Patient with a Sword

Nursing theory provides a structure that will ensure the highest standards and most comprehensive care in any exigency. Madeleine Leininger’s Culture Care Diversity and Universality Theory1 offers nurses guidelines for care in situations that will encompass respect for an individual’s culture and religion. An example of the application of this theory in practice can be seen in a clinical scenario where an elderly patient wearing a sword hidden under his clothes presented a disconcerting challenge to emergency treatment. The sword was soon identified as a religious article and was not intended to be used as a weapon.

Clinical Scenario

At 2:30 a.m., the on-call team was summoned for immediate response to the hospital. A patient with chest pain would be arriving from home for cardiac catheterization. The team, including two nurses, arrived within twenty minutes. They scrubbed up and readied supplies for the procedure. Time was of the essence. The patient arrived. He was a 75-year-old non-English speaking man of Indian descent who was accompanied by family members. The family was asked to go to the waiting room, except for one to remain for translation purposes.

Figure 1

As he was readied for the procedure, a sword was found to be hanging from a cloth belt underneath his shirt. He appeared upset and grabbed for it. Anxiety punctuated by a tense standoff ensued as the staff withdrew and turned to the remaining family member for an explanation. He indicated that there was nothing to fear as the sword was not a weapon. It was to be understood within the cultural background of the patient who wanted to wear it as a religious article. Once the patient was reassured and calmed, he was able to be sedated with his sword in place. It was then removed during the procedure. He had two cardiac stents successfully placed. His sword was then replaced during recovery.

The sword was most likely a Kirpan (see Figure 1) worn as a part of Sikh religious traditions.2 Healthcare practitioners should be able to provide culturally appropriate treatment in such a situation. The possibility existed that this patient would have refused medical care if it did not comply with his beliefs. Fortunately, his family was able to communicate his needs to an open, understanding and creative staff.

Culture Care Diversity and Universality Theory

Madeleine M. Leininger’s nursing theory of Culture Care Diversity and Universality encourages the introduction of transcultural care into clinical practice. Understanding a patient’s cultural preferences, beliefs, and values will assist and should result in their deliberate incorporation into a care plan. The nurse can then provide care in a respectful and compassionate manner. Culturally aware and competent providers can promote improvements in patients’ wellbeing. Nurses cope with unprecedented cultural diversity due to global migration. Commitment to the practice of culturally competent care also presents an opportunity for professional satisfaction.1 Leininger founded the Transcultural Nursing Society (TNS), whose position statement makes a commitment to “the rights of all peoples to enjoy their full human potential, including the highest attainable standard of health. TNS was established to safeguard human rights and quality health care through the discovery and implementation of culturally competent care.”3

Nursing Considerations for a Sikh Patient

Figure 2

Sikhism developed in northern India in the 15th century and now practiced world-wide. The primary language may be Punjabi, Hindi, or English. There are cultural variations and personal levels of observance, as is true of many religions. The nurse must therefore consult with individual patients concerning their religious needs rather than proceeding on presuppositions. There is a common belief in Karma, that every action has a consequence in this or a reincarnated life.Family members may be consulted to ascertain individual needs. Levels of observance may include wearing five articles of faith, following practices of cleanliness, and wearing head coverings of a turban or scarf. A vegetarian diet may be followed. The five articles of faith (Figure 2) are termed the “Five K’s” as each begins with the letter “K” in Punjabi. These include:

  1. Kes: hair is uncut, including a man’s beard
  2. Kirpan: a sheathed sword that hangs from a cloth belt
  3. Karha: a steel wristband
  4. Kangha: a wooden comb worn in a hair knot
  5. Kacchera: shorts worn as an undergarment

The Kirpan is worn in a sheath, either over or under one’s clothes. Stereotypical reactions may be attributed to a lack of familiarity with Sikh customs. Of the 25 million Sikhs worldwide, over 500,000 live in the United States. They maintain respect for all people, including men, women, rich, poor and all faiths. Sikhs do not proselytize and are not involved in converting anyone to their religion.2, 4, 5 Additional practice and religious information may be obtained by consulting supplementary resources (see Table 1).


The initial perception of this patient and his sword was incorrect. It was fortunate that his relative was able to relieve staff fears. At the very least, the procedure could have been delayed within a situation that required a greater degree of religious and cultural recognition. Knowledge of transcultural nursing concepts is needed for quality patient care. Travelers, immigrants and refugees who move globally will be encountered in healthcare settings. Respecting a patient’s cultural needs will help meet standards of holistic healing and well-being. The International Council for Nurses6 reminds us of our responsibilities not only to be compassionate but to be mindful of religious and cultural practices.

Susan Ann Vitale is pediatric and adult NP and teaches in the Nurse Practitioner and Doctoral Nursing programs at Molloy College in Long Island. Lisa Maldonado is an RN previously working in a cardiac specialty on Long Island. She is now attending school in California to become an NP.

1. Leininger, M. Madeleine Leininger’s theory of culture care diversity and universality. In M. Parker & M. Smith (eds.). Nursing theories & nursing practice, 3rd ed. Philadelphia, PA: F.A. Davis Company; 2010:17-336.
2. Queensland Health. Health Care Providers’ Handbook on Sikh Patients. Division of the Chief Health Officer, Queensland Health, Brisbane. 2011.
3. Transcultural Nursing Society Position Statement. 2014.
4. Pluralism Project at Harvard University. Sikhism. 2014.
5. Singh D and Singh K. Care of the elderly: a Sikh perspective. Nursing & Residential Care. 2010;12:138-139.
6. International Council of Nurses. The ICN Code of Ethics for Nurses. 2012.

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