UNIVERSITAS INDONESIA

APPLICATION OF TRANSCULTURAL NURSING

Home Group 2 :

Awanda Putri Puspitasari (1706038771)

Citra Intan Widyasari (1706039124)

Sheren Christin Natalia (1706039010)

Vediana Aulia Rahman (1706039231)

Faculty of Nursing

Regular Student

2019
Table of Contents
CHAPTER I.................................................................................................................................. 1
INTRODUCTION ......................................................................................................................... 1
CHAPTER II ................................................................................................................................ 3
THEORY OVERVIEW................................................................................................................... 3
2.1 Concepts of Transcultural Nursing Theory...................................................................... 3
2.2 Metaparadigma of Leininger's Theory ............................................................................ 5
2.3 Leininger’s Theory Assumption ....................................................................................... 6
2.4 Leininger’s Transcultural Model (Sunrise Model) ........................................................... 8
CHAPTER III............................................................................................................................. 13
CASE: DIABETES MELLITUS IN JAVANESE PEOPLE ................................................................... 13
3.1 Definition and Etiology of Diabetes Melitus ................................................................. 13
3.2 Risk Factors of Diabetes Melitus .................................................................................. 13
3.3 Central Java People with Diabetes Melitus................................................................... 16
3.4 Components of Transcultural Nursing Related to Central Java Cultural Behaviour ..... 16
3.5 Nursing Care Plan for Risk for Unstable Blood Glucose Level....................................... 18
CHAPTER IV ............................................................................................................................. 19
CONCLUSION AND SUGGESTION ............................................................................................ 19
4.1 Conclusion ..................................................................................................................... 19
4.2 Suggestion ..................................................................................................................... 19
Bibliography ............................................................................................................................ 20

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 CHAPTER I

INTRODUCTION

Transcultural nursing is very important to be studied and explored further if we

want to apply it in life cycle. As a prospective nurse, it is very important to know the
application of transcultural nursing especially in its application in daily life. The
application of transcultural nursing in everyday life can be attributed to transcultural
nursing theories such as Leininger transcultural nursing theory. From the transcultural
nursing theory of Leininger, we can see how the role of Sunrise models in producing
a nursing care plan adapted to the various components that influence the provision of
nursing care.
We know that in Indonesia it consists of millions of people with various
cultures, races, ethnicities, and religions. Health problems that often appear in each of
these cultures will also be different when compared to other cultures. Therefore we
must be able to look at what interventions we should give to each culture if we get a
health problem or an illness.
The making of the nursing care plan can be related to the transcultural nursing
theory by Leininger, especially the Sunrise model. If we follow the guidelines in
Sunrise Leininger’s model of transcultural nursing, we must first be able to know
widely about the views of each culture regarding a disease and the problems that
often occur. After we know these views, we must relate them to the seven
components of Leininger's theory which will influence how a nurse arranges a
nursing care plan or nursing intervention for each of these cultures. Furthermore, in
providing intervention must be in accordance with the habits or culture adopted by
each ethnic or culture. So that the nursing care plan can be received and applied to the
maximum, that the process of healing a health problem can be overcome effectively
and efficiently.

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 One example is when we will provide health services to someone from a
Central Javanese cultural background. First we must know in advance the views,
habits, and things that are adopted by the people of Central Java. Furthermore, if a
health problem or an illness appears, we associate it with seven factors that might
influence the problem or cause of the disease. After that, we can determine the
nursing care plan that is appropriate and expected to be accepted in accordance with
the culture of the people of Central Java.
The purpose of this paper is to re-examine the transitional nursing theory by
Leininger. In addition, another goal is that we can develop a nursing care plan aimed
at each culture in Indonesia in accordance with Sunrise Model Leininger. In this
paper, we will mainly discuss the health problems of the people of Central Java
related to diabetes mellitus which often attacks the people of Central Java because of
poor living habits, especially in terms of diet and food choices.

