Summary Of WOUND HEALING

The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. This overview will help in identifying the various stages of wound healing.

I. Inflammatory Phase

A) Immediate to 2-5 days B) Hemostasis

• Vasoconstriction
• Platelet aggregation
• Thromboplastin makes clot

C) Inflammation

• Vasodilation
• Phagocytosis 

II. Proliferative Phase

A) 2 days to 3 weeks B) Granulation

• Fibroblasts lay bed of collagen
• Fills defect and produces new capillaries

C) Contraction

• Wound edges pull together to reduce defect

D) Epithelialization

• Crosses moist surface
• Cell travel about 3 cm from point of origin in all directions 

III. Remodeling Phase

A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds

C) Scar tissue is only 80 percent as strong as original tissue

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Staffing in Nursing Servce

Introduction:

In an organization always there are too many things to think about, too many factors to consider, too diversified knowledge required for solution for the unaided capacity one leader to encompass. So, the chief and other executives at head of major organization need help and the individual officer and units that render this help are known as staff officers of the units. Staffs is an expans

ion of the personality of the executive which means more eyes, more ears, and more hands to help the executive in forming and carrying out his plans.

Meaning of staffing:
Staffing is a selection, training, motivating and retaining of a personnel in the organization. Before the selection of the employees, we have to make analysis of the particular job, which is required in the organization, then comes the selection of personnel.

Actions involved in staffing:

1. Identifying the type and amount of service needed by agency client.
2. Determining the personnel categories that have the knowledge and skill to perform needed service measures.
3. Predicting the number of personnel in each job category that will be needed to meet anticipated service demands.
4. Obtaining, budgeted positions for the number in each job category needed to service for the expected types and number of clients.
5. Recruiting personnel to fill available positions.
6. Selecting and appointing personnel from suitable applicants.
7. Combining personnel into desired configurations by unit and shift.
8. Orienting personnel to fulfil assigned responsibilities.
9. Assigning responsibilities for client services to available personnel.

Staffing involves man power planning:
Man power planning may be defined as a strategy for the acquisition, utilization, improvement and preservation of the human resources of an organization. This involves ensuring that organization has enough of the right kind of people at the right time and also adjusting the requirements to the available supply.

The main objectives of man power planning include:

1. Ensuring maximum utilization of the personnel
2. Assessing future requirements of the organization
3. Determining the recruitment sources.
4. Anticipating from past records, i.e. resignations, simple discharge, dismissal and retirements.
5. Determining training requirements for management's development and organizational development.

Major activities of manpower planning:

* Forecasting future manpower requirements
* Inventorying, present manpower resources and analysing the degree to which these resources are employed optimally.
* Anticipating manpower problem by projecting present resources into the future and comparing them with forecast of requirement of requirement to determine their adequacy, both quantitatively, and qualitatively
* Planning the necessary program, recruitment, selection, training, development, motivation and compensation, so that future manpower requirements will be met.

Steps of manpower planning:

1. Scrutiny of present personnel strength.
2. Anticipation of man power needs.
3. Investigation of turnover of personnel
4. Planning job requirements and job descriptions

Steps of staffing:

1. Determine the number and types of personnel needed to fulfil the philosophy, meet fiscal planning responsibilities, and carryout the chosen patient care management organization
2. Recruit, interview, select, and assign personnel based on established job description performance standards.
3. Use organizational resources for induction and orientation
4. Ascertain that each employee is adequately socialized to organizational values and unit norms.
5. Use creative and flexible scheduling based on patient care needs to increase productivity and retention
6. Develop a program of staff education that will assist employees meeting the goals of the organization.

Philosophy of staffing:
Philosophy: a statement encompassing ontologic claims about the phenomena of central interest to a discipline, epistemic claims about how the phenomena came to be known, and what members of the discipline value.
There are three general philosophies of personnel management. The first is based on organizational theory, the second on industrial engineering, and the third on behavioural science.
The organizational theorist believes that

* Human needs are either so irrational or so varied and adjustable to specific situations that the major function of personnel management is to be pragmatic as the occasion demands.
* ? If the jobs are organized in a proper manner, he reasons, the result will be most efficient job structure, and the most favourable job attitudes will follow as a matter of course.

