Running head: APPLICATION OF TRANSCULTURAL NURSING IN TREATING 1

Application of Transcultural Nursing in Treating Addiction

Leora Bain, BSN, RN

Grand Canyon University: NUR 502

March 12, 2018

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Application of Transcultural Nursing in Treating Addiction

Nurses encounter patients suffering with addiction daily, across the healthcare

continuum. Individual nurses utilize a variety of nursing models and approaches when caring for

this population. Arguably, the most widely used model in treating addiction is the

Transtheoretical Model for Change. This model focuses on the addict and where they are in the

change process within the six stages for change (DiClemente, 1993). This theory is

psychological in nature and for nurses whom utilize it, it is a borrowed theory. While this theory

addresses where a patient may be in the change process, it does not address treatment differences

among patients with varying cultures. Furthermore, it does not identify addiction as a culture,

which this writer postulates is a necessary component in treating addiction.

The purpose of this discussion, is to explore the utilization of the transcultural nursing

(TCN) method in treating this population. Further, this discussion will examine the definition of

addiction as a culture. In identifying addiction as a culture, nurses can effectively utilize the

transcultural nursing method in treatment.

Scope of the Problem

In 1971, President Richard Nixon enacted the “war on drugs,” which increased federal

funding to create “drug-control agencies and drug-treatment programs,” (Encyclopedia

Britannica, n.d., para. 2). Since that time, struggles with drugs and addiction continue and little

has affected the overall outcome. According to the Centers for Disease Control ([CDC], 2017),

from 2016-2017 alone, the total number of deaths in the U.S. rose from 52,074 to 71,614 (p. 2).

This is an increase of 19,540 deaths in one year, and this is only the preliminary numbers. In

addition to these numbers, the National Institute on Alcohol Abuse and Alcoholism ([NIAAA],

2017), reports an estimate of 88,000 deaths annually from alcohol related incidences. This is a
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total of 159,614 lives lost in one year from drug and alcohol abuse. In considering this, it is also

important to determine how many people are actively living with an addiction.

Currently, there is an estimated “15.1 million people” suffering “with alcohol use

disorder” with 5.6 percent of the population of underage children being affected (Ahrnsbrak,

Bose, Hedden, Lipari, & Park-Lee, 2017). In addition, there is an estimated “7.4 million people”

suffering “with illicit drug use disorder” (Ahrnsbrak et al., 2017). This is a current estimate of

22.5 million Americans 12 years of age or older suffering with addiction in the United States.

With current data, it is safe to assume that nurses are interacting with addicts in all stages of the

health care continuum. It is for this reason, that it is imperative for nursing to explore different

approaches in treating patients suffering with addiction.

Madeleine Leininger’s Transcultural Nursing Model

One method to be considered, is in utilizing the transcultural approach when caring for

patients suffering with addiction. Madeleine Leininger began developing the Transcultural

Nursing Method (TCN) in the 1950’s and first published the theory in 1991 (Petiprin, 2016).

Utilizing her education in both anthropology and nursing, Leininger combined her knowledge of

culture and nursing by creating the concept of “culture care,” (Murphy, 2006, p. E144). Before

this time, there was no literature on the concept of transcultural nursing (Murphy, 2006).

Leininger coined the terms associated with the model, and played an integral role in advancing

the mission of the theory to a worldwide audience (Murphy, 2006). Today, TCN is not only a

model but also a “nursing specialty and general practice area” (Murphy, 2006, p. E143).

According to Leininger (2012), this is the only nursing model, to that date, elevated to this level

of regard (part 1). Consequently, while the applications for this model have been widely

celebrated, there is much room for continued research.

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Past applications of TCN include applications throughout the field of nursing worldwide.

A data base search of “transcultural nursing” reveals the scope of this model. Law & John (2012)

utilized TCN to define homelessness as a culture, and described the application of the model in

caring for this population. Murphy (2006) describes the initiative of teaching TCN in the

educational setting, stating “all nurses need to be prepared in transcultural nursing,” (p. E145).

This is an initiative supported by the affirmation of TCN as a specialty, as well as the plethora of

literature on the subject. Thus, the application of TCN will be considered in this discussion for its

application in treating patients suffering with addiction.

