Ms. Linda is a 12year old who was diagnosed with Asthma 2 years ago. She is expected to carry her inhaler to school as she experiences 2-3 asthma attacks every week. In addition, she is required to be cautious about the environment she chooses to play in as it should be an environment without allergens like dust and other pollutants from plants and people. In addition to all this, she has an appointment with her physician every month.
The first perspective of Roy’s adaptation model is the physiologic mode. The perspective gives a list of 5 things viewed as basic needs (Masters, 2011). Ms. Linda has impaired oxygenation as she experiences frequent asthmatic attacks that obstruct the upper respiratory tract. Ms. Linda also cannot participate in all childhood activities required of her. In addition, she is unable to rest adequately especially when asthmatic attacks occur at night. A question that a nurse attending to Linda may ask herself in relation to Roy’s perspective of the physiologic need includes is; does the condition of asthma impair Linda’s oxygenation?
The second perspective is the self-concept (Connell, 2013). Ms. Linda has a poor body sensation; she often wonders why her body keeps reacting to allergens. She also has a poor concept of self and she prefers that her friends do not know that she is asthmatic. She keeps telling her mother that it is unfair that she cannot go out to play in the field because of pollen that may trigger an attack. She complains that her illness makes her less of a person.
The role function focuses on what is expected of the person as a member of the society and if their condition interferes with this role (Roy, 2009 & Phillips, 2010). Does the condition affect Linda’s classes or her role as a student? Is Linda able to interact well with her peers? Does Linda tolerate activities that other children her age are able to tolerate or does the condition make her dull and antisocial?
The interdependence model focuses on the interaction that is related to giving and receiving from others (Roy, 2009 & Phillips, 2010). Does the condition affect the relationship between Linda and her parents? Has Linda become over-dependent on people because of the condition? Is Linda able to meet her self-care needs or does she rely on someone else to do them for her?
The Calister Roy adaptation model fits well since the model allowed me to look at the patient as a whole individual and not just the physiological mode. It helped me identify other problems related to the condition and by that the nursing care I would give would be adequate. The mode gives me a broader view of the clinical problem and it also gives me an idea of what to look at when taking the history of a patient.
The assignment made the model more practical as it required the use of a hypothetical person. Thus, when faced with the same situation in the hospitals or clinics, I will be in a better position to handle it than I was before this assignment. The model also gives a clear definition of health and nursing. This aids in the management as the nurse is aware of what is expected of her in caring for her patients.
In summary, assuming the different theoretical perspectives were not as simple; it required a lot of work. The end result on the other hand was positive; the patient was able to be assessed in all areas. This ensures that the patient receives nursing care that is holistic.
References
Connell, W.F. (2013). The Roy Adaptation Model. Web.
Masters, K. (2011). Nursing theories: A Framework for Professional Studies. Burlington, MA: Jones & Barlett Learning.
Phillips, K.D. (2010) Sister Callista Roy: Adaptation Model. In A. M. Torney & M. R. Alligoods (Eds) Nursing Theorists and their Work (7th ed., pp 335-365). Maryland heights, MO: Mosby.
Roy, Sr. C., (2009). The Roy Adaptation Model (3rd ed.) Upper Saddle River, NJ: Pearson.
It is crucial to state that the Cherokee Self-Reliance theory by John Lowe is based on the Native American value system and cultural characteristics. The historical context for the creation of this theory is the statement by Cherokee leaders in 1976 that self-sufficiency is an essential component of people’s lives (Lowe, 2002). They also indicated self-sufficiency in the Cherokee Nation’s constitutional mission statement. Thus, the theory arose in response to the needs of the people after leaders expressed concern about the self-sufficiency of community members. The approach has influenced the overall health of the Cherokee population, especially since the theory was created to reduce drug use, reduce diabetes, and the rate of committing suicide. It is significant to mention that the goal is to accelerate people’s goodness and health status in relation to their value system. Cherokee Self-Reliance theory encouraged the concept that people should be concerned about their health and take responsibility for their actions (Lowe, 2002). Thus, the basic concepts are discipline and connection to cultural roots. There are three primary structures: discipline, assurance, and responsibility. Hence, the Cherokee Self-Reliance theory suggests a method for nurses to work with patients.
