts in transcultural nursing are defined, and strategies for the care of ethnically diverse populations are discussed. Finally, resources for improving cultural sensitivity and knowledge for nurses in various settings are suggested. An understanding of how pain varies for women of varying cultures and how to best provide appropriate nursing care begins with an understanding of some concepts from the field of transcultural nursing. The American Nurses Association (ANA) recognized the importance of these ideas in its Position Statement on Cultural Diversity in Nursing Practice, 1991 (ANA, 1991). This document declared that a knowledge of cultural diversity isSensitive nursing care and appropriate client advocacy cannot be accomplished without a knowledge of cultural diversity.Table 1Emergent Cultural AssessmentNationalityWhat is her country of origin?When did she relocate?LanguageWhat is her native language?How well does she understand English?Is an interpreter available?Are there barriers between the interpreter and the patient? (modesty, cultural taboos about certain bodily functions or words, power or control issues)ReligionWhat is her religion?Does she observe any religiouspractices that will affect immediatecare? (receiving blood, keeping herhead covered, no male attendants)Expectationsabout careWhat symptoms brought the patient toseek care?What treatment does she expect?What fears does she have about herpregnancy and treatment? Open table in a new tab Table 2Assessing the Clinical EnvironmentDoes the standard nursing assessment include culturalcomponents?Does the environment allow for cultural differences?Do staff members make disrespectful comments aboutpatients when patients are not present?Are differences respected and accommodated?Are practitioners primarily from a different culture thanmany of the clients? Does this create problems?Are interpreters available when needed?Are resource materials available for staff members aboutbeliefs and customs of frequently encountered ethnicgroups?Are written materials for patients available in frequentlyencountered languages? Open table in a new tab vital at all levels of nursing. The ANA statement maintains that cultural assessment of the client is an expected nursing function and that sensitive nursing care and appropriate client advocacy cannot be accomplished without knowledge of cultural diversity. This attention to cultural diversity in nursing practice must be attendant in all aspects of nursing, from practice and education to policy development and administration. . The American Nurses Association (ANA) and practice that focuses on the values, beliefs, and practices of individuals from diverse cultures to provide culture-specific care and to promote culturally congruent health care to individuals, families, and institutions (Reynolds and Leininger, 1993Reynolds C.L. Leininger M. Madeleine Leininger: Cultural care diversity and universality theory. Sage, New York1993Google Scholar). This term was coined and defined more than 25 years ago by the acknowledged founder of transcultural nursing, Madeleine Leininger. Nurses have followed Leininger's lead and have begun investigating how culture affects health, illness, and nursing care. Culture has been defined by many writers. Barnouw, in his thorough review of culture and personality, makes an important point with this definition: "Culture is the way of life of a group of people, the complex of shared concepts and patterns of learned behavior that are handed down from one generation to the next through the means of language and imitation" (1985, p. 5). Highlighting the words leartied behavior, emphasizes that learned patterns are only relatively fixed because culture can be distinguished by plasticity and change. When people live in a new culture, they adapt in various ways to that culture. Culture provides the individual with ways of coping with the world. As one follows the prescribed format of one's culture, one gains a mastery and sense of confidence. However, culture also can provide threats, including beliefs in evil spirits and malevolent gods, that present a dangerous world view. The United States and Canada are home to countless cultural groups. Some groups are more properly referred to as ethnic groups, with "ethnic" groups being considered a minority group of a larger community. Some may be identified only by their countries of origin, such as newly arrived Mexicans or Vietnamese. Others may be in a more specifically defined group, such as WASPs (white, Anglo-Saxon, Protestants), a label that defines race, cultural origin, and religion, while implying a longevity in the United States. There also are subcultures within large cultural or ethnic groups. For example, there is a drug- using subculture in the American inner cities, which is characterized by certain beliefs, values, and practices. Cultural blindness is the inability to recognize one's own culture and is surprisingly