Theoretical Foundation of Transcultural Nursing

MADELEINE LEININGER
(JULY 13, 1925 – AUGUST 10, 2012
- An internationally known educator, author,
theorist, administrator, researcher,
consultant, public speaker, and the
developer of the concept of transcultural
nursing
- She earned a nursing diploma from St.
Anthony’s Hospital School of Nursing,
followed by undergraduate degrees at Mount
St. Scholastica College and Creighton  The concept of transcultural nursing
University. appeared less than 30 years ago since
- While working in a child guidance home MADELEINE LEININGER first began to
during the 1950s, she experienced what she develop a theory of transcultural nursing as
described as a cultural shock when she part of a doctoral study in anthropology.
realized that children’s recurrent behavioral  Transcultural Nursing was developed
patterns appeared to have a cultural basis. because of the need to work with people from
She identified a lack of cultural and care widely divergent cultural atmosphere.
knowledge as the missing link to nursing.  It is critical that nurses, because of their
- She was the first in the 1960s to coin the direct patient care, understand and work
concept of “culturally congruent care,” which
effectively within this diverse cultural
was the goal of the Theory of Culture Care, atmosphere.
MADELEINE LEININGER (JULY 13, 1925 –
 People from various cultures and subcultures
AUGUST 10, 2012) and today the concept is
are more common in today’s world and these
being used globally.
people are sensitive to the preservation of
- As for being a pioneer nurse anthropologist,
their cultural heritage and customs.
she was appointed Dean of the University of
 The most important aspect in developing
Washington, School of Nursing in 1969 and
cultural competence is understanding the
remained in that position until 1974. In 1973,
interrelatedness of cultural concept.
under her leadership, the University of
 Transcultural scholars and academics refer
Washington was recognized as the
to care as universal phenomenon that
outstanding public institutional school of
transcends cultural boundaries, and their
nursing in the United States.
aim is to incorporate transcultural
- Her appointment followed a trip to New
nursing into nursing curricula and clinical
Guinea in the 1960s that opened her eyes to
practices through a research-based
the need for nurses to understand their
knowledge of cultures.
patients’ culture and background to provide
care. She is considered by some to be the  The term TRANSCULTURAL NURSING is
“Margaret Mead of nursing” and is sometimes used interchangeably with
recognized worldwide as the founder of cross-cultural, intercultural, or
transcultural nursing, a program that she multicultural.
created at the School in 1974.  In analyzing the Latin derivations of the
- Her official certifications read LL (Living prefixes associated with these terms, you will
Legend), Ph.D. (Doctor of Philosophy), LHD notice that trans means across, inter
(Doctor of Human Sciences), DS (Doctor of means between, and multi means many.
Science), RN (Registered Nurse), FAAN  TRANSCULTURAL NURSING is an area of
(Fellow American Academy of Nursing), and study or practice that considers or the
FRCNA (Fellow of the Royal College of specific values, beliefs, and ways of life of
Nursing in Australia). people of diverse similar cultures, with the
goal of using this knowledge in creative ways
to provide culturally congruent care.

 Transcultural nursing is the blending of

anthropology and nursing in both theory and
practice. Recognizing that nursing is an art
and a science, transcultural nursing enables
us to view our profession from a cultural
perspective.
 Anthropology refers to the study of humans
and humankind, including their origins,
behavior, social relationships, physical and
 mental characteristics, customs, and refers to differences in race, ethnicity, national origin,
development through time and in all places religion, age, gender, sexual orientation, ability or
in the world. disability, social and economic status or class,
 Transcultural nursing is not just for education, and related attributes of groups of people
immigrants, people of color, or members of in society.
the federally defined pan ethnic minority 2. There has been a rise in multicultural and life ways
groups, i.e., Blacks, Hispanics, Asians/ identities, with people expecting their cultural beliefs,
Pacific Islanders, and American values, to be understood and respected by nurses
Indians/Alaska Natives. and other health care providers.