Analysis
While analyzing the basic postulates of the theory, it can be specified that the approach is based on the interrelated three interrelated categories to have a clear framework. To describe the clarity and accessibility of the approach, there is a general notion of fidelity to self in theory (Lowe, 2002). This perspective allows people to understand and embrace the Cherokee cultural values and worldview. Cultural specificity is a basic concept to summarize Lowe’s concept. Therefore, people with cultural affiliations can maintain a balance in their lives. The theory is developed in the context of culture and lifestyle, which is why it aims to maintain balance in all spheres of people’s lives, especially in health care (Lowe, 2002). The importance of the theory is that it provides general information about the Cherokee people. This is because the literature is deficient in concentrating on and giving information about values and their impact on the lives of the nations. This information is essential for nurses of other origins because they also work with the Cherokee people.
Evaluation
The theory demonstrates a description of Cherokee adolescents from a cultural perspective. Cherokee Self-Reliance theory can be used as an aid in the way communication is established between nurses and the community of Cherokee (Lowe, 2002). The nurse-client relationship promotes Cherokee self-reliance and is key to effective nursing care. It is especially applicable to adolescent males in the article (Williams, 2013). Thus, with the assistance of theory, nursing staff in their practice can eliminate preconceptions about the significance of self-sufficiency. Instead, they can become cultural mediators to help adolescents according to the core concepts of their beliefs. For example, medical professionals can, in a rehabilitative narcotics center, devise a plan of care in such a way as to enhance the self-independence of patients. Only if this method does not produce the desired results proceed to the standard of care. Thus, using this theory in nursing will contribute to establishing a trusting relationship with patients and the medical peer community (Williams, 2013). Consequently, assisting patients in learning self-sufficiency skills will allow them to recover from their harmful addictions.
Development
The theory has been examined in studies conducted by scientists. For example, an experiment was performed in which health care professionals used the approach in the Cherokee drug treatment center. All participants in this experiment noted that self-sufficiency would prevent the Cherokee from abusing drugs and alcohol (Lowe, 2002). Nevertheless, the theory does not have significant support among scientists because it needs more implementation in medical practice to demonstrate its effectiveness. Hence, the Cherokee Self-Reliance theory needs further practical research to confirm its viability in medical practice.
References
Lowe, J. (2002). Cherokee Self-Reliance. Journal of Transcultural Nursing, 13(4), 287-295.
Psychiatrists and nurse practitioners who possess cultural-competence skills find it easier to deliver evidence-based care to their patients. Madeleine Leininger’s Transcultural Nursing Theory offers powerful insights that can ensure culturally-competent care is available to more patients with psychological needs. This research paper gives a detailed analysis of the Transcultural Nursing Theory. The paper goes further to explain how the theory can be used to inform nursing practice.
Theory Name and Background
Selected Theory
Nurses can use different theories to address the health needs of their clients. Although all mid-range and grand theories of nursing can support the practices of many caregivers, Madeleine Leininger’s theory of Transcultural Nursing appears to stand out. The theory is applicable in different settings to support the needs of many patients with psychological issues (Douglas et al., 2011). From a personal point of view, I strongly believe that the Transcultural Theory of Madeleine Leininger can support my nursing practice. This is the case because the cultural attributes of an individual will determine his or her psychological health outcomes.
Theorist’s Background
Madeleine Leininger is one of the famous theorists whose achievements redefined the meaning of nursing. She was “born in July 1925 and later pursued a Diploma of Nursing from the famous St. Anthony’s Hospital School of Nursing” (McFarland & Wehbe-Alamah, 2014, p. 8). Leininger went ahead to complete her degree from Creighton University (McFarland & Wehbe-Alamah, 2014). She later earned a Master of Science degree. The theorist completed her PhD from the University of Washington in 1966. Her competencies in social and cultural anthropology played a significant role in the development of the Transcultural Nursing Theory. Throughout her career period, Leininger provided quality nursing education to many students and clients. She supported the needs of many people from diverse backgrounds. These practices equipped her with powerful ideas that led to the development of the nursing model.
Crucial References
Leininger polished the Transcultural Nursing Theory in 2002. She had already published several researches that guided her throughout the theory-development process. One of her famous works is the book “Culture Care Diversity and Universality”. This book was published in 1991. She later wrote a second book titled “Transcultural Nursing” in 1995. These works guided the theorist to develop various nursing dimensions and concepts. She later formulated a number of concepts that led to the creation of this nursing theory (Prosen, 2015). Her background in nursing education and collaboration with different scholars played a positive role in the development of the theory.
