^Walker, PhD, i?/V Abstract: The concept of tolerance is analyzed using a method outlined by Walker and Avant.

This analysis claries the meaning of tolerance in such diverse disciplines as nursing, medicine, social science, and theological education. Although tolerance subsumes respect, empathy, and acceptance, it implies unequal power relations and moral neutrality. Because tolerance exposes intolerance and indifference, the practice of inclusion may be more promising. Tolerance is revealed as a useful, but limited concept for nurses arid other helping professionals. Keywords: Concept analysis, culture, diversity, inclusion, tolerance

Tolerance: A Concept Analysis

alph Waldo Emerson introduced the iconic phrase "melting pot" in his journals, which were published and circulated in 1912 (Luedtke, 1979). This term has been used to describe the multicultural society found in the U.S. From colonial times and centuries earlier, the U.S. was populated by immigrants from different cultures, leading to coexistence of people from diverse ethnic, religious, and political backgrounds. With this coexistence came trie need for such concepts as tolerance. Some may question relevance of the concept, tolerance, to nursing and other helping professions. From caring for patients of diverse backgrounds to collaborating with the rest of the healthcare team, professional helpers must practice tolerance daily. The authors chose to analyze the concept of tolerance for two reasons. As a labor and delivery nurse at a busy county hospital, the first author had the privilege of caring for women and their families with diverse cultural backgrouncis. She learned about the importance of being tolerant to these women and honoring their customs and traditions. As a professor of nursing, the second author prepares nursing students to be tolerant of patients they care for and individuals with whom they work. Cultural competence is often cited as an expectation of basic nursing education and a requirement for registered nurses' continuing education (Fitzgerald, Cronin, & Campinha-Bacote, 2009; Sealey, Burnett, & Jorinson, 2006). Yet, is it possible to be culturally competent, particularly when the culture is not one's own? Perhaps tolerance is a more attainable goal. If so, then a clear understanding of the concept is wattanteci. Method Concept or linguistic analysis is often used in theory development to clarify concepts or imprecisely defined terms. It enables researchers to carefully examine the structure and function of a concept by highlighting the attributes and characteristics that uniquely distinguish it from other concepts (Walker & Avant, 2005). In this article, the authors examine the concept of tolerance using a modification of Wilson's (1963) classic analytic procedure detailed by Walker and Avant (2005). The modified approach includes eight discrete steps: (1) selecting the concept, (2) determining the purpose of the analysis, (3) identifying the concept's uses, (4) specifying its defining attributes, (5) constructing cases, (6) identifying antecedents and consequences, (7) describing empirical referents, and (8) providing a workable definition of the concept.

Review of Literature Tolerance is a complex concept with many meanings and definitions. For instance, in bridge building and agriculture, tolerance refers to the ability to withstand wind, gravity, drought and other challenges of nature. In manufacture of food and drugs, tolerance denotes the type and amount of contaminants permissible in the final product. Although the term tolerance appears in the literature of^such diverse disciplines as engineering, manufacturing, and safety technologies, fiir the purpose of this analysis, the focus was narrowed to four disciplines: nursing, medicine, social science, and theological education. Nursing Activity tolerance refers to the type and amount of exercise a patient is able to perform without undue exertion or injury. Cardiopulmonary function or risk is a primary consideration. Best known for standardizing nursing diagnoses, Marjory Gordon (1976) taught nurses how to properly assess activity tolerance. Her assessment parameters included heart rhythm, pulse strength, blood pressure; respiratory rate and rhythm; skin color; skin temperature and moistness; posture and equilibrium; activity rate, and emotional state. Nurses used these predictive and concurrent measures to assess patients' activity tolerance and guide the activity of patients diagnosed with respiratory and cardiac diseases. Cady (2001) reviewed pain physiology, opioid receptor action, and cellular mechanisms of opioid tolerance among patients treated for cancer or neuropathic pain. Opioid tolerance is a physiological phenomenon of an opioid narcotic's diminishing potency with continued use; it is manifested by desensitization and needing higher doses to achieve the same therapeutic effect. Cady examinee! management of opioid tolerance, including interventions to reverse it. Jarzyna (2005) addressed the challenge of caring for a patient post-operatively or at a time of traumatic physical injury if that patient regularly uses opiates for pain control. The author strove to educate readers about shirts in the dose-response curve, proper pain assessment skills, and how to remove judgment or personal opinion when caring for opiate-tolerant individuals. To examine possible cultural and gender influences related to the tolerance of depression, Loewenthal, Macleod, Lee, Cook, and Goldblatt (2002) conducted interviews and distributed a survey to men and women from a Protestant or Jewish family of origin. Their findings suggested that Jewish participants demonstrate higher tolerance for depressive symptoms than Protestant Volume 15, Number 2