3. The increased use of health care technology
 The goal of transcultural nursing is to sometimes conflicts with cultural values of clients,
develop a scientific and humanistic body such as Amish prohibitions against using certain
of knowledge to provide culture specific apnea monitors, IV pumps, and other such health
and culture universal nursing care care technologic devices in the home.
practices to individuals, families, groups, and 4. Worldwide, there are cultural conflicts, clashes,
communities from diverse back grounds. and violence that have an impact health care as
 Culture specific, refers to values, beliefs, more cultures interact with one another.
and patterns of behavior that tend to be 5. There was an increase in the number of people
special or unique to a group and that do not traveling and working in many worlds. different parts
tend to be shared with members of other of the world.
cultures. 6. There was an increase in legal suits resulting from
 Culture universal refers to the commonly cultural conflict, negligence, ignorance, and
shared values, norms of behavior, and life imposition of health care practices.
patterns that are similarly held among 7. There has been a rise in feminism and gender
cultures about human behavior and issues, with new demands on health care systems to
lifestyles. meet the needs of women and children.
 Transcultural nursing requires sophisticated 8. There has been an increased demand for
assessment and analytic skills and the ability community and culturally based health care services
to plan, design, implement, and evaluate in diverse environmental con texts
nursing care for individuals, families,
groups, and communities representing HISTORY OF TRANSCULTURAL NURSING
various cultures.  In the 1950’s Dr. Madeleine M. Leininger
noted cultural differences between patients
IMPORTANT IDEAS TO BE UNDERSTOOD and nurses while working with emotionally
ABOUT TRANS-CULTURAL NURSING SUCH AS disturbed children.
THE FOLLOWING:  This clinical experience led her in 1954 to
1. Care needs to be systematically studied to learn study cultural differences in the perceptions
about human care (caring) in diverse and similar of care and in 1965 she earned a doctorate
cultures in the world and environments. in cultural anthropology from the University of
2. Nurses need to be knowledgeable about their own Washington.
cultural care heritage and of biases, beliefs, and  She also recognized Washington. that one of
prejudices to work effectively with clients. anthropology's most important contributions
3. Nurses need to use trans culture-specific and to nursing was the realization that health and
comparative knowledge to guide caring practices for illness states are strongly influenced by
culturally congruent care. culture,
4. A focus on cultural care competencies for diverse  The cultural care worldview flows into
cultures and universals (commonalities) is essential. knowledge about individuals, families,
5. Nurses should seek comprehensive, holistic, and groups, communities, and institutions in
comparative culture care phenomena. diverse health care systems. This knowledge
6. Maintaining an open learning-discovery process provides culturally specific meanings and
about care and culture is imperative. expressions about care and health. The next
7. Nurses need creative ways to provide culturally focus is on the generic or folk system,
congruent care practices professional care systems, and nursing care.
 In 1995, Leininger defined transcultural
IMPORTANCE OF TRANSCULTURAL NURSING nursing as “a substantive area of study and
Leininger (1995) cites eight factors that practiced focused on comparative cultural
influenced her to establish transcultural care (caring) values, beliefs, and practices of
nursing: individuals or groups of similar or different
1. There was a marked increase in the migration of cultures to provide culture well specific and
people within and between countries worldwide. universal nursing care practices in promoting
Transcultural nursing is needed because of the health or being or to help people to face
growing diversity that characterizes our national and unfavorable human conditions, illness, or
global populations. In its broadest sense, diversity death in culturally meaningful ways .”
  The theory first appeared in Leininger’s Leininger also indicates that nursing as a
Culture Care Diversity and Universality, caring science should focus beyond
published in 1991, but it was developed in traditional nurse-patient interactions and
the 1950s. The theory was further developed dyads to include families, groups,
in her book Transcultural Nursing, which was communities, total cultures, and institutions.
published in 1995. In the third edition of  SOCIETY AND ENVIRONMENT Leininger
Transcultural Nursing, published in 2002, the did not define these terms; she speaks
theory-based research and the Transcultural instead of worldview, social structure, and
theory application are explained. environmental context.
 WORLDVIEW is how people look at the
MAJOR CONCEPTS OF THE TRANSCULTURAL world, or the universe, and form a “picture or
NURSING THEORY value stance” about the world and their lives.