Issues Addressed by the Theory
This theory is embraced by many caregivers, doctors, and psychologists because of its ability to transform the nature of care. Caregivers are always required to offer quality support to individuals from different backgrounds. Unfortunately, many practitioners find it hard to deliver quality support to clients from different cultural backgrounds. The Transcultural Nursing Theory gives detailed arguments that can guide nurses to offer culturally-competent care to their patients (McFarland & Wehbe-Alamah, 2014). The theory has been widely used by healthcare professionals to develop new skills and implement appropriate nursing strategies (Douglas et al., 2011). The theory has therefore made it easier for psychiatrists and nurses to support the health needs of many patients from diverse backgrounds.
Theory Description
Deductive Reasoning
Madeleine Leininger uses deductive reasoning to develop the Transcultural Nursing Model. The approach starts with a general rule or argument. Once the rule has been outlined, several ideas are identified to show how the idea can be used (Prosen, 2015). This means that, if “the original rule is true, then the conclusions must be acceptable” (Prosen, 2015, p. 150). Madeleine Leininger begins by indicating that human wellness is reshaped by a number of factors. Some of these factors include cultural attributes, social skills, and coping strategies. The author of the theory goes further to outline various cultural attributes that affect the health outcomes of many patients. She concludes by explaining why providers of health care should be aware of the cultural issues affecting the welfare of their patients. The next thing is to engage in positive intercultural communication in an attempt to improve the health outcomes of the targeted patients.
Concepts of the Theory
Several concepts have been used by Madeleine Leininger to describe the theory. In order to support the theory, Leininger defines the concepts both operationally and theoretically. The major concepts used to support this theory include trans-cultural nursing, ethno-nursing, nursing, cultural competence, cultural congruent care, culture care universality, and culture care re-patterning (Prosen, 2015). This discussion shows clearly that the theorist uses and applies the theories consistently. The concepts are combined with other sub-concepts such as cultural imposition, professional care, ethnohistory, and cultural care accommodation (Douglas et al., 2011). The “concept culture care re-patterning helps nurses to reestablish the best approaches towards improving the health outcomes of more patients” (Douglas et al., 2011, p. 324).
Definition of the Major Concepts
One of the outstanding facts about this theory is that each and every concept is defined explicitly. This means that the theorist uses direct descriptions to define the concepts. Additionally, the concepts are analyzed and interpreted carefully in an attempt to support the performance of many healthcare professionals. The first concept is trans-cultural nursing. This concept is defined as a branch of nursing that focuses on the cultural aspects affecting the health outcomes of a client. Ethno-nursing is the second concept and refers “to the study of nursing care practices as perceived by a designated culture through its direct value system and experience” (McFarland & Wehbe-Alamah, 2014, p. 48).
Nursing is another powerful concept used to describe the model. The theorist defines nursing as a scientific discipline aimed at improving the quality of care using culturally-competent approaches (Jeffreys, 2008). The other concept is known as cultural-congruent care. This concept refers to the supportive and facilitative decisions that fit the cultural needs of a patient. The culture care universality concept focuses on “the uniform patterns manifested among cultures and capable of improving people’s health outcomes” (McFarland & Wehbe-Alamah, 2014, p. 54).
Relationships among the Major Concepts
In order to support the meaning of these concepts, Leininger presents a number of propositions that make the theory applicable in different healthcare settings. The first proposition is that different cultural groups practice nursing (or patient care) using different strategies. Despite such differences, some key commonalities in inpatient care exist across all cultures. The second proposition is that caring should be a holistic practice aimed at examining and predicting the health of a patient. Although human care is universal, practitioners should use various patterns, expressions, and meanings to empower their patients. The other proposition is that caring is an essential practice towards supporting the survival, welfare, and growth of all human beings (McFarland & Wehbe-Alamah, 2014). Failure to offer culturally-competent support will affect the health outcomes of many patients. These propositions play a critical role in linking the above concepts. Healthcare practitioners should consider these assumptions in order to deliver quality support to more patients from diverse backgrounds.