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 CHAPTER II

THEORY OVERVIEW
2.1 Concepts of Transcultural Nursing Theory
a. Human Care and Caring
The concept of human care and caring refers to the abstract and manifest
phenomena with expressions of assistive, supportive, enabling, and
facilitating ways to help self or others with evident or antici- pated needs
to improve health, a human condition, or lifeways, or to face disabilities or
dying.
b. Culture
Culture refers to patterned lifeways, values, beliefs, norms, symbols, and
practices of individuals, groups, or institutions that are learned, shared,
and usually transmitted from one generation to another.
c. Culture Care
Culture Care refers to the synthesized and culturally constituted assistive,
supportive, enabling, or facili- tative caring acts toward self or others
focused on evident or anticipated needs for the client’s health or well-
being, or to face disabilities, death, or other human conditions.
d. Cultural and Social Structure Dimensions
Cultural and social structure dimensions refer to the dynamic, holistic, and
interrelated patterns of structured features of a culture (or subculture),
including religion (or spirituality), kinship (social), political characteristics
(legal), economics, education, technol- ogy, cultural values, philosophy,
history, and language.
e. Environmental Context
Environmental context refers to the totality of an environment (physical,
geographic, and sociocultural), situation, or event with related experiences

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 that give interpretative meanings to guide human expressions and
decisions with reference to a particular environment or situation.
f. Trans-cultural Nursing
Transcultural nursing refers to a formal area of humanistic and scientific
knowledge and practices focused on holistic Culture Care (caring) phe-
nomena and competencies to assist individuals or groups to maintain or
regain their health (or well- being) and to deal with disabilities, dying, or
other human conditions in culturally congruent and beneficial ways.
g. Culture Care Preservation or Maintenance
Culture Care preservation or maintenance refers to those assistive,
supportive, facilitative, or enabling professional actions and decisions that
help people of a particular culture to retain or maintain mean- ingful care
values and lifeways for their well-being, to recover from illness, or to deal
with handicaps or dying.
h. Culture Care Accommodation or Negotiation
Culture Care accommodation or negotiation refers to those assistive,
supportive, facilitative, or enabling professional actions and decisions that
help people of a designated culture (or subculture) to adapt to or to
negotiate with others for meaningful, beneficial, and congruent health
outcomes.
i. Culture Care Re-patterning or Restructuring
Culture Care repatterning or restructuring refers to the assistive,
supportive, facilitative, or enabling professional actions and decisions that
help clients reorder, change, or modify their lifeways for new, different,
and beneficial health outcomes.
j. Culturally Competent Nursing Care
Culturally competent nursing care refers to the explicit use of culturally
based care and health knowledge in sensitive, creative, and meaningful
ways to fit the general lifeways and needs of individuals or groups for

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 beneficial and meaningful health and well being, or to face illness,
disabilities, or death.

2.2 Metaparadigma of Leininger's Theory

Leininger defines the transcultural nursing paradigm as a perspective, belief, values,
concepts in the implementation of nursing care in accordance with the cultural
background of the four central concepts of nursing, namely:
a. Human
Humans are individuals, families or groups that have values and norms that are
believed and are useful for making choices and making choices. According to
Leininger, humans have a tendency to maintain their culture at any time wherever
they are.
b. Health
Health is the overall activity that the client has in filling his life, lies in the range of
health and illness. Health is a belief, value, pattern of activities in a cultural context
that is used to maintain and maintain a balanced / healthy state that can be observed
in daily activities. Clients and nurses have the same goal, namely to maintain a
healthy state in an adaptive range of health.
c. Environment
Environment is defined as the overall phenomenon that affects the development, trust
and behavior of the client. Environment is seen as a totality of life where clients with
their culture interact with each other. There are three environmental forms, namely:
physical, social and symbolic. The physical environment is a natural environment or
created by humans such as the equator, mountains, dense settlements and climate like
houses in the Eskimo area that are almost closed because there is never a sun all year
long. The social environment is the whole social structure that is related to the
socialization of individuals, families or groups into the wider community. Within an
individual's social environment must follow the structure and rules that apply in that
environment. The symbolic environment is the whole form and symbol that causes

