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. 2006 Apr;94(2 Suppl):E143–E151.

Mapping the literature of transcultural nursing*

Sharon C Murphy 1
PMCID: PMC1463039  PMID: 16710461

Abstract

Overview: No bibliometric studies of the literature of the field of transcultural nursing have been published. This paper describes a citation analysis as part of the project undertaken by the Nursing and Allied Health Resources Section of the Medical Library Association to map the literature of nursing.

Objective: The purpose of this study was to identify the core literature and determine which databases provided the most complete access to the transcultural nursing literature.

Methods: Cited references from essential source journals were analyzed for a three-year period. Eight major databases were compared for indexing coverage of the identified core list of journals.

Results: This study identifies 138 core journals. Transcultural nursing relies on journal literature from associated health sciences fields in addition to nursing. Books provide an important format. Nearly all cited references were from the previous 18 years. In comparing indexing coverage among 8 major databases, 3 databases rose to the top.

Conclusions: No single database can claim comprehensive indexing coverage for this broad field. It is essential to search multiple databases. Based on this study, PubMed/MEDLINE, Social Sciences Citation Index, and CINAHL provide the best coverage. Collections supporting transcultural nursing require robust access to literature beyond nursing publications.

INTRODUCTION

This study is part of the ongoing project undertaken by the Nursing and Allied Health Resources Section of the Medical Library Association to map the literature of nursing. An overview of the project describes the background and methodology in detail [1]. This study focuses on the literature of transcultural nursing. Its purpose is to identify the predominant format of literature used in the field, determine the currency of the most frequently used literature, identify the core journals of the field, and assess the level of indexing coverage of the core journals by major bibliographic databases. The results can be applied to collection development and instruction activities, assist in the identification of core literature and access tools for practitioners and librarians, and provide documentation and recommendations to the producers of bibliographic databases seeking to cover the literature of transcultural nursing more comprehensively.

TRANSCULTURAL NURSING

Transcultural nursing is both a specialty and a general practice area. It focuses on worldwide cultures and comparative cultural caring, health, and nursing phenomena. Established as a formal area of inquiry and practice more than forty years ago, transcultural nursing's goal is to provide culturally congruent care.† As summarized by one nursing leader in the field, “Transcultural nursing is a body of knowledge that helps us [to] provide culturally relevant care” [4].

MEDLINE's Medical Subject Headings (MeSH) define transcultural nursing in the scope note as a nursing specialty created to answer the need for developing a global perspective in the practice of nursing in a world of interdependent nations and people. The focus of this nursing discipline is on integrating international and transcultural content into training. As an example, courses include study in the area of cultural differences, nursing in other countries, and international health issues and organizations.

Madeleine Leininger, founder and leader of the field, defines transcultural nursing as:

a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs and practices of individuals or groups of similar or different cultures. Transcultural nursing's goal is to provide culture specific and universal nursing care practices for the health and well-being of people or to help them face unfavorable human conditions, illness or death in culturally meaningful ways. [5]

Transcultural nurses study the interrelationships of culturally constituted care from a nursing perspective. Possessing a combination of education and field experience, they provide knowledgeable, competent, and safe care to people of diverse cultures. Their study encompasses cultural care symbols, expressions, and meanings [6]. Research in transcultural nursing focuses on discovering largely unknown and vaguely known cultural care and health concerns from two perspectives: The emic perspective focuses on the local, indigenous, and insider's culture; the etic perspective focuses on the outsider's world and especially professional views [7].

Transcultural nurses are specialists, generalists, and consultants. Functioning in diverse clinical practice settings and in schools of nursing, they assist others to become sensitive to and knowledgeable about diverse cultures. They may identify cultures that are neglected or misunderstood [8] and help health care systems assess how they serve, or fail to serve, diverse cultures in a community. Whatever the setting, transcultural nurses are committed to cultural openness, a lifelong stance that promotes cultural self-awareness and continuing development of transcultural skills [9, 10].

The model for graduate education in this specialty consists of programs based on sequential courses with both classroom and clinical field experiences. These programs are generally a part of a graduate program or track preparation in transcultural nursing. The Transcultural Nursing Society <www.tcns.org> is the major organization in the discipline today. It offers certification and recertification as a certified transcultural nurse (CTN), an important process first implemented in 1988.

