Transcultural Nursing in Remote Areas

Two nurses meeting with a couple in a hospital room.
Over the course of the next few decades, America’s population will become more racially and ethnically diverse, with minority groups projected to make up more than half the population by 2045, according to the U.S. Census Bureau.

Meanwhile, the number of people living in or moving to rural and remote areas of the U.S. is growing. According to census data, while the majority of Americans still live in urban areas, roughly 20% of the country lives in rural areas. A smaller but still sizable percentage of the population lives in remote areas. More Americans are showing interest in moving to rural and remote areas where access to health care may be challenging.

As the nation undergoes these demographic and societal shifts, nurses and other medical professionals will increasingly come into contact with patients of varying backgrounds. Concepts such as cultural competence and transcultural nursing — a nursing philosophy that emphasizes incorporating patients’ cultural backgrounds into their medical care — are essential to providing quality health care.

Nursing professionals working in rural and remote areas, in particular, need to have an understanding of these practices to provide culturally sensitive care, which holds benefits for both patients and providers.

What Is Transcultural Nursing?

While the concept of transcultural nursing was established almost 70 years ago, its principles are more relevant than ever as the world becomes more diverse and interconnected. What is transcultural nursing exactly?

Culture can influence health care in many different ways, such as how patients perceive their illness, whether they seek treatment, and how they respond to treatment. It may also influence what kinds of medications patients take or are open to taking. The term "transcultural nursing" refers to a nurse’s ability to factor a patient’s cultural background — including beliefs and values, religion, lifestyle, and family history — into medical care.

Understanding and respecting a patient’s cultural background and using that knowledge to develop a care plan is critical. It can have a direct impact on the quality of care delivery and, ultimately, the health of the patient. According to Cigna, culturally sensitive health care can help reduce many health disparities, including language barriers, medical biases, issues related to care access and quality, and low health literacy.

Nurses are well suited to provide culturally sensitive care because the profession generally approaches medical care from a holistic perspective, viewing the patient as a whole person rather than merely an illness or set of symptoms. Also, because they are often the first point of contact for patients, nurses are uniquely positioned to provide culturally sensitive care at the earliest stages of treatment.

Health care centered on transcultural nursing often begins with a culturological assessment, which identifies a patient’s cultural background. This information is then used to craft the nursing care plan. The culturological assessment process may also involve a self-assessment that focuses on how nurses are influenced by their own cultural background and attitude toward caring for patients from different cultures.

History of Transcultural Nursing

Transcultural nursing first emerged as an area of study and practice in the mid-1950s, spearheaded by Dr. Madeleine Leininger. Leininger, a registered nurse, developed the theory of transcultural nursing — also known as Culture Care Theory — and wrote multiple books on the subject in which she laid out the principles of the theory and explained its practical applications.

The three core principles that Leininger said nurses should follow to achieve culturally sensitive care are:

  • Cultural preservation or maintenance. Nurses work with patients to maintain patients’ cultural values in the context of health care provision.
  • Cultural care accommodation or negotiation. Nurses work with patients to adapt their cultural beliefs or values to a care plan in the interest of producing a positive health outcome.
  • Cultural care repatterning or restructuring. Nurses work with patients to reorder, change, or modify their way of life to improve their health conditions, while still respecting patients’ cultural values and beliefs.

Leininger also led the founding of the Transcultural Nursing Society in 1974. Today, the society advocates for transcultural nursing practices across the globe and provides resources for nurses and other health care professionals to deliver culturally competent care. The society holds an annual conference open to nurses and other medical professionals across the globe to meet and explore contemporary issues in the field of transcultural nursing.

Transcultural Nursing in Rural and Remote Areas

Approximately 60 million people — roughly 20% of the country — lived in rural America as of the 2010 census, according to the U.S. Census Bureau. Due to various factors, populations in rural and remote areas generally face more hurdles in accessing health care than their urban counterparts.

Applying the principles of transcultural nursing in rural and remote areas can help minimize the health disparities these populations often experience.