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participants. The effect of gender was not significant. Investigators concluded that tolerance of depression is related to one's culture and may involve a desire to maintain social distance from sufferers. This information is clinically relevant and can be used when assessing depressed patients and their families. Medicine Gratz et al. (2011) conducted a study to examine whether young women who engage in deliberate self-harm are willing to experience emotional distress and tolerate physical pain. The study group was comprised of 43 young women who had recently exhibited deliberate self-harm. Two measures of pain tolerance were used. Findings supported the hypothesis that young women with a history of deliberate self-harm are less willing to experience emotional distress and have higher pain tolerance than young women who have no history of self-harm. Prolonged exposure to extremely cold temperatures can cause hypothermia; however, some people routinely work in cold environments, e.g., refrigeration facilities or Arctic oil fields. Ozald, Nagai, and Tochihara (2001) assessed cold tolerance and manual performance among 13 males wearing standard protective clothing. They found increases in diastolic blood pressure and peripheral skin temperatures accompanied by decreases in core temperature, pain sensation, and manual dexterity. The authors concluded that workers in severely cold conditions may perceive themselves as acclimated, but physiological indicators suggest cold tolerance (i.e., the inability to feel cold or pain) may be dangerous because it obscures clues to diminished body temperature. Abnormal glucose tolerance is a frequent comorbidity in cysticfibrosispatients. Glucose tolerance testing is used to determine how quickly glucose is cleared from the bloodstream. Commonly it is performed by having patients ingest a standard dose of glucose and checking blood sugar levels two hours later. Higherthan-expected blood sugar may indicate diabetes, insulin resistance, or reactive hypoglycemia. Zeigler, et al. (2011) examined glucose tolerance, incentive spirometry, scores for chest X-rays, and performance in a six-minute walk among 88 cystic fibrosis patients. They found that female patients with glucose intolerance showed poorer performance than males in the six-minute walk, pulmonary function, and radiographie scores. In the chemical dependency and addiction literature, tolerance is a diminished response to repeated or long-term exposure to drugs and/or alcohol. Tolerance results when ingested alcohol changes neurons that regulate behavior. Feinberg-Zadek, Martin, and Triestman (2008) focused on the BK Channel (a calcium-activated potassium channel within the neuronal plasma membrane of the brain). When alcohol is introduced to the blood stream, it binds to BK channels altering protein activity and lipid composition of the plasma membrane and modifying channel opening. Repeat or prolonged exposure to alcohol causes channel opening potential to decrease. Decreased channel opening is the molecular mechanism of tolerance. In the transplantation literature, tolerance is immunological nonreactivity to donor antigens while reactivity to other foreign antigens is maintained. Auchincloss (2001) reviewed the mechanism of clinical transplantation tolerance in attempt to define the concept and describe difficulties faced by clinicians and researchers who induce tolerance in transplant recipients. The thymus plays a crucial role in clinical transplantation tolerance. In the same way the thymus deletes self-reactive T-cells, it can be induced to delete donor-reactive T-cells. Thymic deletion reduces incidence of donor rejection and enhances viability of transplanted tissues and organs. Social Science Harell (2010) examined the influence that exposure to racial and ethnic diversity had on tolerance judgment among young Canadians. Researchers found a positive relationship between diverse social networks and social tolerance. They concluded that the more diverse one's social networks are the more tolerant one