Transcultural nursing has become recognized in nursing and other fields as one of the most significant and growing trends in the twentieth and twenty-first centuries [6, 8]. Nursing leaders assert that cultural awareness and transcultural care are becoming increasingly important as the world becomes intensely close, complex, and multicultural [8, 11]. Changing demographics will continue to fuel demands for health services that fit different cultures. Leininger predicts that both master's and doctorally prepared transcultural nurses will be in high demand in this century as transculturalism increases in health care services [5].

The overall goals of transcultural nursing were reinforced by national mandates in the mid-1990s that required education in the health professions to take innovative approaches to ensure that health practitioners would be culturally sensitive in the twenty-first century [12–14]. This need to incorporate transcultural health perspectives in clinical practice is frequently the focus of educational efforts in health care agencies [15]. In its definition of “optimal primary care,” the Institute of Medicine includes “an understanding of the cultural, nutritional and belief systems of patients and communities” [12]. The position paper of the American Academy of Nursing's Panel on Promoting Cultural Competence in Nursing Education focuses on academic programs and issues related to preparing students for culturally competent practice [16].‡ The paper summarizes the status of cultural knowledge in American nursing and provides guidelines. The Joint Commission on Accreditation of Healthcare Organizations now recommends transcultural care in the United States to provide culturally competent care.§ Leininger postulates that the holistic base provided by transcultural nursing and related health knowledge can prevent legal suits for cultural negligence or cultural errors and improve quality care outcomes [8].

HISTORY OF TRANSCULTURAL NURSING

Leininger was the founder and leader of this new, specific cognitive specialty in nursing. The first professional nurse with graduate preparation to complete a doctorate in anthropology, Leininger took the “culture” construct from anthropology and “care” from nursing and reformulated these two dominant constructs into “culture care” [18]. Her pioneering work began with her theory of “cultural care diversity and universality,” refined by 1975 with the conceptual “sunrise model.” She divides the evolution of transcultural nursing into three eras:

  • establishment of the field (1955–1975)

  • program and research expansion (1975–1983)

  • establishment of transcultural nursing worldwide (1983 to the present) [19]

At the start in the mid-1950s, no cultural knowledgebase existed to guide nursing decisions and actions to understand cultural behaviors as a way of providing therapeutic care [19]. Leininger wrote the first books in this field and coined the terms, “transcultural nursing” and “culturally congruent care.” (Interestingly, from an indexing perspective, the term “Transcultural Nursing” was not added as a MeSH term until 1992.) Leininger developed and taught the first university course in transcultural nursing in 1966 at the University of Colorado. Programs and tracks in transcultural nursing for master's and doctoral preparation were launched shortly after, in the early 1970s.** In recognition of her leadership, Leininger was honored as a Living Legend of the American Academy of Nursing in 1998.

Today, transcultural nursing theory continues to expand and refine itself [4, 21–25]. Recent educational and theoretical approaches in the field include the transcultural assessment model [26], the model of heritage consistency [27], the model for cultural competence [24], the health care services model [28], and advocacy for the application of transcultural nursing in clinical and community contexts as well as a transcultural nursing assessment guide [21, 22].

Formally chartered in 1974, the Transcultural Nursing Society was originally established as an information-sharing group in the 1970s. Its members and publications significantly advanced transcultural nursing ideas and recruitment and retention efforts in the new field. Today, it is a worldwide organization that remains integral to the field. Members are active in consultation, teaching, research, direct care, and policy making in national and transnational arenas. The society's official publication is the Journal of Transcultural Nursing, which debuted in 1989. The journal continues to focus on substantive theoretical, research, and practice dimensions of transcultural nursing phenomena. Leininger served as editor from its inception through 1995. A vibrant and essential resource, the Journal of Transcultural Nursing is included as a source journal in this study.

TRANSCULTURAL NURSING AND NURSING EDUCATION

During the past three decades, nursing leaders have increasingly recognized the need for schools of nursing to prepare faculty and educate students to provide culturally competent care to diverse populations. One leader notes that graduate educational preparation as a transcultural advanced practice nurse is needed “to ensure culturally congruent care (which has been especially forsaken in most acute care settings), while participating in the multidisciplinary planning and case management phases of the provision of care” [29]. Other nursing leaders agree that the recruitment of graduate-prepared transcultural nursing faculty in schools of nursing worldwide is a current urgent need in nursing [5, 25]. In the mid-1990s, Leininger declared that the major question for nursing educators worldwide is how to best educate nearly five million nurses in the world so that they will be effective in providing culturally congruent care [29, 30].