 TRANSCULTURAL NURSING is defined as  SOCIETY AND ENVIRONMENT Leininger
a learned subfield or branch of nursing that did not define these terms; she speaks
focuses upon the comparative study and instead of worldview, social structure, and
analysis of cultures concerning nursing and environmental context.
health-illness caring practices, beliefs, and
values to provide meaningful and efficacious CULTURAL AND SOCIAL STRUCTURE
nursing care services to their cultural values DIMENSIONS
and health-illness context. - defined as involving the DYNAMIC
 ETHNONURSING is the study of nursing PATTERNS and features of interrelated
care beliefs, values, and practices as structural and organizational factors of a
cognitively perceived and known by a particular culture (subculture or society)
designated culture through their direct which includes religious, kinship (social),
experience, beliefs, and value system political (and legal). Economic, educational,
(Leininger, 1979) technological, and cultural value, ethno-
 NURSING is defined as a learned humanistic historical factors, and how these factors may
and scientific profession and discipline which be interrelated and function to influence
is focused on human care phenomena and human behavior in different environmental
activities to assist, support, facilitate, or contexts.
enable individuals or groups to maintain or  ENVIRONMENTAL CONTEXT is the totality
regain their well-being (or health) in culturally of an event, situation, or experience that
meaningful and beneficial ways, or to help gives meaning to human expressions,
people face handicaps or death. interpretations, and social interactions in
 PROFESSIONAL NURSING CARE particular physical, ecological, sociopolitical,
(CARING) is defined as formal and and/or cultural settings.
cognitively learned professional care  CULTURE is learned, shared, and
knowledge and practice skills obtained transmitted values, beliefs, norms, and
through educational institutions that are used lifeways of a particular group that guides their
to provide assistive, supportive, enabling, or thinking, decisions, and actions in patterned
facilitative acts to or for another individual or ways.
group to improve a human health condition  CULTURE CARE is defined as the
(or well-being), disability, lifeway, or to work subjectively and objectively learned and
with dying clients. transmitted values, beliefs, and patterned
 CULTURAL CONGRUENT (NURSING) lifeways that assist, support, facilitate, or
CARE is defined as those cognitively based enable another individual or group to
assistive, supportive, facilitative, or enabling maintain their well-being, health, improve
acts or decisions that are tailor-made to fit their human condition lifeway, or deal with
with the individual, group, or institutional, illness, handicaps, or death.
cultural values, beliefs, and life ways to  CULTURE CARE DIVERSITY indicates the
provide or support meaningful, beneficial, variabilities and/or differences in meanings,
and satisfying health care, or well-being patterns, values, life ways, or symbols of
services. care within or between collectives related to
 HEALTH It is a state of well-being that is assistive, supportive, or enabling human
culturally defined, valued, and practiced. It care expressions.
reflects individuals’ (or groups) ‘ability to  CULTURE CARE UNIVERSALITY
perform their daily role activities in culturally indicates the common, similar, or dominant
expressed, beneficial, and patterned uniform care meanings, patterns, values,
lifeways. lifeways, or symbols manifest among many
 HUMAN BEINGS Such are believed to be cultures and reflect assistive, supportive,
caring and capable of being concerned about facilitative, or enabling ways to help people.
others’ needs, well-being, and survival.
 GENERIC (FOLK OR LAY ) CARE The SUNRISE MODEL is relevant because it
SYSTEMS are culturally learned and enables nurses to develop critical and complex
transmitted, indigenous (or traditional), folk thoughts about nursing practice. These thoughts
(home based) knowledge and skills used to should consider and integrate cultural and social
provide assistive, supportive, enabling, or structure dimensions in each specific context,
facilitative acts toward or for another besides nursing care’s biological and psychological
individual, group, or institution with evident or aspects.
anticipated needs to ameliorate or improve a
human life way, health condition (or well- The cultural care worldview flows into
being), or to deal with handicaps and death knowledge about individuals, families, groups,
situations. communities, and institutions in diverse health care
 EMIC Knowledge gained from direct systems.
experience or directly from those who have This knowledge provides culturally specific
experienced it. It is generic or folk meanings and expressions concerning care and
knowledge. health.
 PROFESSIONAL CARE SYSTEMS are The next focus is on the generic or folk
defined as formally taught, learned, and system, professional care systems, and nursing
transmitted professional care, health, illness, care. Information about these systems includes the
wellness, and related knowledge and characteristics and the specific care features of
practice skills that prevail in professional each. This information allows for the identification of
institutions, usually with multidisciplinary similarities and differences or cultural care
personnel to serve consumers. universality and cultural care diversity.