Access to Health Care in Rural Areas

Residents living in rural or remote areas of the U.S. often encounter obstacles that can limit their ability to get the health care they need. For one, these areas generally have fewer health care facilities than do urban environments, and therefore fewer health care services are available.

However, even if health care services are in steady supply, residents of these areas may experience other issues that impact their access, such as:

  • Financial means. A lack of health insurance coverage or other means may limit residents’ ability to pay for health care services. According to the findings of a 2019 report from the Robert Wood Johnson Foundation, 45% of adults in rural America said they could not get necessary health care because they were unable to afford it.
  • Distance. Reliable transportation may be an issue in rural and remote areas where health care facilities are far away. After affordability, the most cited obstacle to health care in the report from the Robert Wood Johnson Foundation was distance and/or an inability to get to a health care location, with 23% of respondents saying it prevented them from receiving needed services. Patients may also be limited in their ability to take time off work — especially paid time off — to receive services.
  • Communication. Patients, particularly those who are not fluent in English or have poor health literacy, may lack the confidence to communicate with health care providers,
  • Trust. Patients in these areas may be concerned about compromising their privacy by using health care services and about the quality of care they receive.

Another issue impacting access to health care is the ongoing nationwide nursing shortage, which has hit rural communities hardest, according to the National Rural Health Association. Rural health care facilities may struggle to maintain appropriate staffing, forcing them to implement short-term fixes or work-arounds that can impact the quality of care.

Further underscoring the importance of transcultural nursing is mounting evidence that more people may be flocking to more rural areas of the U.S. According to 2019 census data, many of the states that had the highest percentage of new residents are among the most rural or remote states in the country, including Hawaii, Alaska, Montana, New Hampshire, North Dakota, and Wyoming.

This data was collected prior to the COVID-19 pandemic, which may have exacerbated this trend due to the need for social distancing and the subsequent surge in remote work. A survey Gallup took at the end of 2020 indicated heightened interest in moving to more rural areas, with nearly a third of Americans saying they would prefer to live somewhere rural rather than urban or suburban. That is up from 27% who said they would prefer to live in a rural area in 2018.

Importance of Nurses

Nurses are vital to bridging cultural gaps and the health disparities they can cause. In many rural and remote communities, where access to health services is limited, nurses are often the primary care providers. A 2018 study by the Journal of General Internal Medicine found that nurses and other nonphysician clinicians were more likely to practice in rural areas than physicians.

Nurses in rural and remote areas also often live in the communities they work in and, as a result, have a better understanding of the culture of those areas and the issues impacting public health.

Given the hurdles patients in these areas face, transcultural nursing principles are critical to overcoming health disparities. To ensure that they are providing culturally sensitive care, nurses can employ a few relatively simple practices, including the following:

  • Establish clear communication. Nurses should understand their patients’ preferred method of communication and arrange for an interpreter if necessary.
  • Be aware of nonverbal cues. Nurses should be aware of the importance of nonverbal communication and how it can differ significantly across cultures.
  • Ask about relevant traditions or customs. Part of the culturological assessment may include exploring spiritual or religious practices, dietary considerations, and cultural norms that may impact a patient’s health situation.

Culturally competent nursing care is especially important in light of the growing shortage of primary care physicians across the country. As with the nursing shortage, this issue has disproportionately impacted rural communities. According to the Association of American Medical Colleges, only 11% of physicians nationwide practice in rural communities. Meanwhile, of the 7,200 federally designated health professional shortage areas (HPSAs), 3 in 5 are in rural regions.

Achieving Cultural Competency in Nursing

Transcultural nursing is a form of cultural competency in nursing. Culturally competent health care tailors treatment to patients’ social, cultural, and linguistic needs. The concept of cultural competence is broader than transcultural nursing, putting the onus on not only nurses but every health care professional, as well as the health systems they represent.

Effective cultural competence is vital to delivering quality health care and improving patient outcomes. Studies have shown that patients — particularly those from minority groups — are more likely to trust their provider and be more engaged with their treatment when their provider shares or understands their cultural values or beliefs. This increased trust and engagement can lead to increased adherence to treatment guidelines and, ultimately, better health outcomes.