common. Many people may be able to name their cultural or ethnic group but are unaware of how membership in that group influences their lifestyles and actions. It seems that once we are immersed in the culture that dominates our lives, we may lose the ability to see other courses of action. Ethnocentrism is the belief that one's own culture is superior to that of others. Cultural blindness and ethnocentrism can result in cultural imposition, the forcing of one's own beliefs or practices on others. Culture clashes can be the result of these phenomena. In the health care environment, culture clashes frequently result in less than optimal care and less-than satisfied clients and personnel. Culture is a well known influence in the expression and perception of pain and a mediator in the inference of pain in others. Pain is a subjective experience of physical, psychologic, or spiritual experiences and can be modified by neurochemistry, cognition, and sensory and socioenvironmental factors. Social scientists and clinical researchers have reported strong associations of culture with pain responses, beliefs, and behaviors. In the 1940s, Chapman and Jones performed some of the pioneering work on pain and culture (Reid, 1992Reid V.J. Implications for physician patient interaction.Ethnicity, interpersonal factors and pain expression. Doctoral dissertation, Virginia Commonwealth University1992Google Scholar). They used a radiant heat technique to test pain threshold, comparing age- and gender matched whites and African- Americans; they concluded that were there differences in tolerance levels and hypothesized that the differences might be attributable to a learned pain response. Zborowski, 1952Zborowski M. Cultural components in response to pain.Journal of Social Issues. 1952; 8: 16-30Crossref Scopus (553) Google Scholar performed the most widely cited work on pain and ethnicity. In that research, he compared Italian, Jewish, Irish, and "Old American" (defined as native- born Anglo-Saxons) patients at a large veteran's hospital in New York. He found greater emotional response and heightened expression of pain in the Jewish and Italian patients than in the Irish and Old American patients (Zborowski, 1952Zborowski M. Cultural components in response to pain.Journal of Social Issues. 1952; 8: 16-30Crossref Scopus (553) Google Scholar). Flannery et al., 1981Flannery R. Sos J. McGovern P. Ethnicity as a factor in the expression of pain.Psychosomatics. 1981; 22: 39-50Abstract Full Text PDF PubMed Scopus (23) Google Scholar studied 74 women who had delivered neonates; the study compared Irish, Italian, African-American and Protestant Anglo- Saxon women. On one scale, the Urogenital Anxiety Scale, a difference was noted between African-American, Italian, and Protestant Anglo-Saxon patients. However, when socioeconomic factors were covaried, no significant differences remained. Despite this and some other equivocal studies, there remains a prevalent clinical assumption that ethnicity modifies pain. In fact, Greenwald, 1991Greenwald H.P. Interethnic differences in pain perception.Pain. 1991; 44: 157-163Abstract Full Text PDF PubMed Scopus (125) Google Scholar, studying in western Washington state the expression of pain in patients with cancer, observed ethnic differences; these differences were seen despite a high degree of assimilation into the dominant United States culture having occurred in the patients. Reid, in a careful investigation of pain, personality, and ethnicity, studied 108 female subjects and tested their responses to immersion of an extremity in a cold water bath (cold pressor test). Reid tested the relationship between ethnicity and pain expression and the relevance of race and interpersonal impact of the experimenter. She found a significant racial difference in pain tolerance, with whites showing a higher pain tolerance than did African-Americans. Her findings also indicated that education was a powerful predictor of pain tolerance. Her data suggest that study subjects who found the experimenter to be friendly showed greater tolerance to pain than did those who found the experimenter to be dominant and hostile. When the experimenter was of the same race as the subject, she was perceived as being more friendly than when the experimenter's race differed from that of the subject. Reid concluded that interpersonal impact has a powerful influence on the expression of pain and for the meaning of the pain to the patient. The ethnicity and culture of the clinician may be as important as the patient's culture in determining the impact of pain and how it is treated. Davitz and Davitz, 1985Davitz L.L. Davitz J.R. Culture and nurses' inferences of suffering.in: Copp L.A. Perspectives on pain. Churchill Livingstone, New York1985: 17-28Google Scholar analyzed nurses' perception of their patients' pain. Because pain is a subjective phenomenon, the researchers wondered how the nurse's ethnicity influences the nurse's