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is of social diversity. Tolerance includes willingness to extend civil liberties to groups whose political views one dislikes. Analyzing the perception of minority influence and the process of minority success, Prislin and Filson (2009) found strong evidence to support their hypothesis that social change occurring through advocacy of tolerance is viewed more positively than social change occurring through attempts to convert others. When social change occurs through promotion of tolerance, outcomes include greater acceptance of minorities and stronger within-group identification. General acceptance, a sense of belonging, reconciliation, and conflict resolution may occur also. Araya and Ekehammer (2009) conducted an experiment to demonstrate that participants who were primed with a literary task including words related to tolerance would rate a fictional character as tolerant. Three separate experiments using the literary task failed to confirm their hypothesis. Participants in the experimental group judged the fictional character as less tolerant, while control group participants whose literary task contained neutral words judged the character as more tolerant. Araya and Ekehammer concluded that interventions thought to increase tolerance might actually encourage intolerance and stereotyping. Their finding is contrary to common belief. Another plausible explanation is that the experimental task may have sensitized participants to intolerance so they were more likely to recognize it. To explore the perspective of tolerance as a concept, personality trait, and standard of life, Sikorskaia (2008) distributed a survey entitled "Tolerance in Volunteer Social Work" to 150 young adult volunteers from Russia and Germany. Survey results revealed almost 65% of respondents defined tolerance as showing respect and solidarity with others by recasting difference as diversity, rather than deviance. Vblunteerism instills humane and tolerant attitudes, which positively affect society as a whole. Tolerance in volunteer social work practice includes a willingness to allow expression of difference and a willingness to learn from Others. Contemporary thoughts on the tolerance paradox (i.e., being intolerant of someone who is intolerant) need to be reconsidered. Kanisaukas (2010) investigated tolerance as a voluntary decision within social and political aspects of life. He suggested that due to contradiction inherent in the tolerance paradox, it is impossible for someone to be completely tolerant. Tolerance boundaries are in place to keep humans from tolerating what is morally bad or harmful. Tolerance boundaries are not meant to stifle variety. Diversity must be present in order for society to survive. Tolerance increases one's ability to deal with diversity and may change one's definition of what is acceptable. Tolerance may not be positive or universal. Situational context and ethical norms are commonly the deciding factors between positive and negative tolerance. Pasamonik (2004) explained that people have opinions and views that may demand tolerance, but tolerance is a learned value of those living in liberal western society. Most conflict in our diverse and global society comes from religious, scientific, or political intolerance. Pasamonik suggested that it is impossible to be tolerant of people who are not tolerant of you because they become a threat. Rather than a blind political correctness, she encouraged introspection of one's own moral and ethical beliefs in order to set firm tolerance boundaries and warned of the fine line between tolerance and indifference. Tolerance makes one rely less on stereotypes for judgments while broadening perspectives and maintaining harmony/unity. Theological Education Because educators must equip theological students to receive others' perspectives openly while balancing commitments to their own beliefs. Shady and Larson (2010) compared three educational models derived from Jewish theologian Martin Buber: Tolerance, Empathy, and Inclusion. The authors proposed that tolerance is an inadequate goal. Even though mutuality and Volume 15, Number 2