The industrial engineer believes that

* The man is mechanistically oriented and economically motivated and his needs are best met by attuning the individual to the most efficient work process.
* The goal of personnel management therefore should be to concoct the most appropriate incentive system and to design the specific working conditions in a way that facilitates the most efficient use of the human machine.
* By structuring jobs in a manner that leads to the most efficient operation, the engineer believes that he can obtain the optimal organization of work and the proper work attitudes.

The behavioural scientist believes that

* The behavioural scientist focuses on group sentiments, attitudes of individual employees, and the organizations' social and psychological climate.
* Personnel management generally emphasizes some form of human relations education, in the hope of instilling healthy employee attitudes and an organizational attitudes and an organizational climate which he considers to be felicitous to human values. He believes that proper attitudes will lead to efficient job and organizational structure.

Philosophy of staffing in nursing:

* Nurse administrators of a hospital nursing department should adopt the following staffing philosophy.
* Nursev administrators believe that it is possible to match employees' knowledge and skills to patient care needs in a manner that optimises job satisfaction and care quality.
* Nurse administrators believe that the technical andv humanistic care needs of critically ill patients are so complex that all aspects of that care should be provided by professional nurses.
* Nursev administrators believe that the health teaching and rehabilitation needs of chronically ill patients are so complex that direct care for chronically ill patients should be provided by professional and technical nurse.
* Nursev administrators believe that patient assessment, work quantification and job analysis should be used to determine the number of personnel in each category to be assigned to care for patients of each type( such as coronary care, renal failure, chronic arthritis, paraplegia, cancer etc)
* Nurse administratorsv believe that a master staffing plan and policies to implement the plan in all units should be developed centrally by the nursing heads and staff of the hospital.
* Nurse administrators believe the staffing plan details such asv shift- start time, number of staffs assigned on holidays, and number of employees assigned to each shift can be modified to accommodate the units' workload and workflow.

Objectives of staffing in nursing:

* Provide an all professional nursev staff in critical care units, operating rooms, labour and emergency room
* Provide sufficient staff to permit a 1:1 nurse- patient ratio for each shift in every critical care unit
* Staff the general medical, surgical, obstetricsv and gynaecology, paediatric and psychiatric units to achieve a 2:1 professional- practical nurse ratio.
* Provide sufficient nursing staff in general,v medical, surgical, obstetrics and gynaecology, paediatric and psychiatric units to permit a 1:5 nurse patient ratio on a day and afternoon shifts and 1:10 nurse- patient ratio on night shift.
* Involve the heads of the nursingv staffs and all nursing personnel in designing the department's overall staffing program.
* Design a staffing plan that specifies how many nursing personnelv in each classification will be assigned to each nursing unit for each shift and how vacation and holiday time will be requested and scheduled.
* Hold eachv head nurse responsible for translating the department's master staffing plan to sequential eight weeks time schedules for personnel assigned to her/ his unit.
* Post time schedules for all personnel at least eight weeks inv advance.
* Empower the head nurse to adjust work schedules for unit nursing personnelv to remedy any staff excess or deficiency caused by census fluctuation or employee absence.
* Inform each nursing employee that requests for specificv vacation or holiday time will be honoured within the limits imposed by patient care and labour contract requirements.
* Reward employees for long termv service by granting individuals special time requests on the basis of seniority.

NORMS OF STAFFING( S I U- staff inspection unit)

* Norms: norms are standards that guide, control, and regulate individuals and communities. For planning nursing manpower we have to follow some norms. The nursing norms are recommended by various committees, such as; the Nursing Man Power Committee, the High-power Committee, Dr. Bajaj Committee, and the staff inspection committee, TNAI and INC. The norms has been recommended taking into account the workload projected in the wards and the other areas of the hospital.
* All the above committees and the staff inspection unit recommended the norms for optimum nurse-patient ratio. Such as 1:3 for Non Teaching Hospital and 1:5 for the Teaching Hospital. The Staff Inspection Unit (S.I.U.) is the unit which has recommended the nursing norms in the year 1991-92. As per this S.I.U. norm the present nurse-patient ratio is based and practiced in all central government hospitals.