Evaluation
Explicit and Implicit Assumptions
There are several assumptions or beliefs underlying this theory. Such assumptions make it easier for more nurses to use the theory effectively. To begin with, the theory assumes that nursing is a trans-cultural discipline that should be used to serve all people from different parts of the world (Jeffreys, 2008). In order to produce positive results, nurses should focus on the needs of all people from different backgrounds. The other assumption is that nursing care should be beneficial and culturally-competent. The theorist also assumes that nurses who fail to offer culturally-congruent care will affect the health outcomes of their clients. This is the case because such patients will show signs of noncompliance and stress. The theory goes further to assume that global cultures have specific commonalities that should be embraced by healthcare providers. This means that the values needed for cultural-competence care should be reshaped by the political, cultural, language, and technological contexts of the targeted cultural groups (Jeffreys, 2008). These assumptions play a positive role in ensuring that more caregivers support the needs of their clients.
Nursing Meta-Paradigms
It is agreeable that Madeleine Leininger’s theory is founded on the four meta-paradigms of nursing. These meta-paradigms are clearly explained in an attempt to support the health needs of more patients. To begin with, health is defined as “the state of well-being that should be culturally practiced, defined, and valued” (McFarland & Wehbe-Alamah, 2014, p. 27). This means that a healthy individual should be able to perform the most desirable activities in a positive manner. The second meta-paradigm outlined in the theory is people or human beings. According to the theory, people are entities capable of caring for one another. Nurses should, therefore, promote the most appropriate interactions by attracting different cultural groups, health institutions, communities, and families (Viadas, 2015). The third meta-paradigm defined by the theory is the environment. Leininger embraces this meta-paradigm from a global perspective. The theory focuses on the social structure dictating the health outcomes of a patient. Nursing, on the other hand, is treated as a humanistic discipline aimed at assisting individuals or cultures to regain their health outcomes from a cultural perspective (Viadas, 2015). These four meta-paradigms make it easier for healthcare providers to formulate the most appropriate nursing philosophies.
Clarity of the Theory
The Transcultural Nursing Theory is a powerful framework capable of supporting the health needs of many people across the globe. This is the case because the concepts and meta-paradigms of nursing are defined in a clear manner. This clarity makes the theory applicable in a wide range of healthcare settings. The author offers clearly-defined concepts, propositions, sub-concepts, and assumptions. The deductive approach makes it easier for the theorist to come up with one of the most appropriate theories in nursing (McFarland & Wehbe-Alamah, 2014). The author presents a wide range of propositions that can be used by psychiatrists to support the mental health needs of their clients. This clarity is what makes the theory admirable and applicable in various healthcare settings. Practitioners who want to support the health needs of their clients should, therefore, be on the frontline to use this theory. Although the concepts might be complex and incomprehensible, the outstanding fact is that nurses can use the model to develop sustainable healthcare delivery models.
Application
Guiding Nursing Actions
One of the outstanding aspects of this theory is that it is applicable in a wide range of health settings. The definition of different concepts in the model makes it easier for different practitioners to support the health needs of their patients. The theory can be used by nurses to examine and understand the unique cultural aspects of their clients. Healthcare professionals provide medical care to patients from diverse backgrounds. Such patients tend to portray specific religious, cultural, and social values (McFarland & Wehbe-Alamah, 2014). These values might dictate the health outcomes of targeted patients. Nurses should, therefore, monitor the unique needs of their respective patients. A caregiver who understands the cultural and social aspects of his or her clients will be able to offer quality care. This theory acts as a powerful guideline that can support the needs of many patients.
Nurses and psychiatrists can identify the best resources and competencies in order to support their clients’ health needs. In the recent past, healthcare professionals have been embracing the importance of cultural-competence in nursing practice. This single fact shows clearly that nurses can use the concept to provide culturally-competent care to their patients. The practice will maximize the outcomes of their patients and support their professional objectives. This theory can make it easier for nurses to deliver quality care to more people from diverse backgrounds. This approach will transform the field of nursing and ensure desirable services are available to more patients across the world (McFarland & Wehbe-Alamah, 2014).
Using the Theory in Nursing
I am currently working as psychiatric nurse practitioner (PNP). This fact explains why I am expected to support the psychological needs of more patients from different backgrounds. That being the case, I will always use this theory to support the health needs of such clients. The theory will play a critical role towards redefining my nursing philosophy (Larson, 2014). For instance, I have understood the importance of involving different players throughout the healthcare delivery process. This practice will make it easier to understand the diverse cultural attributes and needs of my clients.