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Table 1. Antecedents, Criteria, and Consequences for the concept. Tolerance

Antecedents Contact with others in a multicultural society Belief commitments Moral attitudes Differences

Criteria Willingness to allow Respect Acceptance Empathy Diminished response

Consequences Reconciliation Broadened perspective Harmony/unity Understanding

understanding may emerge when tolerance is practiced, distance between people is maintained. On the other hand, empathy is too intimate, too close. Individuals who practice empathy often become immersed in the other person's perspective and lose sight of their own perspective. Shady and Larson view inclusion as ideal because it allows one to come alongside the other person, balancing tolerance and empathy. Behind tolerance is intolerance. Before one becomes tolerant, there must be an initial objection. Without an initial objection, tolerance is just indifference. Taylor (1999) challenged morality of the concept from a Judeo-Christian perspective asserting that tolerance is generic openness or neutrality - much too weak a concept for true reconciliation. Taylor explained that the JudeoChristian God is more tolerant than people, but also far less tolerant. God forgives sin and demands repentance. Although some view tolerance as an appreciation of diversity, a willingness to welcome others, Taylor believes tolerance is merely a modest acceptance and a means to co-exist. Instead of tolerance, Taylor suggests showing love, which may be a much greater challenge. Tolerance is not condemning someone else for believing in or doing something that one disagrees with. Hazell (1999) implied that one must disagree with someone or something before tolerance can occur. Tolerant individuals are fair-minded and democratic; they exhibit empathy, flexibility, nonjudgmentalism, and caring. The U.S. prides itself for holding tolerance as a principal value, but a double standard exists. Evangelical Christians believe they must lead others to salvation through Christ, but tolerance preservers say evangelicals should not impose their belief on others. Restricting evangelicals' faith practice is an intolerant act coming from "tolerant" people. Bretherton (2004) claimed tolerance is a pretense or cover-up for aggression and encouraged readers to remember the backbone of tolerance is respect. Outcomes of tolerance include knowledge of other worldviews leading to compromise, affirmation, and reconciliation. Summary Clear distinctions in definition, application, and use of the concept of tolerance were evident among the four disciplines. Nursing and medicine emphasized physiologic and biologic aspects of tolerance. Drug tolerance was a common topic; tolerance to pain, alcohol, and cold was presented as reduced perception of potentially harmful stimuli, which may prove dangerous or fatal. Social science and theological education exposed tolerance as a global, culrural, and religious concept. The discipline of theology education highlighted tolerance as an inadequate way of interacting with others. Social science literature did not discount tolerance as hopelessly flawed, but as a manner of being or behaving that may be learned and worked toward. Diverse disciplines conceptualized tolerance differently giving insight into the concept's meaning and portraying tolerance in positive and negative ways.

Antecedents, Attributes, and Consequences Antecedents, criteria, and consequences illustrate the benefit of having broad ideas about tolerance in order to construct a comprehensive definition. Table 1 represents an abbreviated and selective list of antecedents, criteria, and consequences for the concept of tolerance taken from the disciplines of nursing, medicine, social science, and theological education. Defining Criteria The literature revealed many similarities in defining criteria for the concept, tolerance (see Table 1). The first criterion, willingness to allow, appeared repeatedly in the literature of all four disciplines. Willingness to allow encompasses several criteria, such as willingness to learn, willingness to welcome, willingness to extend civil rights, willingness to experience distress, fair-mindedness, co-existence, and generic openness. Respect was a criterion found in many sources. In the social science literature, respect was described as a foundation for tolerance and solidarity. Acceptance was selected as a criterion because people long for acceptance or to be accepted. Empathy was chosen instead of acknowledgement, cooperation, or humane attitude because empathy has a deeper meaning. Diminished response emerged from both nursing and medical literature, in which it was cJescribed as a neutral stance; neutrality and indifference were highlighted also in the theological education literature. Model Case Tolerance A devout Muslim student (Student M) attends nursing school at a private Christian university. Because day long classes are held on Tuesdays and Thursdays, Student M must take time during class breaks to pray. Despite its designation as "Christian", the university encourages and values diversity. Other nursing students are aware of Student M's need for prayer time. They don't object to Student M praying in the classroom during breaks. After a while, the other students stop staring at Student M with voyeuristic intrusiveness or absent-minded bewilderment; instead, they demonstrate respect by adjusting their vocal volume for quieter conversations. The students empathize with Student M and provide assistance rearranging heavy desks to make room for her prayer mat. Student M's classmates seldom include her in social gatherings, but they welcome her contributions to study groups. The model case illustrates all five defining attributes of tolerance. Student M's classmates allow her to express her religious devotion without impediment or criticism. They express acceptance, respect, and empathy by making adjustments to the immediate social and physical environments. Over time. Student M's classmates display diminished response to her prostrate prayers. Volume 15, Number 2