 ETIC The knowledge that describes the Next are nursing care decisions and actions
professional perspective. It is professional which involve cultural care preservation or
care knowledge. maintenance, cultural care accommodation or
 ETHNOHISTORY includes those past facts, negotiation, and cultural care repatterning or
events, instances, experiences of restructuring. It is here that nursing care is delivered.
individuals, groups, cultures, and instructions
that are primarily people centered (ethno) THREE MODES OF NURSING CARE DECISIONS
and describe, explain, and interpret human AND ACTIONS
lifeways within cultural contexts over short or  CULTURAL CARE PRESERVATION is also
long periods of time. known as maintenance. It includes those
 CARE as a noun is defined as those abstract assistive, supporting, facilitative, or enabling
and concrete phenomena related to professional actions and decisions that help
assisting, supporting, or enabling people of a particular culture to retain and/or
experiences or behaviors toward or for preserve relevant care values so that they
others with evident or anticipated needs to can maintain their well-being, recover from
ameliorate or improve a human condition or illness, or face handicaps and/or death.
lifeway.  CULTURAL CARE ACCOMMODATION,
 CARE as a verb is defined as actions and also known as NEGOTIATION, includes
activities directed toward assisting, those assistive, supportive, facilitative, or
supporting, or enabling another individual or enabling creative professional actions and
group with evident or anticipated needs to decisions that help people of a designated
ameliorate or improve a human condition or culture to adapt to or negotiate with others for
lifeway or face death. a beneficial or satisfying health outcome with
 CULTURE SHOCK may result when an professional care providers.
outsider attempts to comprehend or adapt  CULTURE CARE REPATTERNING OR
effectively to a different cultural group. The RESTRUCTURING Includes those assistive,
outsider is likely to experience feelings of supporting, facilitative, or enabling
discomfort and helplessness and some professional actions and decisions that help
degree of disorientation because of the clients reorder, change, or greatly modify
differences in cultural values, beliefs, and their life ways for new, different, and
practices. beneficial health care pattern while
 CULTURAL IMPOSITION refers to the respecting the clients’ cultural values and
outsider’s efforts, both subtle and not so beliefs and still providing a beneficial or
subtle, to impose their own cultural values, healthier lifeway than before the changes
beliefs, behaviors upon an individual, family, were established with the clients.
or group from another culture.

MADELEINE LEININGER’S
SUNRISE MODEL THEORY
 care is beneficial and healthy, it contributes
to the wellbeing of the client(s) –whether
individuals, groups, families, communities, or
institutions –as they function within the
context of their environments.
- Nursing care will be culturally congruent or
beneficial only when the nurse knows the
clients. The clients’ patterns, expressions,
and cultural values are used in appropriate
and meaningful ways by the nurse with the
clients.
- If clients receive nursing care that is not at
least reasonably culturally congruent (that is,
compatible with and respectful of the clients’
lifeways, beliefs, and values), the client will
demonstrate signs of stress, noncompliance,
cultural conflicts, and/or ethical or moral
concerns.

ANALYSIS:
- In Leininger’s nursing theory, it was stated
that the nurse would help the client move
towards amelioration or improvement of their
health practice or condition. This statement
would be of great difficulty for the nurse
ASSUMPTIONS: because instilling new ideas in a different
- Different cultures perceive, know, and culture might present an intrusive intent for
practice care differently, yet there are some the “insiders.” Culture is a strong set of
commonalities about care among all world practices developed over generations that
cultures. would make it difficult to penetrate.
- Values, beliefs, and practices for culturally - The whole activity of immersing yourself
related care are shaped by, and often within a different culture is time consuming to
embedded in, “the worldview, language, understand their beliefs and practices fully.
religious (or spiritual), kinship (social), Another is that it would be costly on the part
political (or legal), educational, economic, of the nurse.
technological, ethnohistorical, and - It is highly commendable that Leininger
environmental context of the culture. formulated a theory that is specified to a
- While human care is universal across multicultural aspect of care. On the other
cultures, caring may be demonstrated side, too much was given to the culture
through diverse expressions, actions, concept per se that Leininger failed to
patterns, lifestyles, and meanings. discuss the functions or roles of nurses
- Cultural care is the broadest holistic means comprehensively. It was not stated how to
to know, explain, interpret, and predict assist, support, or enable the client to be
nursing care phenomena to guide nursing attuning them to an improved lifeway.