This theory goes further to support the power of collaboration (Larson, 2014). This practice can support the professional needs of many healthcare workers. I will therefore use this knowledge to create different multidisciplinary teams. Successful multidisciplinary teams should be comprised of different professionals such as nurses, psychiatrists, social workers, caregivers, and doctors (Larson, 2014). The use of such teams will definitely support my approach towards providing cultural-competent care to patients with various psychological needs. This practice will eventually support the needs of more people in the society. Psychiatrists who want to realize their professional goals should therefore embrace the power of the Transcultural Nursing Theory. Consequently, such professionals will ensure every patient receives evidence-based and sustainable mental care. This practice will make it easier for more patients to realize their personal goals.
References
Douglas, M., Pierce, J., Rosenkoetter, M., Pacquiao, D., Callister, L., Hattar-Pollara, M.,…Purnell, L. (2011). Standards of practice for culturally competent nursing care: 2011 update. Journal of Trans-cultural Nursing, 22(4), 317-333.
Jeffreys, M. (2008). Dynamics of diversity: becoming better nurses through diversity awareness. NSNA Imprint, 1(1), 37-41.
Larson, M. (2014). Cultural immersion and compassionate care in a study abroad course: the Greek connection. Journal of Compassionate Health Care, 1(1), 1-8.
McFarland, M., & Wehbe-Alamah, H. (2014). Leininger’s culture care diversity and universality. Burlington, MA: Jones & Bartlett Learning.
Prosen, M. (2015). Introducing trans-cultural nursing education: implementation of Transcultural Nursing in the postgraduate nursing curriculum. Procedia – Social and Behavioral Sciences, 174(12), 149-155.
Viadas, C. (2015). Historic perspectives from anthropology: reflections proposed to Transcultural Nursing. Investigación y Educación en Enfermería, 33(2), 375-379.
In this article, the researches’ main purpose is to analyze the competence and experience level of professional nurse practitioners and new graduated nurses. The study has been conducted according to Benner’s model consisting in the identification of relations between nurses’ competence and their experience. The examination has been accomplished by means of chi-square analysis. The article is of great importance for research paper as the given study directly relates to Benner’s theory.
In the article, Altmann summarizes the main concepts of Patricia Benner work From Novice to Expert in order to identify whether this book is a philosophy but a theory. To do that, the author’s goal is to define the difference between a theory and a philosophy and to the stages of epistemological process occurring in the health care environment. Therefore, this summary directly relates to my research as it is based on Benner’s book.
This paper describes clinical decision support systems (CDSS), software aimed at improving the quality of care and providing an easier access to medical digital data. The authors believe that this program is not always efficient for those who lack experience. This article is not appropriate for my work, as the merits of CDSS are vaguely defined.
The authors state that clinical environment help novice nurses to apply the theoretical principles in practice and to view different situation in a full context. However, the problem is that nurse graduates are frequently guided by more experienced nurse practitioners that deprive them of possibility to make independent decisions, which is the reason of novice nurse leaving the profession. Therefore, the researchers discuss the necessity to insert decision-making training programs to health care environment. This work is, therefore, relevant to my own research, as it refers to Benner’s concepts of nurse transaction from novice to experts.
In the article, the researches touch upon the necessity to support novice nurse faculty members and their engagement into clinical environment. They also believe that mentoring is the key point triggering the novice nurse into academic life. The work implicitly reveals the Benner’s concepts of novice nurses’ penetration to experienced nurse stuff.
In the article, the authors intend to define the effectiveness of novice nurse transition to the role of intense care unit nurse if working with more experienced nurses. In particular, they discuss quantitative and qualitative results of “Shadow-A-Nurse” ICU Program after two years of its implementation. This source is rather helpful for further research in that field, as the program accomplishment is based on Benner’s application of skill acquisition model.
Reference
Alber, L., Augustus, L., Hahn, S., Penkert, J. (2009). Applying Benner’s Model to Psychiatric Mental Health Nurse Practitioner Self-Ratings of Role Competence. J Am Psyhiatr Nurses Assoc, 15(2), 126-137.
Altmann, Tanya. (2007). An Evaluation of the Seminal Work of Patricia Benner: Theory or Philosophy? Contemporary Nurse. 25, 114-123.