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With few exceptions, however, they tend to marginalize her in activities unrelated to school. Borderline Case - Beyond Tolerance A young and skillful White nurse works with culturally diverse staff on a cardiac step-down unit. The young nurse, who views herselfas tolerant, is reading Kathyrn Stockett's The Help, a story about indignities suffered by black women who worked^for prominent White families in Jackson, Mississippi during the 1960s. Upon observing the young nurse reading Stockett's novel and asking her about it, a middle-aged African American ward secretary exclaims, "Aw hell, noney, I don't have to read that sh- - to know what it's about. I live it every day. " The young nurse bristles and walks off. Later the young nurse seeks the counsel of a trusted and experienced African American nurse, who helps her to understand the history of race relations in the South and the fact that prejudice, if more subtle, still persists in their workplace and beyond. With new understanding and sincerity the young nurse initiates a conversation with the ward secretary, apologizes for her abrupt behavior, and invites the war-d secretary to lunch. The borderline case reveals most criteria characteristic of tolerance. Although the young nurse is startled and perhaps offended by the ward secretary's frank and forthright comment, she adopts a new perspective (empathy) which enables her to initiate a conversation {allow), offer an apology {respect), and extend an invitation to lunch {acceptance). The criterion lacking in this scenario is diminished response. The nurse's revised attitude and behavior surpass mere tolerance. Related Case Inclusion High school students file into the cafeteria for lunch. One round table in the corner is designatedfor the special education class. Two students sit at that table while a tracking aide stands nearby. The cafeteria comes alive with laughter and talking. While the special education students eat in silence at their table in the corner,fivegirls take their normal seats. Soon the girls notice the students sitting alone. Rather than gesturing disapproval or making snide remarks like many of their peers, the girls rise almost in unison, move toward the special education table, and politely ask the two students already seated there if they might join them for lunch. Animated and amicable interactions ensue leading to genuine friendships. The related case depicts inclusion, a concept similar to tolerance. The girls in this scenario move outside the lock-step moral code of adolescence to embrace students who are different. Inclusion begins with empathy, acceptance, and respect, but it exceeds the boundaries of tolerance with a passionate opposition to exclusion and a commitment to actively include others. Contrary Case - Intolerance Sri Lanka-trained obstetrician. Dr. R, who was hired by a rural health clinic, is concluding the 12th week of her six-month probationary period during which time, according to her contract, she may be terminated without cause. A divorced, single mother ofteenaged twin sons. Dr. R formerly worked at public hospitals in Madras, India and two large U.S. cities where she gained colleagues' respectfor her professionalism and client-centered practices. But she is now the recipient of derision and scorn. Her supervis-

ing physician remarks that she is a "poorfit"for the rural practice group, which includes several women, among them an Ethiopian internist and an Iranian urologist, both educated in the U.S. Dr. R braids her long hair, but loose strands fall over her ears and forehead. She wears a sari under her lab jacket and sports a diamond stud in her nose, which was custom in her hometown offaffna. Several coworkers complain vigorously about Dr. R's dress and demeanor, but her patient satisfaction scores meet or exceed the clinic average. Twice when Dr R was "on call", her timely and precise response to obstetric emergencies resulted in good outcomes for moms and their babies. Nonetheless, she receives a termination notice signed by the clinic's Board ofDirectors. The contrary or negative case demonstrates an absence of tolerance. Judgments about Dr. R seem to be based on factors other than her job performance. Intolerance for difference appears to fuel the animosity toward Dr. R, but why she was fired remains unclear. Antecedents From a broad range of antecedents for tolerance identified in the literature review, four were selected (see Table 1). Contact with others in a multicultural society was chosen because without frequent contact with people from other cultures in the same society, there would be little need for tolerance. Moral attitudes refer to personal values and how they are embodied in each individual. Belief commitments often interfere with the ability to exhibit tolerance toward others and were included for that reason. The word, differences, was chosen to encompass such antecedents as opinions, world views, and divergent thinking or behavior. Many other antecedents were not used, including pain, emotional distress, and alcohol use. Although these antecedents came from literature that helped clarify the concept, tolerance, they are not suitable for the purpose of this analysis. Consequences Numerous consequences for tolerance were condensed to a list of four (see Table 1). Reconciliation was chosen instead of resolution because it had a more positive connotation. Broadened perspective is listed as a positive outcome of tolerance that may be generalized to other situations. Harmony/unity was chosen instead of commonality because harmonious living and community building are more essential for survival in a diverse world than focusing on sameness. Understanding was selected rather than absence of rejection because being understood is a basic human need that underscores self-esteem and social belonging. Operational Definition Tolerance is acceptance of and respect for people with different values, beliefs and cultural backgrounds than one's own accompanied by a willingness to allow others to maintain and express their values, beliefs and culture. A person practicing tolerance will show empathy for others and a diminished response to their differences. Empirical Referent Tolerance may be measured using a questionnaire created by Pasamonik (2004). The questionnaire requires participants to express their feelings when coming into contact with 10 different people (e.g., "An unpleasant smelling homeless man" or a "girl with Down's syndrome"). The researcher records how many times participants use positive or negative words to describe their feelings. Positive words indicate tolerance and negative words indicate intolerance. Validity of this qualitative measurement depends on participants' candid and honest responses. Implications for Professional Helpers The concept of tolerance was variously defined within the