care practices. - Because of the intrusive nature, resistance
- All cultures have generic or folk health care from the “insiders” might impose a risk to the
practices, that professional practices vary nurse’s safety, especially for cultures with
across cultures, and that there will be cultural highly taboo practices.
similarities and differences between the - Because of its financial constraints and
care-receivers (generic) and the professional unclear ways of being financially
caregivers in any culture. compensated, it can be the reason why
- Care is the distinct, dominant, unifying, and nurses do not engage much with this kind of
central focus of nursing, and while curing and nursing approach.
healing cannot occur effectively without care,
care may occur without a cure. STRENGTHS:
- Care and caring are essential for humans’  Leininger has developed the Sunrise Model
survival and their growth, health, well-being, in a logical order to demonstrate the
healing, and ability to deal with handicaps interrelationships of the concepts in her
and death. theory of Culture Care Diversity and
- Nursing, as a transcultural care discipline Universality.
and profession, has a central purpose of  Leininger’s theory is essentially
serving human beings in all areas of the parsimonious in that the necessary concepts
world; that when culturally based nursing are incorporated in such a manner that the
 theory and its model can be applied in many evidence-based, and equitable. (The National
different settings. Quality Forum)
 It is highly generalizable. The concepts and The goal is to provide the highest quality of
relationships presented are at a level of care to every patient, regardless of race, ethnicity,
abstraction, which allows them to be applied cultural background, English proficiency, or literacy.
in many different situations. A health care provider is culturally competent
 Though not simple in terms, it can be easily when: He /she can deliver culturally appropriate and
understood upon the first contact. specifically tailored care to patients with diverse
values, beliefs, and behaviors.
WEAKNESS:
- The theory and model are not simple in Why do we need cultural competence in 21st
terms. century?
 Everyone has a right to healthcare that
CONCLUSION: meets their needs.
According to transcultural nursing, nursing  Immigration will impact demographics.
care aims to provide care congruent with cultural  Growth of minority population.
values, beliefs, and practices. Cultural knowledge
plays a vital role for nurses on how to deal with the FRAMEWORK FOR DELIVERING CULTURALLY
patients. To start, it helps nurses to be aware of how COMPETENT SERVICES
the patient’s culture and faith system provide Compinha Bacote and Munoz (2001) proposed a live
resources for their experiences with illness, component model for developing cultural
suffering, and even death. It helps nurses competence.
understand and respect the diversity that is often 1. Cultural awareness involves self-
present in a nurse’s patient load. examination of in-depth exploration of one's
It also helps strengthen a nurse’s cultural and professional background. This
commitment to nursing based on nurse-patient component begins with insight into one's
relationships and emphasizing the whole person cultural healthcare beliefs and values. A
rather than viewing the patient as simply a set of cultural awareness assessment tool can
symptoms or illness. Finally, using cultural be used to assess a person's level of cultural
knowledge to treat a patient also helps a nurse be awareness.
open-minded to treatments that can be considered 2. Cultural knowledge involves seeking and
non-traditional, such as spiritually based therapies obtaining an information base on different
like meditation and anointing. cultural and ethnic groups. This component
is expanded by an easing information offered
CULTURAL RESPECT through sources such as journal articles,
Cultural respect is vital to reduce health disparities seminars, textbooks, internet resources,
and improve access to high-quality healthcare that is workshop presentations and university
responsive to patients' needs, according to the courses.
National Institutes of Health (NIH). Nurses must 3. Cultural skill involves the nurse's ability to
respond to changing patient demographics to collect relevant cultural date regarding the
provide culturally sensitive care. This need is patient's presenting problem and accurately
strikingly evident in critical care units. perform a culturally specific assessment The
Giger and Davidhizar model offers a
Cultural Competence, a journey not a destination. framework for assessing cultural, racial, and
 Cultural Awareness ethnic Difference in patients.
 Cultural knowledge and skill 4. Cultural encounter is defined as the
 Cultural encounter process that encourages nurses to directly
engage in cross-cultural interactions with
CULTURAL COMPETENCE patients from culturally diverse backgrounds.
