1. Narayan, Mary Curry MSN, APRN, BC, CTN

Article Content

Several years after becoming a nurse, I joined a service organization, which sent me to a Yupik Eskimo village close to the Bering Sea in Alaska. During my 2 years there, I was the sole professional healthcare provider for a village population of about 500 residents. Besides being a thoroughly enriching and rewarding experience, this experience gave me a lifelong interest in the challenges and issues involved in cross-cultural healthcare.


Soon after arriving in Alaska, I realized that the assumptions I held about what health is, how one knows one needs medical attention, and what kinds of treatments are thought to be helpful were different from the ones my Yupik patients held. Furthermore, I realized that their nonverbal communication and social etiquette patterns were very different from the patterns I had always used and understood. I was almost overwhelmed by the new challenges I faced in establishing rapport and providing culturally acceptable and comfortable care.


My realization that special knowledge and skills are needed when healthcare providers interact with people of different cultures was further strengthened when I returned to "the Lower 48." On becoming a visiting nurse in the culturally diverse Northern Virginia area, just outside of our nation's capital, I became even more convinced that nurses need what has become known as "cultural competence."


When I finally sought advanced nursing knowledge and skills through my MSN program, I focused on advanced practice in home health nursing and transcultural nursing, and sought certification not only as a clinical specialist in home health nursing, but as a certified transcultural nurse (CTN).


Transcultural Nursing Society and Certification

Madeline Leininger, a nurse theorist and anthropologist, established the Transcultural Nursing Society in 1974. The Society, whose mission is to promote safe and effective care for patients of diverse and similar cultures, offers annual conferences, publishes the Journal of Transcultural Nursing, and certifies nurses in transcultural nursing (Transcultural Nursing Society, 2005).


To become a CTN, the applicant must have graduate education in transcultural nursing, obtain an MSN degree, and pass a written and oral examination, which is graded by a jury panel at the annual TNS meeting. Certification is for 5 years. To be recertified, the CTN must provide evidence of professional growth in transcultural nursing and evidence of contributions to transcultural nursing practice, consultation, research, or leadership.


To learn more about the Transcultural Nursing Society and how to become a CTN, see the Society's Web site at


The Certified Transcultural Nurse in Practice

Since becoming a CTN, I have had many opportunities to provide consultation and education to other nurses. For instance, I gave several presentations to the staff at my agency on how to provide culturally competent care. Once the staff recognized my knowledge and interest in cross-cultural healthcare, they would frequently call me for advice on how to manage issues that occurred because of cultural differences. I found I could frequently resolve problems by providing cultural insight and perspective and by guiding the staff through ways of developing a mutually agreeable care plan that met the patient's cultural needs and the clinician's need to provide quality care.


I sought opportunities to provide expert care to patients of diverse cultures and felt that they benefited from the care I gave, based on the knowledge and skills I obtained as a CTN. I served on my agency's Bioethics Committee, where I was amazed at how many ethical conflicts were related to ethnic and religious cultural differences between the staff and the patients. I also sat on the health system's patient education committee, where I advocated for culturally and linguistically competent resources. Soon, I was being asked to write book chapters and journal articles and to give presentations at conferences and workshops. In fact, these days, I spend most of my time teaching about transcultural nursing, instead of practicing transcultural nursing.


My work as a CTN has been stimulating and rewarding. However, as of yet, I have not been able to implement the transcultural nurse specialist role in the way I would like. I would like to spend more time in practice, as a clinical specialist for patients in need of cultural expertise, just as certified diabetic educators (CDEs), certified registered nurse infusionists (CRNIs), and psych-mental health clinical specialists do for an agency's patients with those specialty needs. Probably because of the economic pressures that leave home health agencies with little room for experimentation with new roles, I have not yet found a home health agency close to home willing to employ me as a transcultural nurse specialist. However, I believe future trends will enable me to expand my role to providing culturally comfortable care to individual patients.


A Promising Future

The need for cross-cultural healthcare expertise is only going to grow. Among the pressures that are leading to a need for more CTNs are:


* Demographic projections indicating that cultural diversity will continue to expand (U.S. Census Bureau, 2002);


* The Office of Civil Right's (2000) interpretation of Title VI, Civil Rights Act, requiring equal services to patients despite national origin and language;


* The Office of Minority Health's (2000)National Standards for Culturally and Linguistically Appropriate Services;


* The Institute of Medicine's report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (Smedley et al., 2002), indicating health of cultural minorities is substandard, in part because providers lack cultural sensitivity and competence;


* The Healthy People 2010 goals (U.S. Department of Health and Human Services, n. d.), focusing on the need to "eliminate health disparities" among various segments of the population; and


* Accreditation organization standards, equating quality care with providing culturally sensitive assessments and adapting care to cultural needs and preferences of diverse patient populations.



Patients need nurses whose knowledge and skills enable the patients to achieve optimal health and well-being through culturally comfortable care. CTNs are nurses who have proven they have this knowledge and skill.




Office of Civil Rights, Department of Health and Human Services. (2000). Policy guidance on Title VI of the Civil Rights Act of 1964: Prohibition against national origin discrimination as it affects persons with limited English proficiency. Federal Register, 65(169), 52762-52774. [Context Link]


Office of Minority Health, Department of Health and Human Services. (2000). National standards for culturally and linguistically appropriate services in the delivery of healthcare. Federal Register, 65(247), 80865-80879. [Context Link]


Smedley, B., Stith, A., & Nelson, A. (2002). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Institute of Medicine (IOM) Report. Washington, DC: National Academy Press. [Context Link]


Transcultural Nursing Society. (2005). Information about the society. Retrieved October 21, 2005 from [Context Link]


U.S. Census Bureau. (2002). National population projects. Retrieved October 21, 2004 from [Context Link]


U. S. Department of Health and Human Services. (n.d.). Healthy people 2010: What are its goals? Retrieved October 21, 2005 from