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literature. Social scientists have researched and written extensively about tolerance related to culture. Nursing focused on the concepts of pain and medication tolerance. Similarly, medicine reported the physiologic aspects of tolerance for glucose metabolism, cold exposure, and transplants. The disciplines of social science and theological education offered an unexpected view of tolerance, reconsidering whether tolerance is a suitable or sufficient way of relating to others (Shady & Larson 2010). During this analysis, the authors' ideas about tolerance as a concept supporting social justice (Eppinga, 2006) shifted and changed. Discovering that one of the most common criteria in the literature was willingness to allow provoked the question whether anyone has the authority or prerogative to "allow" others to believe or behave as they want. The shadow-side of tolerance induces people to tolerate others because tolerance is expedient, or it insinuates that some person or group wields power over others. Also the defining criterion o diminished response implies a benign or modest acceptance of others whereby tolerance becomes an indifference to difference, rather than a celebration of diversity. To address diversity in a more positive and sensitive light, nurses and other professional helpers have begun to embrace cultural curiosity, cultural humility, cultural intelligence, and cultural responsiveness. Cultural curiosity can be nurtured by clinics and hospitals that encourage exploration of other cultures through exchange programs with such countries as South Africa (Wheeler, 2009) or outreach initiatives in underserved areas of the U.S. Compared with cultural competence, cultural humility does not have an end point or goal; there is no confidence in having "mastered" another culture. Cultural humility requires life-long commitment to self-reflection, self-evaluation, and self-critique (Millet, 2009; Racher & Annis, 2007; Ross, 2010). Cultural intelligence recognizes the limitations of cultural insight and sensitivity when English-speaking professionals try to decode meanings in a multicultural, multilingual society without the requisite skill or support (Cheng, 2007). Cultural responsiveness is a collaborative effort to invigorate practice with awareness of power inequities between providers and their clients (Madsen, 2007). Despite its limitations as a concept, tolerance is a useful starting point for considering culture and all sorts of difference (Walker, 2009). When regarded as a professional expectation, rather than a goal (Shady & Larson, 2010), tolerance may open one's eyes to intolerance related to social class, national origin, sexual orientation, religion, race, ethnicity, gender, or age. Conclusion The authors analyzed the concept of tolerance using a method outlined by Walker and Avant (2005). The analysis clarified divergent meanings of tolerance, and revealed surprising results. Although tolerance encompasses respect, empathy, and acceptance, it implies unequal power relations and moral neutrality. More inclusive ways of being in the world and interacting with others must be explored and practiced. REFERENCES
Araya, T, & Ekehammar, B. (2009). When tolerance leads to intolerance: Accessibility effects on social judgment. Scandinavian Journal ofPsychology, 50(4), 325-331. Auchincloss, H. (2001). In search of the elusive Holy Grail: The mechanisms and prospects for achieving clinical transplantation tolerance. American Journal ofTransplantation, 7(1), 6-12. Bretherton, L. (2004). Tolerance education and hospitality: A theological proposal. Studies in Christian Ethics, 77(1), 80-103. Cady, J. (2001). Understanding opioid tolerance in cancer pain. Oncology Nursing forum, 28(10), 1561-1570. Cheng, L.L. (2007). Cultural intelligence (CQ): A quest for cultural competence. Communication Disorders Quarterly, 29(\), 36-42. Eppinga, J. (2006). Shining the spotlight on injustice: An interview with Morris Dees. Journal ofHate Studies, 5(1), 119-123. Feinberg-Zadek, PL., Martin, C , & Triestman, S.N. (2008). BK channel subunit composition modulates molecular tolerance to ethanol. Alcoholism: Clinical and Experimental Research, 32(7), 1207-1216. Fitzgerald, E.M., Cronin, S.N., & Campinha-Bacote, J. (2009). Psychometric testing of the Inventory for Assessing Cultural Competence among Health

