FAMILY NURSING

FAMILY NURSING

 

International Family Nursing

CRITICAL CONCEPTS

• Professional registered and advanced practice nurses cross international borders to practice, consult, educate, and conduct nursing research.

• Although multiple nations are integrating family theories into nursing education and practice, no one family nursing theory is universal in application to all global cultures.

• Cultural awareness, sensitivity, and adaptation are essential to successful international experiences. No nurse can be competent in the care of all culturally diverse patients.

• Health and well-being are ultimately defined by the client, family, community, or culture. Health practices are influenced by poverty, gender inequality, lack of adequate food supply or appropriate intake, lack of pure water supply, poor sanitation, the sociopolitical environment, the level of illiteracy/ education, and spiritual beliefs and rituals.

• Community-based health care is a proven international nursing practice model and research agenda.

• The nurse should not enter a cultural experience with a predetermined definition, theory, and action care plan but rather should enter the encounter with an openness to begin learning by listening and observing.

• Nurses are at risk if they practice with the false assumptions and expectations that all clients from a given culture will respond in the same manner.

• Unless the patient, family, community, and culture unite in common health-promoting beliefs and practices, the health of the family is in jeopardy.

• As women are the primary global lay and professional caregivers, nurses are encouraged to empower women by seeking organizational support of programs that enhance women’s confidence and decision-making abilities, aid in improving women’s access to health care, and develop women’s health partnerships and community-based health workers.

INTRODUCTION

Nurses are the primary providers of global health care, especially to underserved families living in rural and isolated areas (Vonderheid & Al-Gasseer, 2002; Youssef & Tornquist, 1997). Influenced by the love of travel, a spiritual calling, challenging new career opportunities, a desire to serve in unique and diverse settings, or financial enticements, nurses are now crossing international borders in record numbers (see Box 18–1). Wherever and whatever the scope of the nursing practice, care of the family and community, as well as the individual, has long been fundamental to who nurses are and what nurses do. In 1933, Harmer wrote: “The patient caever be rightly understood or adequately cared for considered apart from his family and community relationships . . . the nurse is therefore concerned not only with the care of the individual patient but with the family, the community, and the health of the people” (Harmer, 1933, p. 5). In addition to the United States, nations who formally promote family nursing theories are limited. Examples include Japan, Finland, Sweden, Korea, Iceland, Chile, Portugal, and Canada. As is discussed later in this chapter, this list expands when the definition of family includes community. However, with international nursing migration at an all-time high, it should be presumed that the majority of nurses coming from Third World nations to work in the United States have not been formally educated in family nursing theory (Flynn & Aiken, 2002).

The purpose of this chapter is to introduce issues common to providing family nursing care in culturally diverse international settings, to discuss issues that impact global health and well-being, and to discuss community-based health care as a proven international family nursing practice model. The purpose is not to discuss each family theory from an international perspective. It is to discuss international issues to be considered when applying family theories in international environments. “Nurses” and “nursing” refer to professional registered nurses and advanced practice nurses.

Nursing care promotes family health. The World Health Organization (WHO) defines health not only as the absence of disease or deformity but also as living at the highest standard of well-being possible (Toebes, 1999). International nursing involves all nurses caring for the global community, Westernized nurses caring for patients from and in Third World communities, and Third World nurses advancing in the care of their own. The WHO encourages member nations to have nurse and nurse-midwife involvement in all levels of health policy decision making, in the expansion of nurse and midwifery practice roles and services, in the expansion of resources for nursing education and research, and in the accountability for such actions to the WHO (Thompson, 2002; Vonderheid & Al-Gasseer, 2002). Utilizing the wide range of entry-level education, practice role labels, and requirements, the WHO (2002) identifies the following common attributes of global nursing practice:

• Caring for, supporting, and comforting clients

• Continuously assessing and monitoring health needs and responses to interventions

• Advocacy and education of clients and communities

• Identifying care gaps and developing appropriate responses

• Delivering and coordinating health services across the care spectrum

Infectious diseases, most certainly HIV/AIDS, malaria, upper respiratory, and diarrhea-causing diseases, as well as maternal hemorrhage and infection, continue to disproportionately affect developing nations. Chronic disease, such as cardiovascular disease, diabetes, obesity, and cancer, is now recognized as a global health crisis (Joint WHO/FAO Expert Consultation, 2003). Health conditions are influenced not only by pathophysiological processes but also by poverty, illiteracy, gender inequality, war and conflict, unstable and disinterested governmental systems, and environmental concerns that include inadequate nutrition, safe water sources, and sanitation (Organisation [sic] for Economic Co-operation and Development, 2003).