Because this call to action is a most significant challenge for the nursing profession in the twenty-first century, a recent descriptive survey researched current practices in nursing curricula in the United States regarding transcultural nursing [25]. As a result of the study, Ryan et al. recommended “(a) increased course offerings in undergraduate and graduate programs in transcultural nursing, (b) recognition and incorporation of transcultural nursing as an integral program element and expected competency by accrediting agencies, (c) preparation of faculty in the discipline of transcultural nursing, (d) application of the research-based transcultural nursing knowledge available today, and (e) advanced courses in transcultural nursing with mentorship in clinical transcultural nursing” [25].

Leininger and McFarland contend that “all nurses need to be prepared in transcultural nursing to serve culturally vulnerable populations and to develop professional competencies in transcultural nursing by the year 2015” [5]. Leininger outlines ten challenges that must be met to successfully advance transcultural nursing in the third millennium [31]. “Most importantly,” she notes, “transcultural nurses need to envision themselves as global health care providers and global world citizens” [31].

METHODOLOGY

The methodology used for this study is described in detail in Allen et al. [1]. Three key journals in the field of transcultural nursing served as source journals for the study. The seminal Journal of Transcultural Nursing was included for reasons previously outlined. In addition, the past president of the Transcultural Nursing Society specifically recommended searching all issues of the Journal of Transcultural Nursing, the Journal of Cultural Diversity, and the Journal of Multicultural Nursing and Health in her article on searching for information relevant to the field [32]. Thus, these three journals were chosen as the source journals.

Strengthening these selections, a search in the National Library of Medicine's LOCATORplus catalog for periodicals indexed with the MeSH term, “Transcultural Nursing” or “Cross-Cultural Comparison,” with the keyword, “Nursing,” or the keywords, “Transcultural Nursing” or “Multicultural Nursing,” retrieved these same journals. CINAHL lists all three titles in its journal coverage subsets for both “Nursing” and “Transcultural Care.” The National Library of Medicine does not identify by subject a group of journals in transcultural nursing in its list of indexed journals. The Journal of Transcultural Nursing and Journal of Cultural Diversity are included in its list of journals for nursing. The three source journals chosen are peer reviewed. Both the Journal of Transcultural Nursing and the Journal of Multicultural Nursing and Health are listed in Allen's key nursing journals list [33] and Murphy's nursing research journals guides [34, 35]. In the author's library, the three titles are heavily used, as shown in an ongoing study of journal use. Nursing faculty also contributed informal recommendations for major journals in the field. Although the “Brandon/ Hill Selected List of Print Nursing Books and Journals” for both 1998 and 2000 were consulted, none of the three titles were included in the journal listings.

The Journal of Transcultural Nursing began publication in 1989, followed by the Journal of Cultural Diversity in 1994. The Journal of Multicultural Nursing and Health: Official Journal of the Center for the Study of Multiculturalism and Health Care, also began in 1994 under the title Journal of Multicultural Nursing. It changed to the longer title the following year.

RESULTS

A total of 154 articles were published between 1998 through 2000 in the 3 source journals, the Journal of Transcultural Nursing, the Journal of Cultural Diversity, and the Journal of Multicultural Nursing and Health. Altogether, these articles cited 4,843 items. The Journal of Transcultural Nursing was the source for 2,062 (43%) of these citations. The journal literature accounted for nearly 60% of the total citations. Thirty percent of the cited items were books. Therefore, nearly 90% of the total cited works were to the journal and book literature. Of 1,468 book references, 120 of the references were to Leininger's books. Various editions of her 2 books in particular were highly cited: Transcultural Nursing (45 times), the first comprehensive textbook on the subject now in its third edition, and Culture Care Diversity and Universality (38 times). Government documents, Internet sources, and miscellania accounted for the remaining 11% of cited items. The most frequently cited government documents were Healthy People 2000 and Healthy People 2010. In this study, Internet sources were barely cited. Of the 305 citations in the miscellaneous format type, 16% were to doctoral dissertations. Only 1 instance of media format, a single videotape, appeared in any of the reference lists. Table 1 summarizes the distribution of citations among the 5 format types.

Table 1 Cited format types by source journal and total frequency

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Table 2 provides an analysis of cited items by publication date. Ninety-one percent of the citations were to literature published in the previous 18 years (1982– 2000). In addition, 93% of all the journal articles cited were from this time period. The most current format type was Internet or Websites, with more than 50% of the citations giving a 1998 to 2000 accessed or published date, although this format type comprised the smallest number (27) of cited items. Books were the least current format type for that same time period. The majority of government documents (59%) and over 50% of the journal articles (53%) were cited from 1992 to 1997. These years accounted for the highest percentage (49.5%) of cited items for all of the time periods.