Application of Transcultural Nursing in Addiction Treatment

To properly apply the transcultural nursing method to addiction treatment, the definition

of addiction as a culture must first be established. The Substance Abuse and Mental Health

Services Administration ([SAMHSA], 2014) confirms there is “limited research in this topic” (p.

161). They go on to define the concept here as “drug culture,” which they argue “has its own

history,” “shared values, beliefs, customs, and traditions” as well as its own “rituals and

behaviors” (SAMHSA, 2014, p. 161). In this document, drug culture is identified as a sub-

culture within the culture of origination. Within literature, the widely accepted definition of

“culture” by students of TCN is “shared values, norms and beliefs, and a shared ethno-history,

language, behaviors and habits” (Law & John, 2012, p. 371). Given these two definitions, it

would seem, that addiction can in fact be defined as a culture. For the purposes of this

discussion, addiction as a culture will now be referred to as “drug culture” (SAMHSA, 2014).

With the definition substantiated, application of TCN will now be discussed.

In exploring drug culture, SAMHSA (2014) goes on to discuss the differences between

drug cultures. They state, “people who use different substances, are from different locales, or
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have different socioeconomic statuses; they may also have very different cultural attitudes

related to the use of substances” (SAMHSA, 2014, p. 162). This could explain the rationale for

why certain milieus click, while others may find common ground but lack connection. Therefore,

to apply TCN in treatment, the nurse must first understand which drug culture the patient

identifies with. It is important to note, SAMHSA (2012) has defined drug sub-cultures and

provided criteria to assist in identifying the different cultures (p. 166-167). Once the drug culture

is identified, the nurse may gain a sense of what is important to the patient, thereby gaining a

sense of approach to treatment.

After taking the time to get to know the patient and what is important to them, the nurse

has begun to build rapport. Madeleine Leininger (2012) believed that as nurses showed interest

in their patients, they also built mutual respect and trust which opened the doors to treating the

patient successfully. She further stated, “respect is the number one construct that is universal”

(Leininger, 2012, part 1). Which is to imply, people who feel respected are more likely to

respond positively to suggested treatments. It would thus be fair to say, those who do not feel

respected, are likely to reject treatment and close the door to negotiation. If rapport is adequately

developed between patient and caregiver, the nurse may then move on to the three nursing

decisions set forth within transcultural nursing (Leininger, 2012).

In deciding an approach for developing a care plan, the nurse must make decisions

regarding appropriate steps for the patient in question. While it is safe to assume, most of what

makes up a patient’s “drug culture,” must be negotiated, and restructured, it remains just as

important to ask; what of the “drug culture,” can be safely maintained without the use of

substances and with a reduction in risk of relapse? Perhaps the patient is most relatable to the

“family connection” felt within their “drug culture.” In which case, is peer mentoring the most
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logical approach? In this way, patients may continue to feel connected to members of their

culture without destructive patterns. The nurse can then move on to the next decision.

What of the patient’s drug culture is the patient willing to negotiate? Leininger (2012)

stresses the importance of meeting the patient where they are. This is contra intuitive, since

arguably, most want to end the cycle of addiction here and now. However, while this may not be

a realistic approach, it is important to remember as one hurdle is overcome, others may follow.

This may be one area where treatment methods which require doctor support is needed. These

may include methadone, suboxone, Antabuse, naloxone, or naltrexone. Once this stage is met,

the nurse may consider the final decision in treatment.

How can the patient begin to restructure the negative behaviors of their “drug culture”

into healthful behaviors? For this, the patient must identify for themselves what the negative

behaviors were. Once this is completed, patients may also chose what is the expected outcome of

the new status now held within their culture. Do they desire to be cut off from the “drug culture”

completely, or are they a new candidate for peer support? If being cut off is the ultimate desire, it

is now the nurse’s duty to assist the patient in finding resources to assist in assimilation. This

may be long term treatment centers, outpatient mental health, and/or educating patients on social

norms and community resources.

Once nurses take time to understand their patient and where they fall within the “drug

culture,” they can begin to develop a care plan fit for individual patients. SAMHSA (2014) states

an important piece to delivering culturally competent care within this population, is in educating

patients on “drug culture,” and the “culture of recovery,” (p. 173-174). In doing so, the patient

may learn, there are certain aspects of “drug culture,” that can be “replaced by elements of the
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culture of recovery” (p. 174). Utilizing this method in conjunction with the transtheoretical

model currently in use, nurse’s might lead patients to successful outcomes.