Professionals - Student Version (IAPSS-SV). /ornfl/ of Theory Construction & Testing, 13(2), 64-68. Cordon, M. (1976). Assessing activity tolerance. American Journal ofNursing, 76(1), 72-75. Cratz, K. L., Hepworth, C , Tull, Matthew. T., Paulson, A., Clarke, S., Remington, B., Lejuez, C. W. (2011). An experimental investigation of emotional willingness and physical pain tolerance in deliberate self-harm: the moderating role of interpersonal distress. Comprehensive Psychiatry, 52(1), 63-74. Harell, A. (2010). Political tolerance, racist speech, and the influence of social networks. Social Science Quarterly, 91(3), 724-740. Hazell, J. (1999). The trouble with tolerance. Humanist, 59(6), 33. Jarzyna, D. (2005). Opioid tolerance: A perioperative nursing challenge. MEDSURGNursing, 14(6), 371-377. Kanisauskas, S. (2010). Tolerance boundaries and cultural egalitarianism. Limes, 3(1), 67-79. doi: 10.3846/limes.2010.07 Loewenthal, K., Macleod, A., Lee, M., Cook, S., 8 Coldblatt, V. (2002). Tolerance for depression: Are there cultural and gender differences^ Journal of Psychiatric and Mental Health Nursing, 9(^6), 681-688. Luedtke, L. (1979). Ralph Waldo Emerson envisions the "smelting pot". MELUS, 6(2), 3-14. Retrieved from http://www.jstor.org/stable/467543 Madsen, W.A. (2009). Collaborative helping: A practice framework for familycentered services. Family Process, 48(1), 103-116. Miller, S. (2009). Cultural humility is the first step to becoming global care providers (editonai). Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(1), 92-93. Ozaki, H., Nagai, Y., & Tochihara, Y. (2001). Physiological responses and manual performance in humans following repeated exposure to severe cold at night. European Journal of Applied Physiology, 84(3), 343-349. Pasamonik, B. (2004). The paradoxes of tolerance. Social Studies, 95(5), 206-210. Prislin, R., & Filson, J. (2009). Seeking conversion versus advocating tolerance in the pursuit of social change. Journal of Personality & Social Psychology, 5)7(5), 811-822. Racher, F.E., & Annis, R.C. (2007). Respecting culture and honoring diversity in community practice. Research and TheoryforNursing Practice, 21(4), 255-270. Ross, L. (2010). Notes from the field: Learning cultural humility through critical incidents and central challenges in community-based participatory research. Journal of Community Practice, 18(2), 315-335. Sealey, L.J., Burnett, M., & Johnson, C. (2006). Cultural competence of baccalaureate nursing faculty: Are we up to the taski Journal of Cultural Diversity, 13(3), 131-140. Shady, S. H., & Larson, M. (2010). Tolerance, empathy, or inclusion? Insights from Martin Buber. Educational Theory, 60(1), 81-96. Sikorskaia, L. E. (2008). Tolerance as understood by young Russian and German volunteers in social work. Russian Education " Society, 50(12), 50-62. Taylor, D. (1999). Are you tolerant? Should you be? Christianity Today, 43(1), 42. Walker, C.A. (2009). Diversity, divisiveness and difference, (editorial)./ora/o/ Theory Construction and Testing, 13(2), 44-45. Walker, L.O. & Avant, K.C. (2005). Strategiesfortheory construction in nursing, (4-''Ed). Upper Saddle River, NJ: Prentice Hall. Wheeler, R. (2009). Cultural curiosity. Stanford Nurse, 29(1), 14. Wilson, J. (1963). Thinking with concepts. New York, NY: Cambridge University Press. Zeigler, B., Oliveira, C.L., Eidt-Rovedder, PM., Schuh, S.J., Abreu e Silva, HA., & Tarso Roth Dalcin, P. (2011). Clucose intolerance in patients with cystic fibrosis: Sex-based differences in clinical score, pulmonary function, radiographic score, and 6-minute walk test. Respiratory Care, 56(3), 290-297.

Hilary.Kyl^ Moore, BSN-, RJV j|.,janj51pyed at the Vein'Genijer of North-Texas in Denison, TX;ishe is,a grduate^f'HiTjis', ^^ a'Prbfessor ih'th^Hrfis College-NQrsiig.^He n7ay Bcntacted at c . w a l k e r @ t c u ! e d u . ^ ^ ^

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