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 individuals or groups to feel united like music, art, life history, language and
attributes used.
d. Nursing
Nursing care is a process or series of activities in nursing practice that is given
to clients according to their cultural background. Nursing care is intended to
empower individuals according to the client's culture. The strategies used in
implementing nursing care are:
 Strategy I, protect / maintain culture.
Maintaining culture is done if the patient's culture does not conflict with
health. Nursing planning and implementation is given according to the
relevant values that the client has so that the client can improve or maintain
his health status, for example sports culture every morning.
 Strategy II, Accommodating / negotiating culture.
Nursing intervention and implementation at this stage is done to help clients
adapt to certain cultures that are more beneficial to health. Nurses help clients
to be able to choose and determine other cultures that are more supportive of
improving health, for example a pregnant client has an abstinence that smells
fishy, so fish can be replaced with animal protein sources.
 Strategy III, Change / change client culture

Restructuring the client's culture is done if the culture that is owned is

detrimental to health status. The nurse seeks to restructure the lifestyle of
clients who usually smoke into non-smoking. The pattern of life plan chosen
is usually more profitable and in accordance with the beliefs adopted.

2.3 Leininger’s Theory Assumption

The Culture Care Theory defines nursing as a learned scientific and
humanistic profession that focuses on human care phenomena and caring
activities in order to help, support, facilitate, or enable patients to maintain or
regain health in culturally meaningful ways, or to help them face handicaps or
death.

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 Leininger's model makes the following assumptions:

1. Care is the essence of nursing and a distinct, dominant, and unifying focus.
2. Caring is essential for well-being, health, healing, growth, and to face death.
3. 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.
4. Nursing is a transcultural, humanistic, and scientific care discipline and
profession with the central purpose to serve human beings worldwide.
5. Caring is essential to curing and healing. There can be no curing without
caring.
6. Culture care concepts, meanings, expressions, patterns, processes, and
structural forms of care are different and similar among all cultures of the
world.
7. Every human culture has lay care knowledge and practices and usually some
professional care knowledge and practices which vary transculturally.
8. Culture care values, beliefs, and practices are influenced in the context of a
particular culture. They tend to be embedded in such things as worldview,
language, spirituality, kinship, politics and economics, education, technology,
and environment.
9. Beneficial, healthy, and satisfying culturally-based nursing care contributes to
the well-being of individuals, families, and communities within their
environmental context.
10. 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.
11. Culture care differences and similarities between the nurse and patient exist in
any human culture worldwide.

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 12. 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.
13. The qualitative paradigm provides new ways of knowing and different ways
to discover the epistemic and ontological dimensions of human care.

2.4 Leininger’s Transcultural Model (Sunrise Model)

The function of Leininger’s transcultural model (sunrise model) is used by

nurses as a basis for thinking and providing solutions to client problems (Andrew and
Boyle, 1995).

Figure 1. Leininger’s Sunrise Model of Transcultural Nursing

Symbolizing the essence of transcultural nursing before giving nursing care
plan to clients (individuals, families, communities, institutions), nurses must have a
worldview of dimensions, culture & conditional social structures in a narrow
environment. Concept of transcultural nursing are about culture, cultural value,
difference of culture, ethnocentric, ethnic, race, ethnography, care, caring, cultural
care, and cultural imposition.

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 Assessment (collecting data to identify) client health problems in accordance
with the client's cultural background (Giger and Davidhizar, 1995), designed based
on 7 components.
1. Technological factors
• Includes: any technology that is used by the family to overcome health
problems.
• Regarding to:
• Perception about the use of technology to deal with health problems
• Reasons for seeking health assistance
• Healthy perceptions of sickness
• Medical habits and dealing with health problems
2. Religious and philosophical factors
• Regarding to:
• Adhered religion
• Religious habits that have a positive impact on health
• Efforts to seek health assistance
• Complete self-concept
• Marital status
• Client perceptions of health
• How to adapt to the current situation
• Perspective client to the cause of the disease
• How to treat the disease and how to transmit it to others

3. Kinship and social factors

• Regarding to:
• Full name and nickname
• Clan
• Age or date of birth
• Gender
• Status

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 • Type of family
• Family growth
• Decision making in family members
• Client relationships with family planning
• Routine habits carried out by the family

4. Cultural values and lifestyle factors

• Regarding to:
• Position
• Language used
• Nonverbal language that is often shown by clients
• Self-cleaning habits
• Eating habits
• Abstinence from certain foods related to the condition of the body
• Entertainment facilities used
• Perception of pain related to daily activities