Recommendations of S.I.U:

1. The norms for providing staff nurses and nursing sisters in Government hospital is given in annexure to this report. The norm has been recommended taking into account the workload projected in the wards and the other areas of the hospital.
2. The posts of nursing sisters and staff nurses have been clubbed together for calculating the staff entitlement for performing nursing care work which the staff nurse will continue to perform even after she is promoted to the existing scale of nursing sister.
3. Out of the entitlement worked out on the basis of the norms, 30%posts may be sanctioned as nursing sister. This would further improve the existing ratio of 1 nursing sister to 3.6. staff nurses fixed by the government in settlement with the Delhi nurse union in may 1990.
4. The assistant nursing superintendent are recommended in the ratio of 1 ANS to every 4.5 nursing sisters. The ANS will perform the duty presently performed by nursing sisters and perform duty in shift also.
5. The posts of Deputy Nursing Superintendent may continue at the level of 1 DNS per every 7.5 ANS
6. There will be a post of Nursing Superintendent for every hospital having 250 or beds.
7. There will be a post of 1 Chief Nursing Officer for every hospital having 500 or more beds.
8. It is recommended that 45% posts added for the area of 365 days working including 10% leave reserve (maternity leave, earned leave, and days off as nurses are entitled for 8 days off per month and 3 National Holidays per year when doing 3 shift duties).

Most of the hospital today is following the S.I.U.norms. In this the post of the Nursing Sisters and the Staff Nurses has been clubbed together and the work of the ward sister is remained same as staff nurse even after promotion. The Assistant Nursing Superintendent and the Deputy Nursing Superintendent have to do the duty of one category below of their rank.

Conclusion
The key to success of any hospital primarily depends upon its human resource than any other single factor.The core determinants of staffing in the hospital organization are quality, quantity and utilization of its personnel keeping in view the structure and process. The staffing norms should aim at matching the individual aspiration to the aims and objectives of the organization.

References:

1. Basavanthappa B T. Nursing administration. (Ist edn). Newdelhi: Jaypee brothers medical publishers (p) ltd; 2000.
2. Berkow S, Jaggi J& Fogelson R. Fourteen unit attributes to guide staffing. JONA.vol 37, no.3 mar 2007.

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Nurses' Observation Scale for Inpatient Evaluation (NOSIE)

The Nurses' Observation Scale for Inpatient Evaluation (NOSIE) is a highly sensitive ward behaviour rating scale.

The NOSIE, developed by G.Honifeld and CJ Klett, is a 30-item scale designed to assess the behaviour of patients on an inpatient unit^{1, 2}. The scale was developed in 1965 and still used with a moderate degree of frequency. The advantage of the NOSIE is that it is quick, simple to administer, and may be used to assess patients that may be too ill to participate in more interactive rating scales including nonverbal individuals³.

The scale is frequently used to assess behaviours from baseline, and can be utilized to with most severely ill patients. The scale is frequently utilized to assess change in behaviours from baseline. The rating is based on continuous observation. The scale is rated according to the frequency of occurrence of the 30 designated behaviours during the previous three days. Interrater reliability has been generally demonstrated by interclass correlations for pairs of ratingof 0.73 to 0.74 for manifest and depressive psychosis³.

Nurses play an important part both in pursuing the goals of treatment and in assessing the change in individual patients. The NOSIE is a particularly well- developed rating scale whose content has been tailored to the task of assessing change in long stay patients and has been successfully used for this purpose in the US⁴.

The NOSIE was developed to involve nurse in the assessment of people with psychosis in hospital care. This and similar instruments recognized the crucial role played by nurses in the planning of health care. Since they spent all day with the people- in- care, they were in the best position to comment on the presence or absence of specific patterns of behaviour associated with mental disorder. In studies conducted in UK and America the scale has been found to be a reliable, brief and unambiguous tool for the assessment of people with enduring mental disorder, requiring mental disorder, requiring longer term care. The rating is quick and simple to use and, despite requiring little training of staff, the scale is reliable. ⁵

In a methodological study, validation of two rating scales, Modified Overt Aggression Scale (MOAS) and the Nurses' Observation Scale for In-patient Evaluation (NOSIE), which cover different aspects of psychopathology, were done by a group of Italian researchers. The scales were first translated into Italian and tested their validity and reliability in terms of inter-rater and internal consistency. For validity, both cases and controls were included: for the MOAS comparison was made between patients who were aggressive (cases) to those who were presumably non-aggressive (controls). For the NOSIE, cases were acute inpatients and controls were subjects with expected stable behaviour. The Brief Psychiatric Rating Scale (BPRS) was also administered to cases in order to test convergent validity. Either the NOSIE and/or MOAS scales were administered to 358 psychiatric inpatients. A subset of these patients (131 for the MOAS and 226 for the NOSIE) was also used to test the inter-rater reliability. Both scales showed good psychometric properties. The correlation coefficients between raters were much higher than 0.75 (for the NOSIE) or 0.90 (for the MOAS), while the discriminant power between cases and controls was confirmed for both scales and good concordance with BPRS was observed. The NOSIE showed good internal consistency for all domains except neatness. In general the MOAS showed better results than the NOSIE for all psychometric properties, although both scales are suitable for monitoring the behaviour and aggression of acute ward inpatients.⁶