Nurses are often a patient’s primary care provider, particularly in rural and remote areas where access to health care services may be limited, and play a vital role in culturally competent health care.

How to Be a More Culturally Competent Nurse

In addition to exacerbating preexisting health disparities, failing to factor cultural considerations into health care can have adverse effects for patients, such as diagnostic errors, missed screenings, and unanticipated negative reactions to medication. Therefore, nurses must practice cultural competency when treating patients.

Nurses can ensure that the care they provide is inclusive and sensitive to patients of varying cultural backgrounds in many ways, including the following:

  • Nurses use a culturological assessment, or cultural assessment, to gather information about the patient’s cultural background and take that information into consideration in crafting their care plan.
  • Transcultural nursing also often entails a self-assessment, in which nurses examine and address their own cultural biases. Doing so can help nurses improve their cultural competence.
  • Language can be a significant barrier to health equity, so learning a second language or seeking assistance from an interpreter or bilingual colleague can help overcome cultural disparities.
  • Cultural competence training can help nurses and other providers develop better cultural awareness in various settings and with different cultural groups. Numerous organizations provide training.

Nurses should also be familiar with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. The National CLAS Standards, which the U.S. Department of Health & Human Services developed, are a set of guidelines designed to help providers advance health equity, reduce disparities, and improve the overall quality of care.

Benefits of Culturally Competent Health Care

Exercising cultural competency in health care has numerous benefits. Its primary aim is to reduce the health disparities between patients of different backgrounds and help increase health equity. Achieving this can yield additional benefits on many fronts.

Health Benefits

An analysis by Hospital Pediatrics, a medical journal from the American Academy of Pediatrics, revealed that hospitalized Latino children were more likely to experience preventable adverse events than non-Latino white children, due in large part to language barriers.

On the other hand, by working to minimize disparities, culturally competent care can ultimately improve patient health. It can increase patient engagement, improve the collection of patient data, reduce medical errors, and enhance preventive care and treatment adherence.

Financial Benefits

Culturally competent care can also help a health care organization’s bottom line. It can improve the efficiency of medical services, reducing the cost of medical care for providers, as well as minimize the risk of malpractice lawsuits resulting from misdiagnosis and medical errors.

Nursing care often focuses on preventive care, health promotion and education, and helping patients make better lifestyle choices. In doing so, nurses may be able to help patients reduce their own health care expenses, which is often a concern for minority patients and those in rural areas.

Social Benefits

Practicing cultural sensitivity also helps increase trust in the community — which can be a significant barrier to health equity — and may improve public health.

A study by PLOS One indicated that Black patients at one primary care clinic rated their providers’ behaviors and attitudes significantly higher after employees of the clinic underwent cultural sensitivity training.

Transcultural Care in a Changing America

As America grows ever more diverse, it will be increasingly important for health care providers to provide culturally competent care. Applying the principles of transcultural nursing can help nurses reduce health disparities and increase health equity. These practices are particularly vital for nurses working in rural and remote communities, where they are more likely to interact with patients from different cultural backgrounds.

An advanced degree, such as Hawai‘i Pacific University’s online Master of Science in Nursing to Doctor of Nursing Practice program, can help nurses acquire the skills they need to provide culturally competent care in various settings, including rural and remote areas. The program helps prepare students for leadership opportunities and advance their understanding of transcultural care.

The program’s fully online coursework offers flexibility, with small class sizes that provide an intimate learning experience with accessible faculty. Learn more about the program and how it can help you advance your nursing career today.

Recommended Readings
How Family Nurse Practitioners Can Play a Major Role in Addressing the Growing Physician Shortage in the U.S.  
The Benefits of Advanced Nursing: What Is the Expected MSN Salary Range? 
Careers in Advanced Nursing: What Is a Family Nurse Practitioner?

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Cigna, Cultural Competency in Health Care
Gallup, "Country Living Enjoys Renewed Appeal in U.S."
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Nursing Theory, Madeleine Leininger — Nursing Theorist                    
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