5. Political and legal factors

• Regarding to:
• Regulations and policies relating to visiting hours
• The number of family members who may wait
• How to pay for clients who are treated
6. Economic factors
• Regarding to:
• Client's work
• Source of medical expenses
• saving habits and the amount of savings a month
7. Educational factors
• Regarding to:
• The last level of education

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 • Training that has been obtained
• Type of education and its ability to actively learn independently
Nursing diagnosisis the response of clients according to cultural backgrounds
that can be prevented, changed or reduced through nursing interventions. (Giger and
Davidhizar, 1995). There are three nursing diagnoses that are often enforced in
transcultural nursing care, namely:
• Verbal communication disorders associated with differences in culture
• Disruption of social interactions related to sociocultural disorientation
• Non-compliance in treatment related to the value system that is believed
Planning and implementation in traditional nursing is an inseparable nursing
process.
• Planning is a process of choosing the right strategy and implementation is
carrying out actions that are in accordance with the client's cultural background
(Giger and Davidhizar, 1995).
• There are three guidelines offered in transcultural nursing (Andrew and Boyle,
1995), namely:
• Maintaining the culture of the client if the client's culture does not conflict with
health
• Accommodating the client's culture if the client's culture is less favorable to
health
• Changing the client's culture if the client's culture conflicts with health.
Planning and implementation
a. Cultural care preservation / maintenance
1) Identify differences in concepts between clients and nurses about childbirth
and baby care
2) Be calm and in no hurry when interacting with clients
3) Discuss the cultural gaps that clients and nurses have
b. Cultural care accommodation / negotiation
1) Use language that is easily understood by clients
2) Involve the family in planning care

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 3) If the conflict is not resolved, conduct negotiations where agreement is based
on biomedical knowledge, client's views and ethical standards
c. Cultual care repartening / reconstruction
1) Give the opportunity to the client to understand the information provided and
implement it
2) Determine the level of difference patients see themselves from group culture
3) Use a third party if necessary
4) Translate the terminology of patient symptoms into health languages that can
be understood by clients and parents
5) Give information to clients about the health care system
Transcultural nursing care evaluation is carried out on the success of the client
about maintaining a culture that is in accordance with health, reducing the client's
culture that is not in accordance with health or adapting to a new culture that may be
very contrary to the culture of the client. Through evaluation, it can be seen that
nursing care is appropriate to the client's cultural background.

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 CHAPTER III

CASE: DIABETES MELLITUS IN JAVANESE PEOPLE

3.1 Definition and Etiology of Diabetes Melitus
Diabetes Melitus (DM) is a condition of chronic hyperglycemia accompanied
by various metabolic disorders caused by hormonal disorders that cause various
kinds of chronic complications in the eye organs, kidneys, nerves, blood vessels
accompanied by lesions on the inner basement membrane using examination in a
microscope (AriefMansjoer et al., 2005).
According to ArifMansjoer (2005), there are two classifications in diabetes
mellitus, including: Type I Diabetes (Insulin Dependent Diabetes Mellitus
(IDDM)). This type of diabetes is also a type of diabetes which is often called
DMTI, which is Diabetes Mellitus Depends on Insulin. In this type, caused by
beta cell formation, the island of Langerhans is caused by autoimmune and
idiopathic processes. Type II Diabetes Mellitus, type II diabetes or Non Insulin
Dependent Diabetes Mellitus (NIDDM) or neat DMTTI namely Diabetes Mellitus
Does Not Depend on Insulin. Type II diabetes is caused due to the beta failure
and insulin resistance. Insulin resistance is a decrease in the ability of insulin to
stimulate glucose uptake by peripheral tissue, to inhibit glucose production by the
liver. These beta cells cannot match insulin resistance completely, which can
mean insulin defensiveness, this inability can be seen from reduced insulin
secretion to glucose and glucose stimulation along with other insulin secretion
stimulants, so the pancreatic beta cells desensitize glucose.

