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Caring in the Margins: An Approach to Transcultural Nursing

Our current featured article presents the use of a nursing model in practice.  It is titled “Caring in the Margins: A Scholarship of Accompaniment for Advanced Transcultural Nursing Practice,” authored by Ruth C. Enestvedt, PhD, RN; Kathleen M. Clark, DNP, RN; Kaija Freborg, DNP, RN; Joyce P. Miller, DNP, RN; Cheryl J. Leuning, PhD, RN; Deborah K. Schuhmacher, DNP, RN; Kristin M. McHale, DNP, RN; Katherine A. Baumgartner, DNP, RN and Susan L. Loushin, DNP, RN.  We welcome you to download this article at no cost while it is featured, and share your comments here!  Dr. Enestvedt shared this message giving background to this work for ANS readers, followed by several photographs from the project reported in the article (used by permission):

Point of view shapes interpretation.  How can professionals shift their point of view in encounters with people in unfamiliar cultural settings?  In social margins? 

Ruth C. Enestvedt

Professionals are often in their own familiar settings, or they can structure a setting to fit their context of explanation.  Formal assessment procedures are quite efficient in this process. Field work for a PhD in Critical Medical Anthropology gave me insight into how low income elderly women resist professional control in health care encounters.  These “strategies of resistance”  are frequently troubling to professionals and considered to be e.g. “manipulative behavior” or “non-compliance” or “knowledge deficits” (1). I came to see them from the perspective of the poor elderly women as attempts to assert autonomy in these meetings. I also learned how critical social/cultural context is to understanding the meaning of behavior.  During my field work I had more than a decade in the the low-income public housing complex to gain some appreciation for the context of living in this social margin. In order to begin to understand the complex dynamics of such an unfamiliar setting, it was clear that I had to “de-professionalize” my interactions.

To do so, I developed the following “Rules of Thumb” for my interactions:

  • Acknowledge your ignorance (at least to yourself)
  • Have conversations NOT interviews (you don’t know what questions to ask and people will tend to give answers they think you want)
  • Listen for understanding
  • Beware questions that direct conversation
  • Respond to affirm (honor the complexity in the circumstance, the strength in the response)
  • Give direct answers
  • Assume there’s always more to it.

These insights were developed further in the care model that is central to this article.  They are foundational for Advanced Transcultural Nursing.

1 Scott, J.C.  (1990) Domination and the Arts of Resistance: Hidden Transcripts. New Haven: Yale University Press.


Graduating DNP Class of 2011. From top left to bottom right: Kristin M. McHale*, Susan L. Loushin*, Mary Ann Kinney, Kaija Freborg*, Joyce P. Miller*, Katherine A. Baumgartner*, Jean Gunderson, Deb K. Schuhmacher* (*author)

Kathleen M. Clark visiting with a guest at the Augsburg Central Health Commons (used by permission)

Nursing faculty and a volunteer providing outreach on the streets of Minneapolis

One Comment Post a comment
  1. The authors commendably have developed a context and model for caring for those who have been marginalized by the dominant culture, including health services and structures. It has been established that health care providers, including nurses have unexamined racism and that they often and, usually unknowingly, commit microaggressinns against people based on race, gender, gender identity, sexual orientation, etc.
    An important principle in working inthe diverse world we live in is that you dont expect the “Other” to teach privileged folks about how not to be biased. The idea of using the context to educate students still preserves an “us-them” stance. Inmy ooinion the students should already have dealt with bias and be well schooled in the model of the Commons before offering services.
    The terms solidarity and hospitality should be explained in more depth and contrasted against the extant nursing definitions of relationship and “problem-solving”. Hospitality and solidarity were/are central to the Catholic Worker Movement. In a personalist perspective, Peter Maurin and Dorothy Day described hospitality and indeed the movement continues with Houses of Hospitality wherin guests are welcomed and the “staff” live in the house. Activism is part of the CW. These Houses are in many cities and rural areas also. Dorothy Day wrote about hospitality in several books. The best known is “Loaves and Fishes”
    This is based in religion and indeed much of liberation scholarship comes from Latinamerican communicates de base and writers like James Cone, Jon Sobrino, Gutierrez, and Enrique Dussell. Something missing here is that when nurses change the basic frame for relating as adjacent to the patieny and not pushing or pulling from in front or behind, conflicts are to be expected. Not necessarily between nurse and patient/person, but causes ripples that begin to shake the institutions, including the government. TCN can present a naive approach because to label things cultural, and underneath that rhetoric are the more specificand intersectional situations of violence —race, gender, sexual identities and practices. I think we have to start using the lauguage of those “othered”.
    Thank you for this thought-provoking article

    September 3, 2018

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