 

Health conditions are influenced by environmental concerns.

Common to undeveloped nations is the lack of interest in, and/or infrastructure for, promotion of health and disease prevention.  Nursing care promotes family health. The World Health Organization (WHO) defines health not only as the absence of disease or deformity but also as living at the highest standard of well-being possible (Toebes, 1999). International nursing involves all nurses caring for the global community, Westernized nurses caring for patients from and in Third World communities, and Third World nurses advancing in the care of their own. The WHO encourages member nations to have nurse and nurse-midwife involvement in all levels of health policy decision making, in the expansion of nurse and midwifery practice roles and services, in the expansion of resources for nursing education and research, and in the accountability for such actions to the WHO (Thompson, 2002; Vonderheid & Al-Gasseer, 2002). Utilizing the wide range of entry-level education, practice role labels, and requirements, the WHO (2002) identifies the following common attributes of global nursing practice: United States, England, Germany, Australia, and other developed nations. International nursing migration divides family and friends while widening the gap in the existing crisis health care systems.

NURSING EDUCATION

A growing number of domestic schools of nursing and universities are enhancing international health content in their core curriculum, offering their students international experiences and/or establishing new international health specialty options. Point Loma Nazarene University (San Diego, California) offers their undergraduate nursing students experiences in Romania, India, and Mexico. California State University (Los Angeles, California) includes an optional international health experience in their graduate International Health Family Nurse Practitioner program. Azusa Pacific University (Azusa, California) now offers a Ph.D. in International Health Nursing.

These learning opportunities are consistent with the goals, objectives, and nursing competencies of the American Association of Colleges of Nursing (1998, 2003), the National Organization of Nurse Practitioner Faculties (2004), the World Health Organization, and the International Council of Nursing (Goodyear, 2003). All promote cultural sensitivity in evidence-based research and practice, supported by a growing body of scholarly nursing journals publishing international data and practice guidelines. Such learning opportunities also promote language acquisition, helping to meet the national standards for culturally and linguistically appropriate services in health care (Department of Health and Human Services, 2000).

Based on a survey of 100 schools of nursing, da Gloria Miotto Wright, Godue, Manfredi, and Korniewicz (1998) recommended that the following international health content be included iursing curriculums:

1. Social, political, economic, health, and demographic trends that influence the design and implementation of a health care system at both national and international levels

2. A strategic plan with international health curriculum and activities, with faculty interested in working in teams to create partnership and collaborative strategies

3. An interdisciplinary approach to the international health curriculum with national and international conditions or trends and technical cooperation among countries and through international organizations

4. A vision of international health as a leadership tool for nurses in national and international communities (da Gloria Miotto Wright et al., 1998)

 

COMMON THEORETICAL PERSPECTIVES

Scholarly nurses highly value theories as central to defining the concept and actions of nurses. In the international practice arena, it readily becomes evident that no one theory, nor Western interpretation of a theory, is applicable to all cultures and peoples. For example, family developmental theory assumes progression from single adult to marriage, to young parenthood, to families with adolescents, to launching of the children, to later life (Wong, Perry, & Hockenberry, 2002). This theory does not acknowledge the many global family systems that do not include an adolescent phase or the launching of children to independent living. For instance, Masasi and African tribes have rituals that initiate children into adulthood at puberty. Asian communities often expect multigenerational families to continue living within the same household.

Defining the family, a dynamic process in the United States, is a global challenge. To understand the definition of family within the culture under his or her care, the nurse must move beyond theories to a higher level of knowledge known as belief systems and world-views. This process utilizes synchronic and diachronic patterns of knowledge acquisition. Synchronic family knowledge involves learning how persons, families, and systems operate and what functions they serve.

Diachronic family knowledge investigates and values the history, the personal lived experience of individuals within the family (Heibert, 1994). The nurse should not enter a cultural experience with a predetermined definition, theory, and action care plan but rather should enter the encounter with an openness to begin learning by listening and observing. Orientation and perception of health, illness, and disease must also be considered when applying a theoretical model. Western health care is biomedically based and is the foundation of nursing education in developed nations. Illness and altered health are primarily deemed to have a pathological origin, and professionally trained health care personnel treat patients with medications and technology. Entering global cultures with a biomedical agenda is comparable to colonialism of old. Other health practices may be displaced, communication is often formal, the attitude can be authoritarian and deemed confrontational, the viewpoint is etic (the outsider’s), and knowledge and truth demand objective and scientific data (Heibert, 1994; Shaffer, 1990).