Table 2 Cited format types by publication year periods

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A total of 719 journal titles were cited in the references analyzed. As shown in Table 3, these cited journals were divided into 3 equal zones based on citation distribution. The 25 journals listed in Zone 1, even though they made up just 3.5% of the total titles, accounted for 33% of the citations (939). Zone 1 and 2 titles together accounted for 67% of the cited journal references and consisted of 138 journal titles (19.2% of the total). Zone 3 had 581 journals (80.8% of the titles) and accounted for the remaining 33% of the total number of citations. Of this last group, 358 journals were cited only once.

Table 3 Distribution by zone of cited journals and references

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The 138 journal titles that make up Zones 1 and 2 are listed in Table 4 in descending order by frequency of citation. The Journal of Transcultural Nursing, one of the source journals, tops the list. Zone 1 titles, the most frequently cited journals, are predominantly nursing titles, especially nursing research titles. However, Zone 1 also reflects the primary publications of other significant health-related fields, including medicine, public health, gerontology, and psychology. This interdisciplinary aspect is even more pronounced when reviewing Zone 2 titles.

Table 4 Distribution and database coverage of cited journals in Zones 1 and 2

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Table 4 also indicates the indexing sources and extent of indexing for the 138 titles. CINAHL, PubMed/ MEDLINE, and Social Sciences Citation Index provided the best coverage of titles in Zone 1, the most productive set of sources. PubMed/MEDLINE provided the best overall coverage of Zone 1 and 2 titles combined, followed by Social Sciences Citation Index and CINAHL. CINAHL alone provided full indexing coverage of the three source journals. PubMed/MEDLINE indexes the Journal of Transcultural Nursing and the Journal of Cultural Diversity and did so from their respective beginnings (1989 and 1994). Both titles are listed in its nursing subject set. OCLC ArticleFirst was not reliable for article counts. However, it provided keyword access to a broad range of titles. In transcultural nursing, it covered nearly 91% of the 138 core titles. It remains a good interdisciplinary resource for accessing articles in journals that are not indexed in the other databases listed.

DISCUSSION

Transcultural nursing mirrors the nursing literature and the larger health sciences in general with its reliance on journal and book literature. In this study, these two formats together account for nearly 90% of the total cited works. With nearly 60% of the citations to journal articles, the importance of the journal literature to the study and practice of transcultural nursing is confirmed. However, the book literature is still an important component in the field's research efforts.

As expected, the Journal of Transcultural Nursing and books by the founder, Leininger, surfaced as essential resources in this subdiscipline. In particular, the Journal of Transcultural Nursing remains a powerhouse in the field. Authors of any newly developed core lists to replace the “Brandon/Hill Selected List of Print Nursing Books and Journals” should consider including this title.

Because it is a young field, it is not surprising that 91% of the citations were to literature published in the previous 18 years (1982–2000). This reflects its growing and expanding base of core literature. This time span coincides with Leininger's definition of era three—the establishment of transcultural nursing worldwide—in her previously noted description of the field's evolution.

What was surprising was the small number of citations to Internet resources in this study. This number is sure to increase and gain prominence in the future as the Internet furthers its influence. Also unexpected in the data analysis was the nearly total lack of citations to media formats. Given the nuances of human communication and the adage that a picture is worth a thousand words—perhaps of great help in the multicultural world of transcultural nursing—this is noteworthy. For now, text format still rules the day.

This study identifies the core journals for transcultural nursing. The broad dimensions of the field and its interest in behavioral aspects and research is reflected in the multidisciplinary scope of the core journal titles. While Zone 1 lists primarily nursing titles, Zone 2 contains a significantly larger number of health sciences titles covering a wide range of health aspects and specialty areas. The two zones are complementary and seem to do a good job of balancing research information important to the field. Neither zone alone would adequately do this. As the editors of the journal Evidence Based Nursing noted when analyzing their publication, it is clear that many high-quality research studies relevant to nursing are published in general health care journals as well as in nursing journals [36]. So it is in transcultural nursing.