Understanding the Transtheoretical Model

The transtheoretical model utilizes information from multiple other theoretical designs,

hence the name transtheoretical (DiClemente, 1993). DiClemente (1993) was among the group

of researchers in the late 1970s, who designed the model following an investigation at the

University of Rhode Island (p. 101). Since then, the model has been the basis of development for

further research and addiction program design, and smoking cessation booklets (DiClemente,

1993). It has also been utilized in assessing one’s ability to change unhealthy behaviors such as

overeating, or lack of exercise (DiClemente, 1993). Working as an RN on a co-occurring unit at

Pine Rest Christian Mental Health Services, the author also experienced use of this model for

motivational interviewing. In addition, the stages of change were assessments entered onto care

plans for every patient. However, the stage was determined by nurses or case managers based on

information gained from face-to-face interviews, rather than an assessment tool, as DiClemente

(1993) suggests it should be. While stages of change are the most commonly utilized aspect of

this model, it is important to also recognize the role of its ten processes of change.

DiClemente (1993) states these processes “can be organized into two larger constructs:

experiential and behavioral processes” (p. 101). Perhaps a barrier to complete utilization of the

model, is in not fully considering these ten processes which identify the process, definition, and

interventions (DiClemente, 1993, p. 102). Much emphasis should be placed on utilization of the

interventions for each of these processes. If one does not understand useful and effective

interventions, what use is knowledge of the stages? Furthermore, DiClemente (1993) offers two

visual representations of the model. One shows movement through the stages of change, the
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other shows this in addition to where the ten processes can be seen throughout the model.

Understanding where the ten processes fall within each stage, will also give understanding of

interventions to be utilized, which is the next section of this discussion.

Understanding and Applying the Stages of Change

Many nurses have a basic understanding of transtheoretical stages of change which

include: “precontemplation, contemplation, preparation, action, maintenance, relapse and

recycle” (DiClemente, 1993, fig 3). Patients in the precontemplation stage remain in denial about

their condition with no foreseeable change, (DiClemente, 1993). In the precontemplation stage,

the individual is only able to begin recognizing the problem through “social pressure,” and “self-

reevaluation” (DiClemente, 1993, fig. 3). Self-reevaluation is identified as one of the ten

processes and is defined as, “assessing how one feels and thinks about oneself with respect to the

problem behaviors” (DiClemente, 1993, table 1). According to DiClemente (1993), interventions

should be focused on “value clarification, imagery, corrective emotional experiences, and

challenging beliefs and expectations” (table 1). While he does not discuss interventions for

“social pressure,” there are ways to use social knowledge and status in personal interventions.

This may be performed by providing education about addiction behaviors, social norms, and

health consequences. While a participant may not move from this stage to contemplation for

several days to several years, each interaction in this stage becomes an opportunity for additional

self-reflection. Once the individual recognizes the problem, they are then able to move into the

contemplation stage.

The contemplation stage is reached “when the individual seriously considers the problem

and the possibility of change” (DiClemente, 1993, p. 102). In this stage, three of the ten

processes appear including, “consciousness raising, self-reevaluation, and emotional arousal”

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(DiClemente, 1993, fig. 3). Consciousness raising is defined as “increasing information about

self and the problem” (DiClemente, 1993, table 1). Emotional arousal is defined as “experiencing

and expressing feelings about one’s problems and solutions” (DiClemente, 1993, table 1). In this

stage, interventions would include the self-reevaluation interventions identified in the previous

stage, as well as interventions for the additional processes. This includes “observations,

confrontations, interpretations, bibliotherapy, psychodrama, grieving losses, and role playing”

(DiClemente, 1993, table 1). After this stage, the individual moves into the preparation stage “in

which the person makes a commitment to try to change and prepares for action” (DiClemente,

1993, p. 102).