As the Western model was found to be inadequate and inappropriate for cultural care, anticolonialism emerged to create dialogue for consensus and to hear the insider’s voice (Heibert, 1994). Social science emerged. Sociocultural care seeks to know the client’s subjective reasoning for the illness (de Villiers & Tjale, 2000) while offering the promise of prevention and cure developed within Western health care systems. Messias (2001) stated, “[N]urses and nursing students must engage in constructive challenges to the dominance of Western biomedicine as the framework for social decision-making about health and illness. They must be willing to examine critically the underlying values of medical services, public health, professionalism, community development, and consumer participation”

CULTURAL AWARENESS AND SENSITIVITY

The ability to challenge the Western biomedical model as applicable to the present client and family under the nurse’s care requires cultural awareness and cultural sensitivity. Culture is the environmental influence that forms each individual’s beliefs and values, sense of identity, self-worth, and behavioral guidelines (Cortis, 2003). As culture molds the individual, it also influences family roles, structures, actions, responses, challenges, and adaptations (Mercer, 1989). The family functions within what was taught to the parents about health, illness, disease, roles, rituals, relationships, power structures, decision making, and coping (Denham, 2003). Therefore, cultural awareness and sensitivity are requirements for safe and effective family nursing care (de Villiers & Tjale, 2000).

Leininger, transcultural nursing theorist, developed distinct definitions of nursing within culture, care, and diversity, which should be studied for application in direct care and policy development (Leininger, 1996). Nursing educators, hospital administrators, governmental policy makers, and insurance carriers have written, mandated, and taught about cultural awareness, sensitivity, and competency.  Cultural awareness begins with self-reflection as to one’s owationality, race, ethnicity, cultural norms and practices, values, and beliefs regarding health and well-being. Awareness encourages nurses to analyze and interpret how the beliefs and practices learned within their own home, culture, environment, and faith are or are not in harmony with those taught in nursing schools and practiced in health care services. Awareness is an ongoing process, which may create a level of cultural conflict. Adaptation and conflict resolution are discussed later in this chapter.

Cultural sensitivity is the awareness of others. It entails an understanding that others may view health and well-being beliefs and practices differently. Sensitivity endeavors to capture an essence of the importance of the differences to the client (Sawyer et al., 1995). Cultural sensitivity does not require the nurse to understand the difference. It does require compassion and respect for the client and accommodation to the  belief and/or practice whenever possible. Determining when and how to accommodate particular beliefs and practices requires informed critical thinking on the part of the nurse. Many health care agencies now mandate cultural competency. Comments such as “We are convinced that nurses will be able to provide culturally competent and contextually meaningful care for clients from a wide variety of cultural backgrounds” (Andrews & Boyle, 2003, p. IX) support this goal. Based on research of culturally diverse nursing students in the classroom, Rew, Becker, Cookston, Khosropour, and Martinez (2003) conceptualized cultural competency as awareness (the affective dimension), sensitivity (the attitudinal dimension), knowledge (the cognitive dimension), and skill (the behavioral dimension). The authors define awareness as analysis of how personal beliefs, attitudes, and actions are influenced by one’s cultural background. Cultural sensitivity is determining to value another’s culture. Knowledge is the gaining of facts about the new culture. Lastly, skill is practice integration of actions, those that do not compromise the nurse’s beliefs and yet demonstrate respect for what is important to the other person (Rew et al., 2003).

Westernized nurses, for example, place great value in informing patients of all components of their diagnosis and care plan and in maintaining patient confidentiality. Although this may be the desire of many patients, it is not the standard in global communities and families. Patients of various cultures are known to not want full disclosure (Purnell & Paulanka, 2003). While on a short-term mission caring for families in the mountains of Guatemala, a nurse practitioner strived to educate an older woman of her vaginal cancer and need for transport to the city hospital. The only multilingual female translator was a 15-year-old (not the ideal person), and she refused to deliver the message to the woman. It was discovered that this culture strictly prohibits a younger person from delivering bad news to an older person. To do so would bring shame and disciplinary action to the 15-year-old. The community leaders met and decided it was better for an older man to inform this woman of her condition. The community determined what she would know and          how she would be informed (Elliott, 1992).