A re-evaluation of the Nurses' Observation Scale for Inpatient Evaluation carried out to confirm that it remains reliable in a modern United Kingdom (UK) setting. The scale was tested for the degree of agreement between two individual raters and not, as in previous studies, between two pairs of raters. A total of 100 patients were each rated by two nurses, and a least-squares simple regression model was used to describe the average level of agreement between the pairs of ratings. The result showed that correlation in total scale scores was 0.76 (F = 136, P < 0.0001). The correlations for Negative and Positive Factors were 0.68 (P < 0.001) and 0.75 (P < 0.001), respectively. This study has shown that the Nurses' Observation Scale for Inpatient Evaluation retains satisfactory inter-rater reliability with current clinical populations.  The researchers suggested that NOSIE remained as a useful tool for everyday clinical practice and a basis for meaningful communication between staff about patient status.⁷

A study evaluated the Nurses' Observational Scale for Inpatient Evaluation (NOSIE), the Brief Psychiatric Rating Scale (BPRS), the Mini Mental State Examination (MMSE), and other measures as predictors of assaults that occurred during psychiatric hospitalization. On admission, the MMSE was administered to 335 acutely ill psychiatric patients, and diagnostic and demographic data were recorded. Immediately after admission, patients were rated by nurses using the NOSIE and by psychologists using the BPRS. Patients who committed assaults during hospitalization (N = 47) and those who did not were compared, and relationships between several variables and assaults were evaluated by t tests, Mann-Whitney U tests, chi square tests, and analyses of variance. Results showed a high score on the irritability factor of the NOSIE and failure to complete the MMSE correctly predicted the occurrence or non occurrence of assault 81 percent of the time. None of the other variables examined were significantly related to assaults, including total scores on the BPRS and MMSE, psychiatric diagnosis, and several demographic variables. Scores on a test of distress level shortly after admission and failure to complete the MMSE on admission can help the clinician predict who will later engage in an assault.⁸

The interrater reliability, temporal stability and factorial, convergent, discriminant and predictive validity of the Nurses Observation Scale for Inpatient Evaluation (NOSIE-30) were investigated in a heterogeneous group of psychiatric inpatients in the Netherlands (n = 179). Data in support of the scale's dimensional structure, discriminatory power and convergent validity are presented. Interrater reliability was satisfactory at global scale level. However, 3 subscales (irritability, psychosis and depression) were found to lack interrater reliability. Although temporal stability coefficients were high, large score changes are presupposed to show that pre- versus post therapy differences are attributable to real change rather than error. NOSIE-30 had limited predictive value⁹.

In a methodological study positive and negative a priori symptom scales were operationalized with the BPRS and the NOSIE. Acutely and consecutively admitted psychiatric patients (N = 247) were rated with these scales. Research questions dealt with the psychometric properties of the scales. It was found that the positive symptom scales had sufficient internal consistency; the negative scales did not. Diagnostic groups could be distinguished better with the positive symptom (PS) than with the negative symptom (NS) scales. The outcome of this research suggests that the positive and negative symptoms distinction is less meaningful in cross-sectional research, in which acute patients are rated, than in longitudinal research.¹⁰

The predictive value of the NOSIE, a ward behaviour rating scale, was investigated in a group of long-stay patients. After a follow-up period of 3 1/2 years, it was found that all NOSIE scales differentiated continuing in-patients from those discharged. Regression analysis showed that age and florid psychoticism carried most predictive weight.¹¹

The relation between the NOSIE (Nurses' Observation Scale for Inpatient Evaluation) and the BOP (Dutch version of the Stockton Geriatric Rating Scale) was studied in a psycho-geriatric sample. The results supported the hypothesis of a trans-cultural difference in the use of the NOSIE. Dutch nurses subsume personal neatness under social competence. Anglo-Saxons do not. The factor solution of the NOSIE, with the exception of the depression factor, was comparable with earlier Dutch research, and was interpreted as support for the notion, that the NOSIE is a reliable observation scale. The correlation between factor scales of the NOSIE and the BOP were significant, but of moderate range. This was taken to mean that there is limited convergent validity between the NOSIE and the BOP. A high correlation was found between the infirmity scale and other subscales of the BOP. The BOP as well as the NOSIE were able to purposefully distinguish diagnostic groups when an external criterion or mixed criteria were used. It was concluded that both the BOP and the NOSIE may supplement each other in psycho-geriatric research practice.¹²