The understanding of diverse attitudes, beliefs, Nurses increase cultural competence by
behaviors, practices, and communication patterns directly interacting with patients from
attributable to a variety of factors. Factors race, different cultural backgrounds. This is an
ethnicity, religion, historical and social context, ongoing process, developing cultural
physical or mental ability, age, gender, sexual competence cannot be mastered.
orientation, generational acculturation status. 5. Cultural desire refers to the motivation to
become culturally aware and to seek cultural
CULTURAL COMPETENCE IN HEALTHCARE encounters. This component involves the
According to health policy institute, cultural willingness to be open to others, to accept
competence is the ongoing process of capacity of and respect cultural differences and to be
healthcare system, organizations, and professionals willing to learn from others.
to provide for diverse patient population high quality
care that is safe, patient and family centered, CULTURE IS CENTRAL TO THE DELIVERY OF
HEALTHCARE
  it influences patients’ healthcare beliefs,  USA, England, Germany, and New
practices, attitudes towards care, and trust in Zealand - it's used when meeting for parting
the system and in the individual providers. and if you know the other person well, you
 Cultural differences affect how health can skip this gesture
information and healthcare services are  France and the rest of Europe - people
received, understood, and acted upon. shake hands even if they know each other
well, sometimes even several times a day
PRIMARY REASONS OF CULTURAL  Russia-shaking hands in a doorway is
COMPETENCE IN HEALTHCARE considered impolite and allegedly brings bad
1. Eliminate misunderstanding in diagnosis or luck
in treatment planning that may arise from  India, Middle East, and Asia - people can
differences in language or culture. still hold each other's hands, even after they
2. Improve patient adherence with treatment. shook hands
3. Eliminate healthcare disparities.  Japan-handshakes are considered Impolite,
people bow instead and the lower they bow
Cultural Competence the more respect they are showing
Two Major Categories:
(1) organizational cultural competence INTERPRETERS AND TRANSLATORS
(2) individual cultural competence Interpreters, including sign language
interpreters and deal blind interpreters, are skilled
CULTURAL COMPETENCE and trained professionals who convert "oral or
According to the National Center for Cultural Com, signed information into another language, including
ice (Georgetown University Center for Child and sign language. Translators are skilled and trained
Human Development, cultural competence following persons who convert "written information" into
characteristics: another language.
 A defined set of values and principles and The role of both interpreters and translators
demonstration of behaviors, attitudes, is to ensure clear communication between the health
policies, and structures that enable them to care professional and the displaced person who are
work effectively cross-culturally. speaking or signing different languages. Their goal
 The capacity to (1) valve diversity, (2) is to convert oral, signed, or written information
conduct self-assessment, (3) manage the "meaning for meaning and not purely "word for word.
dynamics difference, (4) acquire and This implies that interpretation and translation must
institutionalize-cultural knowledge, and (5) be done with some context of the message being
adapt to diversity and the cultural contexts of conveyed, as well as the emotions and expressions
the communities they serve. conveyed in the delivery.
 Incorporation of the previously mentioned
items in all aspects of policy making, The National Council on interpreting in Health Care
administration, practice, and service delivery, (2006) has developed the first set of national
and systematic involvement of Consumers, standards for medical interpreting professionals in
key stakeholders, and communities. the ted States. The 32 national standards provide
guidelines on the following name issues:
Culturally Congruent Care  ACCURACY: To enable other parties to have
 a holistic and focuses on the complex, sold know precisely what each speaker
interrelationship of life ways, religion, kinship,  CONFIDENTIALITY: To Honor the private
politics, law, education, technology, and personal nature of the health care
language, environmental context, and interaction and maintain trust among all
worldview-all factors that contribute to parties.
culturally congruent care. (Leininger &  IMPARTIALITY: To eliminate the effect of
McFarland, 2005) Interpreter bias or preference,
 defines as the provision of care that is  RESPECT: To acknowledge the Inherent
meaningful and fits with cultural beliefs and dignity of all parties in the interpreted
life ways. encounter.
 CULTURAL AWARENESS: To facilitate
Some of the most common forms of nonverbal communication across cultural differences.
communication include gestures, facial expressions,  ROLE BOUNDARIES: To clarify the scope
proxemics (interpersonal distances), haptics and limits of the interpreting role to avoid
(touching), posturology (posture), paralinguistics conflicts of interest.
(phonetics) or eye contact. What do certain  PROFESSIONALISM. To uphold the public's
gestures and movements mean in other trust in the Interpreting profession.
cultures?
 PROFESSIONAL DEVELOPMENT: To
attain the highest possible level of
HAND SHAKING
competence and service,
 ADVOCACY: To prevent harm to parties
whom the interpreter serves.