3.2 Risk Factors of Diabetes Melitus

Which includes DM risk factors according to Perkeni (2011), namely:
a. Unmodifiable risk factor is a risk factor that has existed and is attached to
someone throughout his life. So that these risk factors cannot be controlled by
him. DM risk factors that cannot be modified include
1. Race and ethnicity

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 The race or ethnicity in question is for example ethnic or local
culture where ethnicity or culture can be one of the risk factors for DM
originating from the surrounding environment (Masriadi, 2012).
2. Family history with DM
A child who is the first descendant of a parent with DM
(father, mother, male, sister) is at risk of suffering from diabetes. If
one of his parents suffers from DM, the risk of a child getting type 2
diabetes is 15% and if both parents suffer from DM, then the chances
of the child being affected by type 2 diabetes are 75%. In general, if
someone has diabetes, their siblings have a DM risk of 10%
(Kemenkes, 2008).
DM-affected mothers have a greater risk of 10-30% of fathers with
DM. This is due to a decrease in genes while in the womb is greater
than a mother (Trisnawati&Soedijono, 2013).
3. Age
The risk of developing glucose intolerance increases with age.
At the age of more than 45 years, a DM examination should be done.
Diabetes is often found in people of old age because at that age,
physiological function decreases and there is a decrease in insulin
secretion or resistance so that the ability of 9 bodily functions to
control high blood glucose is less optimal (Gusti&Ema, 2014).
4. Birth History
Giving birth to a baby with a birth weight of more than 4000
grams or a history of having gestational diabetes mellitus (DMG) has
the potential to suffer from type 2 diabetes or gestational diabetes.
Women who have given birth to a child weighing more than 4 kg are
usually considered pre-diabetes (Kemenkes, 2008).
b. Modifiable risk factors:
1. Excess weight (IMT > 23 kg/m2)

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 Obesity is an imbalance between consumption of calories with
energy needs stored in the form of fat (subcutaneous tissue of curtain
of intestines, vital organs of the heart, lungs, and liver). Obesity is also
defined as being overweight. The adult body index is normally
between 18.5-25 kg / m2. If it is more than 25 kg / m2, it can be said
that someone is obese (Gusti& Erna, 2014).
2. Lack of physical activity
Lack of physical activity and excess body weight are the most
important factors in increasing the incidence of type 2 Mellitus
Diebets worldwide (Rios, 2010). According to WHO what is meant by
physical activity is an activity of at least 10 minutes without stopping
by carrying out mild, moderate or severe physical activities.
Physical activity and regular exercise are very important in
addition to avoiding obesity, also to prevent the occurrence of type 2
diabetes mellitus. When doing activities and moving, muscles use
more glucose than when they do not move. Thus the blood glucose
concentration will decrease. Through sports / physical activities,
insulin will work better, so that glucose can enter the muscle cells to
be used (Soegondo, 2008).
3. Hypertension (> 140/90 mmHg)
Some literature links hypertension to insulin resistance. The
effect of hypertension on the incidence of diabetes mellitus is caused
by thickening of the arteries which causes the blood vessel diameter to
narrow. This will cause the process of transporting glucose from the
blood to the cells to be disrupted. A person with hypertension is 2.3
times at risk for type 2 Diabetes Mellitus (Wiardani, 2010).

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3.3 Central Java People with Diabetes Melitus
When nurses want to make a nursing care plan, we have to knowing about
habits of the culture especially in Central Java. There several behaviour of
Central Java people that related to causes of people with Diabetes Mellitus.
1. Eat regularly, but with a lot of portion.
2. Often drinking sweet drinks such as tea, coffee, and milk after eating,
especially after breakfast.
3. Often consume fried foods to overcome hunger  fried tempeh, bakwan,
peyek, chips, tahupetis.
4. Frequently consume foods containing starch, sticky rice, flour and rice as
traditional foods arem-arem, lemper, cetil, lupis, rengginang, putuayu,
meniran, gethuk, etc.
5. When celebrating Javanese tradition, it often serves sweet foods, such as
"jenang", porridge with Javanese sugar, "wajik", etc.
6. At certain celebrations there is often held a tradition of “muluk" or "puluk"
eating, which is eating hands on banana leaves with a large amount of food and
the people are free to eat as much as they can without knowing how much they
eat
7. Also often snacking on high carbohydrate foods such as boiled / fried
cassava, boiled corn, boilled / fried breadfruit.
8. In celebrations such as weddings, circumcisions, aqiqahan, the people of
Central Java often serve high-fat food as a buffet dish  Goat curry /
gulaikambing, chicken or meat stews / semur, oseng / stir fried potatoes, oseng /
stir fried innards, etc.