The action stage is when a “person implements the plan to modify the behavior”

(DiClemente, 1993, p. 102). In this stage, four processes are identified which include “self-

liberation, counter conditioning, stimulus control, and helping relationships” (DiClemente, 1993,

fig. 3). The first process, self-liberation, is defined as “choosing and committing to act or

believing in ability to change” (DiClemente, 1993, table 1). The second process, counter

conditioning, is “substituting alternatives for anxiety related to addictive behaviors”

(DiClemente, 1993, table 1). The third process, stimulus control, includes “avoiding or

countering stimuli that elicit problem behaviors” (DiClemente, 1993, table 1). Lastly, helping

relationships is defined as, “being open and trusting about problems with people who care”

(DiClemente, 1993, table 1). Interventions for these processes include: “decision-making

therapy, New Year’s resolutions, logotherapy and commitment enhancing techniques,”

“relaxation, desensitization, assertion, positive self-statements,” “restructuring one’s

environment, avoiding high-risk cues, fading techniques,” and “therapeutic alliance, social

support, and self-help groups” (DiClemente, 1993, table 1). The action stage requires
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implementation of behavior modification and “extends for 3 to 6 months and includes the

detoxification process” (DiClemente, 1993, page 102). Upon successful completion of this stage,

the individual moves on to the maintenance stage.

The maintenance stage focuses on “modifying the life-style to avoid relapse and

accommodate abstinence” (DiClemente, 1993, p. 102). This stage repeats the process of counter

conditioning which allows for continuation of the interventions specifically related to this

process (DiClemente, 1993, fig. 3). Those interventions include “relaxation, desensitization,

assertion, and positive self-statements” (DiClemente, 1993, table 1). In addition to counter

conditioning, social liberation, and reinforcement management are the additional processes

identified in this stage. Social liberation is defined as “increasing alternatives for nonproblem

behaviors available in society” (DiClemente, 1993, table 1). The interventions identified for this

process include “advocating for rights of the repressed, empowering, and policy interventions”

(DiClemente, 1993, table 1). Reinforcement management is defined as “rewarding oneself or

being rewarded by others for making changes” (DiClemente, 1993, table 1). The interventions

for this process are “contingency contracts, overt and covert reinforcement, and self-reward”

(DiClemente, 1993, table 1). The last stage of change is relapse and recycle which does not have

a process identified with it (DiClemente, 1993, fig. 3).

It is important to note, that while a person may relapse and recycle several times, they are

also able to exit this “cyclical process” at the maintenance stage after only one time of reaching

it. This is far less documented; however, the author believes there can be no timeline

manufactured to predict a generalization for all individuals. Likewise, DiClemente (1993) states

“a treatment program that is uniform or views treatment seekers as a homogenous group would

have some difficulty meeting the needs of such separate populations” (DiClemente, 1993, p.
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103). Given this, it is also reasonable to consider the cultural diversity of each individual and

how this might play a role in recovery, as well as movement through the stages of change.

Presumably, having a full understanding of how to implement the transtheoretical model

with each stage of change and its ten processes and interventions, caregivers should be well

equipped to provide effective care. By including a full understanding of TCN, caregivers may

complement treatment and increase patient success. Without understanding how “drug culture,”

or “cultural diversity” plays a role; how can one expect to reach successful implementation of the

interventions? Conversely, if not able to identify the stages and interventions; what benefit is

understanding cultural diversity? It is for this reason, caregivers must understand how the two

theories may be implemented.

Integration of Transtheoretical and Transcultural Theories

Utilizing what has been learned in this document about transtheoretical and transcultural

theories, integration of these will be explained in this section. Utilizing the “Sunrise Model,”

associated with transcultural nursing, one may understand the influences one’s culture has in

perception of “holistic health, illness, and death” (DeMelo, 2013, figure 1). These influences will

affect how a patient views treatment in every stage of the transtheoretical model.

While building rapport and mutual respect is valuable for patients throughout the stages

of change, it is imperative that this is established within the precontemplation and contemplation

stages. It is in these stages, that the nurse’s influence and potential for education is of highest

regard. If a patient is unable to feel respected, they will likely not be open to receiving education

with potential to cause the social pressure or self-reevaluation necessary to move onto the next

stage of change. Understanding this, assists nurses in moving onto the next phase within the
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sunrise model, wherein the nurse will consider “transcultural care decisions and actions”

(DeMelo, 2013, figure 1).