perception of suffering in the patient. The researchers focused on the systems of beliefs and attitudes underlying nurses' judgments of suffering and psychologic distress. First, they tested nurses by having them rate psychologic distress for patients of different ethnic and religious backgrounds, controlling for the age, gender, and physical condition of the patient. They found ethnic or religious background to be an important determinant of the nurses' inference of suffering. The nurses believed that Jewish and Spanish patients suffered the most, whereas Asian and Germanic/Anglo-Saxon patients suffered the least. Davitz and Davitz, 1985Davitz L.L. Davitz J.R. Culture and nurses' inferences of suffering.in: Copp L.A. Perspectives on pain. Churchill Livingstone, New York1985: 17-28Google Scholar suggested that these differences may be the result of acculturation into the nursing subculture and the influence of the greater general American culture. In another project, the Davitzes compared nurses caring for patients of like cultures (for example, Japanese nurses caring for Japanese patients and English nurses caring for English patients); the researchers compared 1,400 nurses in 13 countries. Their findings supported their hypothesis that nurses from different countries differ in their inferences of physical pain and psychologic distress.Pain always has communicative, behavioral, or symbolic implications. Crook (1985, p. 117) states that pain is a form of communication: "Whatever the original cause of the pain, it takes on secondary characteristics of a communicative, behavioral or symbolic nature." Applying Reid's and the Davitzes' findings to this notion, one can see that the communication works both ways. The person experiencing the pain is affected by the nurse, and the nurse is influenced by the patient's pain expressions. This is a critical concept for the nurse because the nurse's interpretation of the pain response surely affects treatment. If nurses are not cognizant of their beliefs and biases, they risk misunderstandings with many of their patients who are experiencing pain. "Pain in labor and childbirth is expected by some women in all societies but may be interpreted, perceived and responded to differently" (Kay, 1982Kay M.A. Anthropology of human birth. F. A. Davis Co., Philadelphia1982Google Scholar, p. 17). Chinese society values silence, and women experiencing the pain of childbirth typically believe they will dishonor themselves and their families by loud or wild response to pain. In Mayan society, women get support and encouragement during each contraction; however, if the women becomes overwrought with pain and fatigue, she may find herself being scolded or physically restrained. The Mayans see increasing pain as an indication of labor progress because the infant is born "in the very center of pain" (Jordan, 1978Jordan B. Birth in four cultures. Eden Press Women's Publications, Inc, St. Alban's1978Google Scholar, p. 27). Women from many South and Central American cultures see pain as important during childbirth and believe that the more intense the pain, the stronger the love toward the infant (Scott-Ramos, 1995Scott-Ramos I. Culturally sensitive care giving for the Latino woman. Lecture presented at the Medical College of Virginia Hospitals. Richmond, VA1995Google Scholar). Free vocalization of pain and beseeching prayer to Allah are common behaviors of Moslem women during labor. Some believe that the louder and more obvious the suffering, the more solicitous the husband will be during the postpartum period (Ahmad, 1994Ahmad S. Culturally sensitive caregiving for the Pakistani woman.. Lecture presented at the Medical College of Virginia Hospitals, Richmond, VA1994Google Scholar). There are numerous ethnologies and other writings that include detailed accounts of birthing customs, including how pain is exhibited and treated in cultures around the world. The Anthropology of Human Birth (Kay, 1982Kay M.A. Anthropology of human birth. F. A. Davis Co., Philadelphia1982Google Scholar) and Birth in Four Cultures (Jordan, 1978Jordan B. Birth in four cultures. Eden Press Women's Publications, Inc, St. Alban's1978Google Scholar) are fine examples. There also are numerous articles in the periodical literature regarding birth customs of particular cultures and subcultures. These ethnologies give specific information about women's responses to pain of labor and birth, as well as the customary response of the birthing attendants. These are fascinating readings for the obstetric nurse, but because each woman blends her native culture and her adoptive culture in a unique way, how can this wealth of information benefit any one particular patient-nurse interaction? An astute assessment can help the nurse to predict or understand her patient's response to labor pain and help in the planning of care. The most important source of information about the patient is, of course, the