3.4 Components of Transcultural Nursing Related to Central Java Cultural

Behaviour
 Technological factors: there are several ways that used to serve food,
means that technology that they use already sufficient.

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 Religion and philosophical factors: there are some celebrations that have
specific food to eat and specific way to held, that passed through
generations until now.
 Kinship and social factors: Javanese are very close even with extended
family, they often do celebration with their neighbor and family.

 Cultural values, beliefs and life ways  they depends on their cultural
values and beliefs, to overcome situations.
 Political and legal factors  traditional rules are very common in
community.
 Economic factors  many foods using ingredients that have a cheap cost
(tempeh cassava) they also have specific occasion to eat expensive food
(aqiqah)
 Educational factors  their food didn’t contain enough nutrition, since
they often consume sweet food and lack of fruit and vegetable.
o Nursing Care Plan

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3.5 Nursing Care Plan for Risk for Unstable Blood Glucose Level

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 CHAPTER IV

CONCLUSION AND SUGGESTION

4.1 Conclusion
The Javanesse People often eat fried foods and drinking sweet drinks such as
tea, coffee, and milk after eating, especially after breakfast. They frequently consume
foods containing starch, sticky rice, flour, and rice. In celebrations such as weddings,
circumcisions, aqiqahan, the people of Central Java often serve high-fat food as a
buffet dish (Goat curry / gulaikambing, chicken or meat stews / semur, oseng / stir
fried potatoes, oseng / stir fried innards, etc.).

Leininger defines the transcultural nursing paradigm as a perspective, belief, values,

concepts in the implementation of nursing care in accordance with the cultural
background of the four central concepts of nursing.

Leininger’s Transcultural Model is used by nurses as a basis for thinking and

providing solutions to client’s problem. The model is symbolizing the essence of
transcultural nursing. Component of transcultural nursing are technological factors,
religious and philosophical factors, kinship and social factors, cultural values and
lifestyle factors, political and legal factors, economic factors and educational factors.

4.2 Suggestion
As a future nurse, we need to know more about transcultural nursing and
Leininger’s Theory. We have to searching for other information besides of the
information that given in this paper. We should control our food and educate people
around us to eat healthy food. We need to treat other people based on what we learnt
from this paper.

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 Bibliography
Andrew. M & Boyle. J.S. (1995). Transcultural Concepts in Nursing Care, 2nd Ed.
Philadelphia: JB Lippincot Company.

Giger. J.J & Davidhizar. R.E. (1995). Transcultural Nursing: Assessment and
Intervention, 2nd Ed. Missouri: Mosby Year Book Inc.

Gusti & Erna. 2014. Hubungan Faktor Risiko Usia, Jenis Kelamin, Kegemukan dan
Hipertensi dengan Kejadian Diabetes Mellitus Tipe 2 di Wilayah Kerja
Puskesmas Mataram. Media Bina Ilmiah. Volume 8. No.1 : 39-44.

Masriadi. 2012. Epidemiologi. Yogyakarta: Penerbit Ombak

PERKENI. 2011. Konsensus Pengelolaan Diabetes Melitus Tipe 2 di Indonesia 2011.

Semarang: PB PERKENI.

Rios, M.S. 2010. Type 2 Diabetes Mellitus. Barcelona: Elsevier Espana.

Soegondo, S., 2008. Hidup Secara Mandiri dengan Diabetes Melitus Kencing Manis
Sakit Gula. Jakarta: Fakultas Kedokteran Universitas Indonesia

Trisnawati, KS., Setyorogo, Soedijono. 2013. Faktor Risiko Kejadian Diabetes

Mellitus Tipe 2 Di Puskesmas Kecamatan Cengkareng Jakarta Barat Tahun
2012. Jurnal Ilmiah Kesehatan. Vol 5 No. 1 : 6-11

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