Twelve Token Economy patients rated by nine staff members were followed for 1 year. Patients discharged within a year after the NOSIE-30 was administered had higher scores on Social Competence, Personal Neatness, Total Positive Factors, Total Patient Assets and a lower score on Total Negative Factors than patients who remained hospitalized. There were higher interrater reliabilities on subscales such as social competence, neatness, and irritability, and less agreement on subscales such as manifest psychosis and social interest. Sex differences found in the raters' perception of a patient behaviour indicated that male raters tend to be more tolerant of a patient's negative behaviours. Results suggest that the NOSIE-30 may have predictive utility. The NOSIE-30 can be a useful tool in staff training and in patient evaluation with a multidisciplinary approach¹³.

References:

1. 
   
   Honigfeld G, Gillis RD, Klett CJ. Nurses' observation scale for inpatient evaluation: a new scale for measuring improvement in chronic schizophrenia. J Clin Psychol.1965;21, 65-71.
   
   
2. 
   
   Honigfeld G, Gillis RD, Klett CJ. NOSIE-30: A treatment-sensitive ward behavior scale. Psychol Rep. 1966; 19, 180-182.
   
   
3. 
   
   Sajotovic M, Ramirez L. Rating scales in mental health. Lexi-Comp, Hudson, 2003.
   
   
4. 
   
   Philip A E. A note on the nurses’ observation scale for inpatient evaluation. Brit. J. Psychiat. 1973; 122, 593-6
   
   
5. 
   
   Reynalds W, Cormack D & Hall. Assessment in psychiatric and mental health nursing,1990).
   
   
6. 
   
   Margari F, Matarazzo R, Casacchia M, Roncone R, Dieci M, Safran S, Fiori G, Simoni L; The EPICA Study Group.Italian validation of MOAS and NOSIE: a useful package for psychiatric assessment and monitoring of aggressive behaviours. Int J Methods Psychiatr Res. 2005;14(2):109-18
   
   
7. 
   
   Lyall D, Hawley C, Scott K.Nurses' Observation Scale for Inpatient Evaluation: reliability update. J Adv Nurs. 2004 May;46(4):390-4
   
   
8. 
   
   Swett C, Mills T.Use of the NOSIE to predict assaults among acute psychiatric patients. Nurses' Observational Scale for Inpatient Evaluation. Psychiatr Serv. 1997 Sep;48(9):1177-80.
   
   
9. 
   
   Hafkenscheid A.Psychometric evaluation of the Nurses Observation Scale for Inpatient Evaluation in The Netherlands. Acta Psychiatr Scand. 1991 Jan;83(1):46-52
   
   
10. 
    
    Dingemans PM.The Brief Psychiatric Rating Scale (BPRS) and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE) in the evaluation of positive and negative symptoms. J Clin Psychol. 1990 Mar;46(2):168-74.
    
    
11. 
    
    Philip AE.Prediction of successful rehabilitation by nurse rating scale. Br J Psychiatry. 1979 Apr;134:422-6.
    
    
12. 
    
    Dingemans PM, Bleeker JA, Bakker-Winnubst M, Frohn-de Winter ML.[Comparison between 2 behavior observation scales in psychogeriatrics. A closer look at the NOSIE and the BOP]  Gerontol Geriatr. 1983 Dec;14(6):223-30.
    
    
13. 
    
    McMordie WR, Swint EB. Predictive utility, sex of rater differences, and interrater reliabilities of the NOSIE-30. J Clin Psychol. 1979 Oct; 35(4):773-5.
    
    
    
    
    
    

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TRANSCULTURAL NURSING (4)

 PURPOSES OF KNOWING THE PATIENTS  CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL

Cultural background affect a person's health in all dimensions, so the nurse should consider the client's cultural background when planning care

Although basic human needs are the same for all people, the way a person seeks to meet those needs is influenced by culture.