patient. Including a cultural assessment technique in the routine assessment of all patients is a vital step in providing optimal health care for women of all cultures. The literature contains numerous techniques for cultural assessment. The Leininger Assessment, the Tripp-Reimer Assessment, and the Boyle and Andrews Assessment (Ramer, 1992Ramer L. Culturally sensitive care giving and child- bearing families. March of Dimes Birth Defects Foundation, White Plains, NY1992Google Scholar) are a few of the widely used assessments. Each one of these includes considerable detail about history, art, religion, music, government, economics, health care values, family structure, communication, and attitudes. These are important characteristics to understand, but it obviously is not practical to do one of the assessments to evaluate each woman entering the health care system. When it is not feasible to do a complete cultural assessment, a briefer assessment can be done. Assessment of the laboring patient often is initiated under emergent conditions; thus, the nurse must have a cultural assessment built into the standard admission assessment. See Table 1 for an example of a cultural assessment that is brief enough to be used in almost any situation. This has been used effectively, even in the most dire emergencies, such as abruptio placentae and umbilical cord prolapse, to assure that communication is effective and the patient has information she needs to make appropriate choices. Such an assessment also ensures that the nurse can provide the necessary reassurance and support. Once this information has been gathered, a nursing diagnosis can be formulated. The following are the nursing diagnoses developed through the North American Nursing Diagnosis Association (NANDA) to address problems sometimes encountered in multicultural practice:1.Impaired verbal communication related to cultural differences2.Impaired social interaction related to social dissonance3.Noncompliance related to patient value system:a.health beliefsb.cultural influences Ramer, 1992Ramer L. Culturally sensitive care giving and child- bearing families. March of Dimes Birth Defects Foundation, White Plains, NY1992Google Scholar and Geissler, 1992Geissler E.M. Nursing diagnoses: A study of cultural relevance.Journal of Professional Nursing. 1992; 8: 301-307Abstract Full Text PDF PubMed Scopus (5) Google Scholar have criticized the NANDA nursing diagnoses; Ramer says that the diagnoses tend to mislabel and stereotype, branding the patient as “wrong” and the caregiver as “right.” Ramer also notes that automatically labeling the patient as “noncompliant” precludes the notion that the patient may be following a culturally acceptable solution to the problem. Geissler, surveying transcultural nursing experts, found the NANDA diagnoses to be limited in their clinical use. As the NANDA system is being reviewed and revised, nurses who are concerned about cross-cultural nursing care will be looking forward to revisions of the NANDA nursing diagnoses that are increasingly useful and reflect nurses’ respect of ethnically diverse clientele. The cultural assessment is a tool for identifying how a patient’s cultural beliefs and practices differ from or coincide with those of the dominant culture. When inconsistencies are identified, it should be determined if the practices or beliefs are neutral or beneficial, and they should be included in the plan of care. When practices seem to be contrary to the health goal, additional information can be obtained to determine the meaning of the practices, how important they are to the patient, and if they can be modified. Experiencing intense pain can impair one’s ability to think clearly and make decisions. The obstetric nurse may first encounter a patient when she in the throes of labor pain. The anxiety provoked by hospital admittance or illness is magnified when it occurs in the context of an unfamiliar culture. Nursing techniques that decrease feelings of alienation will increase the patient’s and family’s comfort and decrease anxiety. It is helpful to identify in advance the most commonly encountered ethnic groups and develop a profile of their culturally specific practices. Such preparation will give the staff a basic knowledge of childbearing practices general to the group and allow them to focus on the individual and her specific needs. Preparation also allows time to prepare materials in the native language, which can be useful for teaching and other communications. When planning improvements for cultural sensitivity in the environment, the focus can be on the groups most frequently encountered. For women who are not fluent in the local language, the nurse should speak slowly and clearly. It is not necessary to speak more loudly. Intonation also can be effective in getting across a point when the language is not understood. A calm, soft voice is soothing; a clear, friendly voice can instill confidence; and a firm, direct