Courtney K. L., Alexander G. L. Demiris, G. (2008). Information Technology from Novice to Expert: Implementation Implications. J Nurse Manag. 16(6) 692-699.
Gillespie, M., and Paterson, B. (2009). Helping Novice Nurses Make Effective Clinical Decisions: The Situated Clinical Decision-Making Framework. Nursing Education Perspectives. 30(3). 164-170.
Hawkins, J. W., and Fontenot, H. (2009). What do you mean me to teach, do research, engage in service, and clinical practice? Views from the trenches: The novice, the expert. Journal of the American Academy of Nurse Practitioners. 25, 358-361.
Messmer, P. M., Jones, S. G., Taylor, B. A. (2004). Enhancing Knowledge and Self-Confidence of Novice Nurses: The “Shadow-a-nurse” ICU Program. Nursing Education Perspectives. 25(3). 131-136.
Nursing is a scientific field that is growing fast through models that influence nursing practices. Many theories shape the ideologies and growing transformations of nursing practices. One of the major nursing approaches that have led to great paradigm shifts is the unitary-transformative theory. The theory promotes the need for a holistic approach to nursing that handles the connection between the universe and human being hence influencing the grand theories and the metaparadigm in nursing.
The greatest impact of the unitary transformative nursing model is the push for connection between human beings and God. The theory makes people look for a higher being that is beyond the world and human beings (Smith & Fitzpatrick, 2019). The connection is key in understanding the health aspects of people. Such understanding makes nurses appreciate that human life is dependent on the environment, and social and religious aspects of life. Notably, the unitary theory makes people appreciate the connection between the universe and human beings.
Additionally, the unitary-transformative concept explains that human life is in form of an energy system that interconnects with the universe.
For example, the paradigm promotes a unitary human being that is a complex organization in matters of health. When nurses appreciate humans as open energy with universal interconnection, then health care practices are fashioned to focus on the energy and the environment (Smith & Fitzpatrick, 2019). For example, the theory helps health practitioners and scholars to understand that human health lacks direction hence people fall sick occasionally which requires care. In short, the unitary-transformative theory helps health practitioners to appreciate the transpersonal model and the sub-atomic particles that are God’s creation. Further, the theory helps nurses offer personalized care to their patients (Smith & Fitzpatrick, 2019). Through the theory, nurses can guide their patients to self-care in a manner that makes the sick understand their health state at any given moment.
Reference
Smith, M., & Fitzpatrick, J. (2019). Perspectives on the unitary transformative person-environment-health process for the knowledge base of nursing. Advances in Nursing Science, 42(1), 43-57. Web.
It is important to note that there is a complex set of constituents when it comes to providing care to a patient. Meta paradigm essentially refers to a holistic approach, where nursing, health, and the environment of patients are taken into consideration. Dorothea Orem’s self-care deficit theory can incorporate meta-paradigms because both frameworks have overlapping points of interest. Meta paradigms can be implemented into the self-care deficit theory’s major concepts, which include nursing, humans, and the environment.
Although there is a multitude of dimensions to the theory, it contains conceptual areas that precisely match those found in the meta paradigm. Firstly, Orem’s theory describes nursing as the art of providing assistance to those who are unable to care for themselves (Gonzalo, 2021). For example, giving specialized assistance to people with disabilities constitutes the nursing component of the metaparadigm. Secondly, it is stated that humans, such as men, women, and children, are material objects for nurses with the need for direct care (Gonzalo, 2021). For instance, a family nurse practitioner would view a family as a social unit emphasizing family-centered care. Thirdly, it is important to factor in the environmental elements, which include culture, family, and community (Gonzalo, 2021). For example, cultural competence would be a meta paradigm being implemented in the theory. Fourthly, health is a state that is functionally and structurally whole, appealing to comprehensive and non-invasive measures (Gonzalo, 2021). For instance, the meta paradigm focuses on holistic treatment, constituting a comprehensive understanding of health under the self-care deficit theory.
In conclusion, meta paradigms can be incorporated into the major concepts of self-care deficit theory, which include nursing, humans, and the environment. Nursing is the art of providing assistance to those who are unable to care for themselves, whereas human beings are material objects for nurses with the need for direct care. Health is structurally and functionally whole, and the environmental elements include culture, family, and community.