As a patient prepares to make a change, their beliefs and expectations will be challenged

(DiClemente, 1993). A culturally competent nurse will recognize how the individual’s beliefs

affect their current behaviors. Nurses may then challenge these behaviors in a way that is neither

offensive, nor shuts down communication, allowing patients to become self-liberated. In this

way, nurses may assist patients in culture care preservation and maintenance, which will

continue through the stages of change.

As individuals progress on to the action stage, the process of “self-liberation” continues

as well as, “counter conditioning, stimulus control, and helping relationships” (Diclemente,

1993, fig. 3). In these stages, in addition to culture care preservation and maintenance, the nurse

must begin to work toward culture care accommodation and negotiation. It is in this stage that

peer support and other treatment measures should be considered. In addition to accommodation/

negotiation, the nurse must also consider “culture care repatterning/restructuring.” Patients in

this phase are also dealing with the process of “stimulus control,” and much stimuli will be

contingent on the drug culture the patient is associated with. Continuing to assist patients through

these stages with the culture care lens, is imperative in the continuation of the recovery process,

leading the patients onto the maintenance stage.

The maintenance stage includes the continuation of “counter conditioning,” as well as

“social liberation, and reinforcement management” (DiClemente, 1993, fig. 3). In this stage, the

cultural nurse will continue the process of “culture care repatterning or restructuring” (DeMelo,

2013, figure 1). This is a crucial step in the assurance that the patient may exit the cycle rather

than relapse and recycle. However, it is important to note that even with the most seamless
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utilization of these two theories, one may still relapse and recycle. Now consider how knowledge

of the stages of change and drug culture can assist in successful assessment and treatment.

Integration into Practice

On a milieu of 22 patients, ten are identified as relating to alcohol culture, seven are in

the action stage for change while three are in precontemplation. Eight are from heroin culture,

with four in the precontemplation stage, two in the contemplation stage, and two in the action

stage. The last four are from cocaine culture and each of them are in the action stage. Those in

the action stage are motivated to change and would likely be able to be productive in attending

therapeutic groups together. They may even be able to motivate one or two in the

precontemplation stage. However, if all seven patients in the precontemplation stage are grouped

together, they may feed off each other and create an unhealthy environment within the group.

Both of these situations should be considered in designing treatment programs and designating

groups.

In designing groups for addiction treatment, the interventions suggested for the stages of

change should be a guiding factor in placing patients into proper group settings. For patients in

the precontemplation stage, education about substances, their action, and long-term effects is

useful. Since the patients are not in a stage of considering change, the best way to assist them in

moving toward this stage is by educating them. Doing so in an educational setting without

interaction between peers is also beneficial, since getting them all together in one group could

become more destructive than constructive. However, in therapeutic groups where interaction is

necessary, it may be more helpful to integrate the patients in different settings. By placing more

patients in the action stage into a group with less patients in precontemplation, the positivity that

the action participants may bring, could also assist the precontemplation patients in moving on to
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the next phase. Therefore, there could be two separate groups with seven action and one

contemplation patients in each, with four precontemplation patients in one and three in the other.

In this way, the action patients will outnumber the patients in precontemplation. This is a concept

that could also be considered in determining appropriateness of roommates. By placing an action

patient in the same room as a precontemplation patient, the action patient could have a strong

influence with the precontemplation patient. These are only a couple examples of how these

theories can be integrated into practice, further application would need to be designed for each

program.

Conclusion

In conclusion, utilization of both the transtheoretical model and transcultural nursing in

caring for patients suffering from addiction, is not only a valid approach but arguably, a

necessary approach. With a total of 159, 614 lives lost annually, and 22.5 million people living

with addiction to illicit substances, it is fair to say the “war on drugs,” has failed and the time to

explore new approaches to treatment is now. While the transtheoretical model has proven to be

useful in this area, there is value in combining this approach with transcultural nursing. In

utilizing current tools to assess culture, along with the creation of tools to identify drug culture, a

nurse may come to a better understanding of their patients. Combining this with assessment tools

to determine the stage of change a patient is in, will assist the nurse in creating successful

interventions. Understanding and applying transcultural care with the transtheoretical model will

lead to truly individualized care plans for this population resulting in better treatment outcomes.
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References

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