Altogether, the 138 core titles reflect not only specific cultural groups but also groups within groups: child-bearing women, children, the aged, those afflicted with specific diseases, and others. It is interesting to note that community health and maternal-child health nurses were among the first to enter the new transcultural nursing programs launched in the mid-1970s [19]. Journals geared to these specialties are well represented here. The social sciences literature besides nursing—particularly psychology, human behavior, and education—is significantly reflected in the list of core journals. Therefore, it was surprising that PsycINFO ranks so low on the indexing scores for the zones both individually and overall.

All told, the core journals indicate the complex nature of transcultural nursing and capture its multidimensional aspects and breadth. As one would expect, many of the titles are based in the United States, but international journals and those committed to publishing global research are also represented.

No one database offers complete indexing coverage of transcultural nursing. To cover the field comprehensively, data support searching multiple databases. Essential first-tier databases to search are PubMed/ MEDLINE, Social Sciences Citation Index, and CINAHL. Because of the very nature of its subject matter, however, the searching net should be cast wider to include other important and complementary biomedical databases. This should include Health Reference Center Academic, Science Citation Index, PsycINFO, EMBASE, and EBSCO Nursing and Allied Health Collection Comprehensive Edition. For currency and completeness, it is also useful to search OCLC ArticleFirst. Bear in mind that OCLC ArticleFirst provides keyword searching, not subject searching, and does not have a controlled vocabulary. This is also true of Social Sciences Citation Index and Science Citation Index, although these databases do have abstracts available. PubMed/MEDLINE scores well but fails to index one of the source journals, the Journal of Multicultural Nursing and Health. CINAHL alone provides complete indexing coverage of the three source journals. Depending on the specific nature of information being researched, all nine databases mentioned may be required. In addition, the Internet and national library catalogs should be searched for non-journal resources.

CONCLUSION

A visionary, Leininger saw transcultural nursing as filling an essential nursing and health care need worldwide half a century ago. This field became a reality with the creative leadership of a relatively small group of tenacious and dedicated professionals. Since its emergence, the young field has made available an impressive array of research literature. Several aspects of this literature received scrutiny in this study.

Transcultural nursing draws on a large field of information, stretching beyond nursing to use research from many health sciences disciplines. As this study demonstrates, the core journal literature amply reflects the literature of medicine, education, psychology, public health, and population studies. Multiple indexing databases should be searched to mine the extensive literature of this field. This study identifies the databases providing the most thorough access to research literature in the field. Librarians who provide nurses with transcultural nursing reference assistance should note that, in addition to the current journal literature, the recent book literature is important to the field.

This study confirms the importance of the recent journal literature to the practice of transcultural nursing. With increasing globalization, libraries supporting nursing schools and professionals would do well to compare their collections with the identified core list of journal titles. This list also identifies potential publishing outlets for transcultural nursing research studies. Currently, the profession relies heavily on the Journal of Transcultural Nursing as a source of information and cited references. Now entering its sixteenth year of publication, the journal has proved itself as a critical resource for practitioners of the specialty.

The major databases should consider joining CINAHL in providing indexing coverage of the three source journals. In addition, they are encouraged to pick up journal titles not currently covered and to provide more comprehensive indexing coverage of those titles in Zones 1 and 2 that show minimal indexing. Based on the indexing, selective indexing coverage, and the broad scope of the field, multiple bibliographic database searching is essential. Retrieval of information relevant to transcultural nursing requires an awareness of the full range of available tools.

Acknowledgments

The author thanks Margaret (Peg) Allen, AHIP, for her thoughtful advice and guidance and Kristine Alpi, AHIP, and Priscilla Stephenson, AHIP, for their timely assistance. The author also gratefully acknowledges and thanks her colleagues at the State University of New York at Buffalo Health Sciences Library and the University Libraries for their abundant support, encouragement, and release time to work on this project.

Footnotes

* Support was provided by the New York State/United University Professions Individual Development Award.

† “Culturally congruent care means to provide care that is meaningful and fits with cultural beliefs and lifeways” [2]. “Culturally congruent nursing care occurs when cultural care values, beliefs, and expressions are known” [3].

‡ The panel defines cultural competence as “a complex integration of knowledge, attitudes and skills that enhances cross-cultural communication and appropriate/effective interventions with others.”

§ “Culturally competent care is care that is sensitive to the differences individuals may have in their experiences and responses due to their heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background [17].”

** Interested readers desiring an in-depth look at the history of transcultural nursing may wish to supplement Leininger's many publications and those of the Transcultural Nursing Society and others with Husting's oral history on the subject [20].

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