• To heighten awareness of ways in which their own faith system. Provides resources for encounters with illness, suffering and death.
• To foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.
• To strengthen in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.
• To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.
• To encourage in developing and maintaining a program of physical, emotional and spiritual self-care introduce therapies from the East, such as ayurveda and pancha karma

Leininger (1991,2002a) has defined transcultural nursing as a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups

Culturally congruent care;

Care that fits the people's valued life patterns and set of meanings -which is generated from the people themselves, rather than based on predetermined criteria. Discovering client's culture care values, meanings, beliefs and practices as they relate to nursing and health care requires nurses to assumes the roles of learners of client’s culture and copartners with client's and families in defining the characteristics of meaningful and beneficial care.(Leininger,2002

Culturally competent care is the ability of the practitioner to bridge cultural gaps in caring, work with cultural differences and enable clients and families to achieve meaningful and supportive caring. Culturally competent care requires specific knowledge, skills, and attitudes in the delivery of culturally congruent care and awareness.

Pacquiato (2003) identifies three distinct levels of cultural competence at the practitioner, organizational and social levels.

Nursing Decisions

Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. All three modes of professional decisions and actions are aimed to assist, support, facilitate, or enable people of particular cultures

The three modes for congruent care, decisions, and actions proposed in the theory are predicted to lead to health and well being, or to face illness and death.

1. Cultural preservation or maintenance: Retain and or preserve relevant care values so that clients can maintain their well-being, recover from illness, or face handicaps and/or death .

2.Cultural care accommodation or negotiation- Adapt or negotiate with the others for a beneficial or satisfying health outcome

3. Cultural care repatterning or restructuring : Records, change, or greatly modify client’s life ways for a new, different and beneficial health care pattern

PURPOSE AND GOAL OF THE THEORY

The central purpose of the theory is to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups.

The purpose and goal of the theory is to use research findings to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures.

Status of Traditional Practices

Many traditional practices are used to prevent and a redemptive practice used to prevent illness and harm treat illness, including objects and substances and religious practices. (Morgenstern, 1966)

USE OF PROTECTIVE OBJECTS

Protective objects can be worn or carried or hung in the home. Amulets are objects with magical powers, for all walks of life and cultural and ethnic backgrounds is example, charms worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil eye or evil spirits. Amulets exist in societies all over the world and are associated with protection from trouble (Budge, 1978)

USE OF SUBSTANCES

Substances are ingested in certain ways or amounts regimen, an effort must be made to determine if they are worn or hung in the home. This practice uses diet and consists of many different observances. It is believed that the body is kept in balance or harmony by the type of food eaten so many food taboos and combinations exist in traditional belief systems. For example, it is believed that some food substances can be ingested to prevent illness. People from many ethnic backgrounds eat raw garlic or onion In an effort to prevent illness or wear them on' the body or hang them in the home.

Jews also believe that milk and meat must never be mixed or eaten at the same meal (Steinberg, 1947) mind, and spirit, or the restoration of holistic health

RELIGIOUS PRACTICES Another traditional approach to illness prevention female centers around religion and includes practices such as from a divine source the burning of candles, rituals of redemption, and In many instances a heritage consistent person may prayer. Religion strongly affects the way people attempt to prevent illness, and it plays a strong role in rituals associated with health protection. Religion dictates social, moral, and dietary practices designed to keep a traditional healer (Kaptchuk and Croucherl987)

Traditional Remedies The admitted use of folk or traditional medicine increasing, and the practice is seen among people from all walks of life and cultural ethnic back ground Use of folk medicine is not a new practice among heritage consistent people, so many of the remedies have been used and passed on for generations. The pharmaceutical, must be made to determine properties of vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been studied tested, cataloged, and used for countless centuries. Many of these plants are used by specific communities. Others cross ethnic and community lines and are used in certain Geographic areas in the person's country of origin.

When patients -do not adhere to a pharmacological regimen an effort must be made to determine the remedy if they are taking traditional remedies. Frequently, the active ingredients of traditional remedies are unknown. If a client is believed to be, taking them an effort must be made to determine the remedy as well as its active in gradients Often, these ingredients can be antagonistic or synergistic to prescribed medications. Over dose may occur.

Healer's

In the traditional context, healing is the restoration of the person to a state of harmony between the body, Within a given community, specific people are known to have the power to heal. The healer may be male or and is thought to have received the gift of healing In many instances a heritage consistent person may consult a traditional healer before, instead of, or in conjunction with a modern  health care provider. Many differences exist between the Western physician and the Eastern A broad range of health and illness beliefs exist many of these beliefs have roots in the culture, ethnic, religious, or social back ground .of a person family, or community. 'When people anticipate fear or experience an illness or crisis, they may use a modern or traditional approach toward prevention and healing.