tone sometimes can help the patient overcome fear and panic. Some cultures have defining qualities of speech and nonverbal communication that may be radically different from that of the local culture. Modifying one’s communication to more closely blend with the patient’s culture may facilitate comfort in the situation. For example, Native Americans and Asians generally are quiet in voice and demeanor. The nurse who usually is boisterous may become more effective by more closely imitating the patient’s style. Use simple sentences and avoid idioms or slang that can be misunderstood. For example, referring to a small fetus as a “peanut” may not be considered a term of endearment in all cultures and could be confusing or insulting. When speaking to a patient from a different culture, it is important to validate that the information was received, either by questioning or having the patient restate the information in her own words. In addition, be alert for actions that indicate she did not understand the message. If communication becomes frustrating, nurses should remember that respect and warmth are characteristics that always can be communicated, regardless of language ability. When verbal communication is a problem, nonverbal messages increase in importance. Focus on the patient’s nonverbal behavior and pay attention to the nonverbal signals you broadcast. Nurses sometimes are unaware of their own facial expressions and may display expressions that are not congruent with the message they want to send. An awareness of body language can help the nurse to provide a therapeutic presence, even when words are not exactly understood. Athough touch is interpreted in different ways across cultures, soothing touch and physical care usually are reassuring to women undergoing the stress of labor or the anxieties of new motherhood. Specific cultural facts may avoid some pitfalls of nonverbal interactions, For example, many Asian cultures consider the head sacred, and touching the head may be considered impolite or impertinent. Eye contact is interpreted differently in different cultures. Westerners may interpret lack of eye contact as disinterest; however, a Chinese client who fails to make eye contact may be indicating respect for the status of the nurse. Middle Easterners may interpret direct eye contact as a sexual invitation (Galanti, 1991Galanti G. Caring for patients from different cultures. University of Pennsylvania Press, Philadelphia1991Google Scholar1, and Vietnamese patients may interpret eye contact as a challenge or a sign of deep passion (Giger CG Davidhizar, 1990, p 407). Other nonverbal aspects of communication such as gestures, demeanor, suitable use of names, and speed of service may be open to different interpretation by different cultural groups. When language is a barrier, it can be helpful to use visual graphs or scales. Check with the pediatric or anesthesia department in your institution to see if they use a visual pain scale. There is a color pain scale, which is commonly used in pediatrics. One visual analog pain scale uses a slide rule that can be used to assess pain in women who can not describe their pain in words. This tool can be helpful during the postpartum period for properly tailoring intravenous or epidural patient-controlled analgesia or other analgesia regimens. Another important tool is a pictorial description of the labor process. It can be used to keep the woman informed of her labor process. A picture of the epidural process helps women decide if they would like to use epidural pain relief and can assist in teaching before the procedure is done. When preparing written or visual materials, it is important to be cognizant of cultural principles and practices. Some materials will be more effective if they portray women and families similar to the women you are trying to reach. However, be aware that written materials can present problems. For example, Vietnamese women (Ha, 1994) have a belief that reading during the postpartum period will cause poor eyesight during old age and may not read printed materials. A number of culturally specific practices may influence comfort for postpartum women. Comfort requires meeting physical and emotional needs immediately after delivery. Acceptable foods and beverages for the postpartum period vary across cultures. In some Western hospitals, the common offering after delivery is a tall glass of ice water or a soda. However, many Asian women may want a warm beverage if they believe in a yin-yang theory of health and illness. After delivery, they believe they must remain warm and eat yang foods, including spices, coffee, beef, and fried foods. Tea, although warm, is considered a yin, or cold, food. A glass of ice water or a cold soda probably would not provide the comfort the nurse wishes to offer. Mexicans also have a hot-and-cold belief system, although the specifics differ. In situations such as these, offering a variety