Nurses are expected to be culturally aware and culturally sensitive in the nursing care of all clients seen within their routine practice role and specialty. However, no nurse can be expected to be competent in the care of all cultures. The wide array of tribes, languages, nations, practices, peoples, families, and cultures proves too vast to know and understand. Leininger stated, “People are born, live, become ill, and die within a cultural belief and practice system, but are dependent upon human care for growth and survival . . . the ultimate goal [for nursing practice] is culturally congruent care” (Leininger, 1988, p. 155). Culturally congruent care promotes nurses’ decisions and actions as to what within the culture should be preserved, what may be accommodated, and what beliefs and practices require repatterning and change (Leininger, 1988). This begins with listening to each patient’s voice. The patient’s voice may be that of the family.

COMMUNITY-BASED HEALTH CARE

A proven and expanding demonstration of nurses listening to client (individuals, families, and communities) voices is community-based health care (CBHC), a global family care model. CBHC entails nurses acting on what they learned by listening and then, as caregivers and educators, training lay workers in the direct care of their own community and family.

Missionary nurse Carolyn Myatt (2000) stated that CBHC is “empowering people to solve their own problems by use of methods and technologies appropriate to the indigenous culture and society which leads to ‘ownership of and responsibility for’ a health care delivery system within the community they them-selves manage and sustain.” Unless the patient, family, community, and culture unite in common health-promoting beliefs and practices, the health of the family is in jeopardy.

” Nurses have been at the forefront of primary health care in communities since the 1978 Declaration of Alma Ata. This declaration called for the action of governments, health care providers, and world communities to promote and provide health education, food supply and nutrition, safe water and sanitation, maternal and child health programs, immunizations, prevention and control of locally endemic diseases, treatment of common disease and injuries, and provision of essential drugs (International Conference on Primary Health Care, 1978; Mosby, 1990). CBHC promotes accessibility to health care by offering “personal, sociocultural, economic, and system-related factors that enable individuals, families, and communities to have timely, needed, necessary, continuous, and satisfactory health services” (Gulzar, 1999, p. 17).

CBHC in India, for example, began through a faithbased central hospital and basic nursing education program. By 1987 the hospital staff was providing care through 10 community-based clinics. Today this CBHC program extends to 140 villages and affects the health of over 150,000 family members. Each village is visited twice a month by a team of nurses and doctors. Nurse-trained village health workers provide continuous community care through well-child and immunization clinics, nutritional rehabilitation programs, HIV/AIDS education and antenatal clinics, and the management of all well-mother deliveries (Noah, 2003).

Another success story is in Papua New Guinea. Here CBHC includes nurses training traditional birth attendants in family planning, pure water supply education, better crop-growing projects, and chicken- and rabbit-raising projects for protein sources. Such a significant improvement in female and neonatal morbidity and mortality took place that the CBHC program was adopted by the island’s government as policy for the entire national health care system. This recognition and policy change led to adoption of the same CBHC design by the Solomon Islands (Myatt, 2000; Nazarene Compassionate Ministries, 2002).

Nigeria’s CBHC program, established after an advanced practice nurse worked for years within a village awaiting community leaders’ willingness to want a community health committee, is now improving family health by having nurses train traditional birth attendants (Stevenson, 2002). The training curriculum and process began by interviewing 51 untrained midwives. They were given a voice and they expressed a willingness to learn. The nurse teaches those who serve the local family and community about the menstrual cycle, antenatal care, management of well labor and birth, basic high-risk management, process of patient transfer, breast-feeding, newborn care, HIV/AIDS, and family planning (Stevenson, 2002). Instruction includes aseptic techniques (prevention of blood-borne contamination and newborn tetanus), proper dosing and use of herbs, cord care, and signs and symptoms of life-threatening illnesses such as malaria (Irinoye, Adeyemo, & Elujoba, 2001).

In Swaziland, the community also chooses who will care for them. The community decides whom to send for the 3-month training. In commitment to the community, training is not held during the important harvest season. While the community-selected representative is attending the course, all local community families unite in care of the children and the household. The majority of the over 3000 attendees to date are women, thus elevating their status within the community. Traditional healers are also part of this select group. Curriculum includes prenatal care, nutrition, HIV/AIDS, pure water supply, sanitation, and the importance of not using the same contaminated razor blade or knife on multiple persons during traditional healing and ritualistic practices (Elliott, 2000).