These approach may originate in culture, ethnicity or religion. These beliefs and practices may be internal or personal and person may be able to define or describe them. However, they may be due to external social forces not within the person's control Examples of external social forces include communication barriers, such as language differences, or economic barriers causing limited access or lack of access to modem, health care facilities.

IMMIGRATION

Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding these areas Health and illness can be interpreted in terms of personal experience and expectations. There are countless ways to explain health and illness, and people base their responses on cultural, religious, and ethnic back ground. The responses are culture specific, based on a client's experience and perception.

Gender Roles

In many cultures, the male is dominant figure. In cultures where this is time, males make decisions for other family members well as for themselves. For example, no matter which family member is involved cultures where the male dominate. The female usually is passive. In African -American families, however as well as in many Caucasian families, the female often is dominant Knowledge of the dominant member of the family is important consideration in planning Nursing care folk illnesses, which are perceived to arise from a variety of causes, often require the services of a folk healer who may be a local curandero, shaman, native healer, spiritualist, root doctor, or other specialized healer. Recognize that the use of traditional or alternate models of health care deliveries widely varied and may come into conflict with Western models of health care practice. Understanding these differences may help you to be more sensitive to the special beliefs and practices of multicultural target groups when planning a program.

ILLNESS CAUSE AND PREVENTION RELATED TO FOOD

Several factors cause illness. A hot-cold imbalance, for example, is primarily caused by improper diet. Food substances are classified as hot or cold with and without regard to their actual temperature. This classification can vary from person to person, but essentially, certain foods are known to be hot, and others are known to be cold. Examples of cold food are, honey, avocados, bananas, and lima beans. Examples of hot foods-are chocolate, coffee, com meal, garlic, kidney beans, onions, and peas. Illness can occur if these foods are eaten in improper combinations or amounts. .

Traditional beliefs about mental health In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or, sometimes, by evil spirits. Mental wellness occurs when psychological and physiologic functions are integrated. Some elderly Asian Americans share the Buddhist belief that problems in this life are most likely related to transgressions committed in a past life. In addition our previous life and our future life are as much a part of the life cycle.

ECONOMIC BARRIERS

Several economic barriers, such as unemployment, underemployment, homelessness, lack of health insurance poverty prevent people from entering the health care system. Poverty is by far the most critical factor. Poverty a relative term and changes from time and place. In the United States, poverty is pervasive and found extensively among people in certain norms geographical areas, such as rural populations, the elderly migrant workers, and illegal aliens. Poor health, crippling diseases, drug and alcohol abuse, poor education; and inferior are contributing social causes of poverty.

Several programs, both governmental and private, aid people with short- and long-tem problems. It is important for the nurse to be aware clients needs and financial resources available in the local community.

Time orientation

It is varies for different cultures groups. A client may be late for an appointment not because of reluctance or lack of respect for the nurse but because he is less concerned about planning ahead to be on time than with the activity in which he is currently engaged.

PERSONAL SPACE AND TERRITORIALITY;

Personal space involves a person's set of behaviors and attitudes toward the space around himself. Staff members and other clients frequently encroach on a client's territory in the hospital, which includes his room, bed, closet, and belongings. The nurse should try, to respect the client's territory as much as possible, especially when performing nursing procedures. The nurse should also welcome visiting members of the family and extended family. This can remind the client of home, lessening the effects of isolation and shock from hospitalization.

SOCIOCULTURAL FACTORS AND THE NURSING PROCESS

Religious belief that effect the care Nursing;

Belief about birth &death.

Belief about diet and food practices.