of foods and encouraging family members to bring food may increase comfort for the postpartum woman. Other postpartum comfort measures that may be culturally influenced are the use of analgesics, preferences regarding visitors, the desire to bathe or shower, the acceptance of nursing functions, environmental ease, and maternal concerns (Collins, McCoy, Sale, CG Weber, 1994). A number of cultures prohibit bathing soon after delivery, yet it is a common expectation in American and Canadian hospitals that the new mother will bathe as soon as she is able. Maternal concerns include the amount of time spent with the infant, including bonding, naming, dressing, and feeding. Each of these practices is influenced by culture. If the mother has different practices than those expected by the hospital staff, conflicts, anxiety, and discomfort may result. For example, Vietnamese families traditionally do not fuss over the new infant, to the point of seeming almost distant. The Vietnamese believe that this practice prevents evil spirits who steal infants from becoming aware of the infant. In this country, such parents have been reported to social service departments because the hospital staff feared that the children would not be properly cared for at home. In reality, the children were being protected by their parents. Does your hospital, birthing center, home health agency, office, or nursing school meet the spirit of the ANA position statement of cultural diversity in nursing practice? Nurses can assess the sensitivity of the clinical environment by honestly answering the questions listed in Table 2. Evaluating existing barriers is the first step toward improvement. Anyone working in perinatal nursing and wishing to improve understanding of women and families of other cultures cannot do better than to begin with the March of Dimes self-study module Culturally Sensitive Caregiving and Childbearing Families (Ramer, 1992Ramer L. Culturally sensitive care giving and child- bearing families. March of Dimes Birth Defects Foundation, White Plains, NY1992Google Scholar). This is a complete program for perinatal nurses and can be used for individual or group study. It includes didactic segments on key concepts of transcultural nursing, cultural profiles of groups commonly encountered in the United States, teaching and clinical guidelines, and plentiful resources for continued learning. The module also contains an extensive section of supplenientary materials that lists organizations, general readings, fiction, and other resources for understanding clients of other cultures. Many community agencies provide interpreters and other consultants to help with improving care for women and families of other cultures. Refugee and immigration services from various churches, civic organizations, or government agencies may be useful resources. These people can be helpful in translating written materials, interpreting one-on-one communications, or providing general information about a specific cultural group. Planning care with respect to a patient’s culture cannot prevent all culture clashes. Large health care institutions may have a department or committee that addresses the multicultural needs of patients or employees. One activity of this type of department may be organizing a language bank, a directory of in-house personnel who are willing to serve as interpreters. Another activity is a cultural exchange based on food, dance, or dress. Large institutions with an international staff or clientele can support other activities, such as volunteer language tutoring. A unit-based committee can accomplish a number of projects to improve the staffs ability to provide culturally sensitive care. Adding a transcultural nursing textbook to the unit library will raise awareness and provide information for care planning. The committee can develop flash cards of common phrases, provide a list of available interpreters, or sponsor a series of brown-bag lunches that feature speakers from commonly encountered cultural groups. Some nurses may think that learning specifics about other cultures will increase stereotyping and lead to less individualized treatment. Galanti, 1991Galanti G. Caring for patients from different cultures. University of Pennsylvania Press, Philadelphia1991Google Scholar explains how generalizing and stereotyping may appear similar but function differently. A stereotype is an endpoint: an assumption about a person is made based on some common information about the person’s group of origin, and one acts on that assumption, whether or not it is accurate for the individual. A generalization is a beginning point. It is information that can be a starting place for sensitive assessment and understanding of a person’s needs. Nurses who learn the general concepts of transcultural nursing and specific facts about people of various cultures will be prepared to provide the most ethical and effective care to all of their patients.