Demonstrated in all programs is an emphasis on prenatal and women’s health care, which is proven to be central to the care and well-being of the entire family. The greater understanding a woman has regarding the importance of nutrition and breast-feeding, consequences of substance abuse and high-risk life- style, family planning, pure water, and well-child care (Feachem, 2001), the greater impact she has on the health promotion and disease prevention in her immediate family and community. As women are the primary global lay and professional caregivers, nurses are encouraged to empower women by seeking organizational support of programs that enhance women’s confidence and decision-making abilities, aid in improving women’s access to health care, and develop women’s health partnerships and community-based health workers (Messias, 2001).

CBHC programs in India, Papua New Guinea, and Nigeria were developed and expanded by Americaurses serving internationally as missionary nurses for the Church of the Nazarene. Swaziland’s CBHC program was developed by an indigenous nurse who had previously been educated by missionary nurses. Orchard and Karmaliani (1999) promote nurses as community development specialists needed in developing countries to aid in the following:

• Altering cultural practices that have a negative impact on health

• Promoting those practices that have a positive impact on health

• Providing health education that both promotes healthy lifestyles and prepares community members to lead and sustain their own community-based health care system Missionary nursing is only one practice methodology through which nurses can improve the health of families and communities.

CBHC programs that do not promote change usually fail because of the lack of community voice throughout the process. The Western approach to health care is to enter a family/community/culture with a predetermined need and plan of interaction. Examples of Western approach model designs include the community-oriented primary care cycle (Goldberg, 2003) and a British community pediatric team model (Gregg & Appleton, 1999). Lacking in both model designs is preplanning interaction with the people.

When the community is not granted an early and continuous voice, programs are not as successful. In general, successful CBHC is dependent on hearing the voice of the family and the community during all stages of program assessment, development, implementation, ongoing management, and evaluation. To further enhance the effectiveness of CBHC and further document the role of family nursing in CBHC, more nursing research is needed.

CULTURAL ADAPTATION

The success of CBHC, or of any family nursing care model in a new culture, requires cultural encounters, which can be interesting, rewarding, and very challenging. These encounters are enhanced when the nurse crosses borders to live and work within a new cultural environment. In that situation, the nurse is isolated from his or her personal cultural norms, values, practices, and resources. Practicing within the home nation challenges the nurse for an 8- to 12-hour shift. Practicing in a new host nation challenges the nurse not only in the service environment but also through all activities of daily living.

In the new international setting, the nurse must relearn, if not come to reunderstand and revalue, new units of intervention, which define identity, health care promotion, disease prevention, and healing. A new process of prioritizing family needs, resources, and actions is required (Long, 2000). Long (2000) described three units of intervention as relationship to self, relationship to others, and relationship to the environment. Relationship to self includes hygiene and personal caregiving, risk behaviors, identity, worth, and efficacy. Relationship to others is the interaction within the family and community. Components include the population group, caregiving agencies and organizations, and the nurse. Relationship to the environment addresses the patterns of exposure to harm, economic structures and employment, and all cultural practices, values, and beliefs.

Anthropologists Spradley and Phillips (1972) utilized The Cultural Readjustment Rating Questionnaire to rate the adaptation of Peace Corps and international students in their stress-related adjustment to a new international environment. The readjustment questionnaire items listed in Table 18–4 demonstrate various conditions and situations the international nurse of today will face. The authors state, “Cultural practices of every sort are reported to induce stress-toilet training, puberty rites, residential change, polygamous households, belief in malevolent gods, competition, and discontinuities between childhood socialization and adult roles” (Spradley & Phillips, 1972, p. 518). There were two unexpected findings of this study. The first was that neither previous intercultural experience nor a similar cultural background to the new culture influenced the appraisal and adaptation process needed within the new environment. Second, knowing the language alone also did not prove significant in cultural adaptation. It remained necessary to understand the cultural definitions of the words and the issues (Spradley & Phillips, 1972). The risk of cultural maladaptation and culture shock is an ever-present reality for international health care workers. Unresolved culture shock may result not only in ineffective and nonproductive nursing care of  the new clients but also in the nurse experiencing depression, psychosis, withdrawal, abnormal and disruptive behaviors, menstrual irregularities, eating disorders, insomnia, stress-induced cardiac and hormonal crisis, and/or suicide. Whether the international nurse is leaving Western civilization to serve in a Third World country or the reverse, mechanisms for support during cultural adaptation are essential for the health and well-being of the nurse. The following case study demonstrates cultural conflict and the need for support during the crisis.