Belief regarding medical care

Comments (cremation is preferred)

ROLE OF NURSE

• The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem. The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms
• Nurses should evaluate their attitudes toward ethnic nursing care. Some nurses may believe they should treat all clients the same and simply act naturally, but this attitude fails to acknowledge that cultural differences do exist and that there is no one "natural" human behavior The nurse cannot act the same with all clients and still hope to deliver effective, individualized ,holistic care.
• Sometimes, inexperienced nurses are so self-conscious about cultural differences and so afraid of making a mistake that they impede the nursing process by not asking questions about areas of difference or by asking so many questions that they seem to try into the client' personal life.
• The process of self-evaluation can help the nurse become more comfortable when providing care to clients from diverse backgrounds
• Culture is the sum total of mores traditions & beliefs about how people function encompasses others products of human works & thoughts. Specific to member of an intergenerational group, community or population.
• Nurses have a responsibility to understand the influence of culture, race &ethnicity on the development of social emotional relationship child rearing practices &attitude toward health.
• A child's self concepts evolves from ideas about his or her social roles
• Primary groups are characterized by intimate contact mutual support and pressure for conformity.
• Important sub culture influences on children include ethnicity social class, occupation school peers and mass culture
• Socioeconomic influences play major role in ability to seek opportunity for health promotion for wellness
• Religious practices greatly influences health promotion belief in families.
• Many ethnic and cultural groups in country retain the cultural heritage of their original culture.
• How culture influences behaviors, attitudes, and values depends on many factors and thus is not the same for different members of a cultural group.
• Ethnocentrism can impede the delivery of care to ethnic minority clients and, when per­vasive, can become cultural racism.
• Stereotyping ethnic group members can lead to mistaken assumptions about a client.
• The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups.
• Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture.
• The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture.
• The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background.
• Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds.
• When nurses provide care to clients from a background other than their own, they must be aware of and sensitive to the clients' sociocultural background, assess and listen carefully to health and illness beliefs and practices, and respect and not challenge cultural, ethnic, or religious values and health care beliefs. The nursing process enables the nurse to provide individualized care
• The nurse should begin the assessment by attempting to determine  the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem. The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms
• Assessment enables the nurse to cluster relevant data and develop actual or potential nursing diagnoses related to the cultural or ethnic need of the client. In addition the nursing diagnosis should state the probable cause .The identification of the cause of the problem further individualizes the nursing care plan and encourages selection of appropriate interventions-cultural variables as they relate to the client. The extended family should be involved in the care the Client's strongest support group. Cultural beliefs and practices can be in-corporate into therapy.
• The client’s the nursing process; educational level and language skills should be considered when planning teaching activities.
• Explanations of and practices into nursing therapies; aspects of care usually not questioned by acculturated clients may be required for non-English speaking or non- acculturated clients to avoid confusion, misunderstanding, or cultural conflict.
• The nurse may have to alter her usual ways of interacting with clients to avoid offend ignore alienating a client with different attitudes toward social interaction and etiquette. A client who is modest and self-conscious about the body may need psychological preparation before some procedures and tests.
• The nurse can find out what care the client considers appropriate by involving him and his family in planning care and asking about their expectations. This should be done in every case, even if the nursing care cannot be modified. Because both the nurse and the client are likely to take many aspects of their cultures for granted, questions should be clear and explanations should be explicit.
• Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client.
• The nurse evaluates the results of nursing care for ethnic clients as for all clients, determining the extent to which the goals of care have been met.

Evaluation continues throughout the nursing process and should include feedback from the client and family. With an ethnic minority client, however, self-evaluation by the nurse is crucial as he or she increases skills for interaction. The nurse should consider questions such as the following:          .

1. Am I open to understanding ways in which the client's values differ from mine?
2. Have I given sufficient attention to communicating with the client with limited language skills?
3. Have I have successful client's family in nursing process?
4. Am I incorporating the client's traditional beliefs and practices into nursing therapies?
5. Is my therapeutic relationship with the client grounded on respect for the client regardless of cultural differences?

CONCLUSION

Nurses need to be aware of and sensitive to the cultural needs of clients. The body of knowledge relevant to this sensitive area is growing, and it is imperative that nurses from all cultural backgrounds be aware of nursing implications in this area. The practice of nursing today demands that the nurse identify and meet the cultural needs of diverse groups, understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide nursing care, and identify and use resources acceptable to the client (Boyle, 1987).

REFERENCES

1. Boyle, JS: The practice of trans cultural nursing, Transcultural Nursing Morgenstern, J: Rites of birth, marriage, death, and kindred occasions

2. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990.

3. Kozier B, Erb G, Barman A, Synder AJ. Fundamentals of nursing; concepts, process and practice, Edn 7th, 2001.

4. Leninger M, McFarland M. Transcultural Nursing: Concepts, Theory, Research, and Practice; Edn 3rd, McGraw-Hill Professional; New York, 2002.

5. Potter A, Perry G .Basic Nursing-Theory and Practice, Edn 3rd Mosby Company.

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