Stages of Culture Shock

The stages of culture shock are common throughout literature and international service preparation materials. Initial shock and adjustment are common for any nurse traveling to and arriving in a new country. Fellow travelers, as well as local customs authorities and weather changes, all may cause the nurse to question the decision of international service. With prior knowledge and arrangements made and a welcoming committee present, early adjustment often proceeds without significant physical and emotional distress (Jones, 2001).

After recuperation from jet lag, the physical symptoms associated with crossing multiple time zones with- in a short period of time (World Health Organization, 2003), the first days and weeks in a new host country are often described as the “honeymoon” phase. This is the euphoria experienced by the temporary traveler to a region. What one sees and hears is interesting because it is superficial. Unfortunately, this phase is easily shattered by random and often unexpected, unexplained new lived experiences.

True conflict begins when the new culture does not conform to the expectations of the nurse (Spradley & Phillips, 1972). Progressive negative attitudes and emotions toward the people and the culture ensue. The very people who could serve to help the nurse adjust become threatening. “The first step in critical contextualization is to study the culture phenomenologically. If at this point the [nurse] shows any criticism of the customary beliefs and practices, the people will not talk about them for fear of being condemned” (Heibert, 1994, pp. 88, 89).

This lack of trust, as well as anger, hostility, and mutual isolation, continues unless active and dynamic intervention takes place. Ideally, the family nurse serving internationally will maintain a home support system with whom the nurse can discuss the areas of conflict. However, this alone is inadequate. Those at home have no insight into the reality of what the nurse is experiencing. Therefore, the nurse should immediately seek supportive host nationals or others from the home nation also living in the host county.

Establishing friendships and mentorship relationships to instruct, guide, and assist in the transition helps prevent culture shock in the nurse and will provide the interventioecessary to halt the cycle of isolation. These friendships can help the nurse understand and respect the value of the new culture to the people. Through successful prevention, intervention, and motivation, individuals often recover from culture shock. As the nurse adapts to new activities of daily living and establishes honored relationships, a sense of well-being and a sense of humor return. As the nurse grows more knowledgeable about local demographics, the role of the nurse and traditional healers, family structures and the family voice for health care communication and decision making, resources and existing programs that support family health, and patterns for nursing care, the nurse becomes more comfortable. True cultural integration or enculturation is a rewarding yet slowly progressing process. Ideally, those who serve internationally should learn and observe for at least 2 years before making comments or recommendations for change. During this time, nationals watch to see whether the nurse can be trusted. Even if the family nurse enters the experience informed about the culture and health care beliefs, it is only through the lived experience of patient care and interaction that the belief begins to have meaning for the nurse. Missionaries report having been deeply embedded within a culture for over 30 years, only to leave with just a basic understanding of the true meaning and worldview behind a belief or practice that is so important to the indigenous people. Eventually the international nurse returns home to experience some degree of reverse culture shock. Home is not the same. Family dynamics changed.  People aged. Even television images of reality changed. Professionally, nursing and biomedical knowledge and truths were challenged and revised. Health care policies and equipment were not stagnant. Common reverse culture shock sources include new awareness of the vast amount of medical waste in Western countries, the gross expenditures for health care services, the inequality of services provided at home versus abroad, and the limited autonomy and role of the nurse within the United States.

SUMMARY

Crossing borders to care for families, communities, and diverse cultures offers professional nurses unique practice, consultation, education, and research opportunities. It also introduces nurses to unique challenges, which can become great rewards. This chapter has discussed the following critical issues, all of which are important to the success or failure of family nursing care in international settings. Whatever the final definition of family may be, international borders are open to nurses who are willing to cross.

• Family nurses need to acquire knowledge about global disease and illness endemic to the new host nation and then listen to family beliefs about the cause of the illness.

• Cultural awareness, sensitivity, and adaptation are essential to meeting the needs of the individual, the family, the community, the culture, and the nurse.

• Realities that influence health, well-being, and nursing care within a culture include poverty, gender inequality, lack of adequate food supply or intake, lack of pure water supply, poor sanitation, and the sociopolitical environment, degree of population illiteracy, and population spiritual beliefs and practices.

• A proven family nursing practice model and research need is community-based health care (CBHC). CBHC listens to the voice of the community throughout all stages of project assessment, development, implementation, and evaluation. Through participatory action research, the needs of the community are met and the role of the family nurse is validated.

• Nurses are the primary global health care providers, and global families need more nurses.

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