22.2: Cultural Models
By the end of this section, you should be able to:
- Explain the purpose of transcultural nursing models.
- Describe the transcultural nursing models of Leininger, Giger and Davidhizar, Purnell, and Campinha-Bacote.
- Appraise the strengths and limitations of various transcultural nursing models.
Transcultural nursing models guide nurses’ provision of culturally competent care. Culturally competent care is a set of congruent behaviors, attitudes, and policies that enable health care professionals to work effectively in cross-cultural situations. It requires not only knowledge of different cultures but also the ability to apply that knowledge effectively. These models are designed to address the unique cultural needs of individuals, families, and communities. Transcultural nursing models aim to integrate transcultural concepts, theories, and practices into nursing education, research, and clinical applications; to improve transcultural nursing knowledge; and to incorporate this knowledge into sensitive and effective nursing care to meet clients’ cultural needs.
Transcultural Nursing Models
Several transcultural nursing models are used in nursing practice, education, and research. They include the culture care theory, transcultural assessment model, model of cultural competence, and model for cultural competence. Transcultural nursing models generally share a common goal of providing culturally competent care to clients from diverse backgrounds. However, each model has its unique focus and approach to achieving this goal. Nurses can use these models to guide their practice and improve their ability to provide high-quality care to clients from diverse cultural backgrounds. This section introduces each of the four models and compares them.
Leininger’s Culture Care Theory
Madeleine Leininger’s theory of culture care diversity and universality , also known as the culture care theory (CCT), is a nursing theory that focuses on the importance of understanding and respecting cultural differences in health care. According to Leininger, nurses should not only be aware of different cultural practices but also incorporate them into their care plans in a way that is congruent with the client’s cultural beliefs, values, and lifeways.
The central idea of this theory is that nurses must understand clients’ values, beliefs, and norms to provide quality care (Figure 22.2). The theory states that culture shapes how people think and behave, as well as their attitudes toward health care providers. If nurses are unaware of these differences, they may make assumptions about their clients’ needs or preferences based on their cultural backgrounds. The theory is based on the following five principles (McFarland & Wehbe-Alamah, 2019):
- Culture is a broad concept that encompasses multiple aspects of human life, including beliefs, values, and practices. Cultural care is a necessary and valuable part of nursing care.
- Care is the essence of nursing. It is an essential and vital part of nursing practice that involves cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are mostly tailor-made to fit with an individual, group, or institution’s cultural values, beliefs, and lifeways.
- Culturally congruent care is the goal of nursing. It aims to provide care consistent with the client’s cultural beliefs, values, and practices.
- Culturally competent care is a process. It involves nursing care that is respectful of and responsive to the cultural beliefs, values, and practices of the client and their community.
- Cultural care preservation, accommodation, and/or repatterning are modes of nursing actions and decisions. These modes of care are used to provide culturally congruent care based on the cultural needs and expectations of the client and their community.
The Leininger culture care theory and resulting sunrise model illustrate how culture is essential to nursing care and how providing culturally congruent care leads to better client outcomes. The sunrise model encompasses various dimensions essential to understanding culture care, including worldview, cultural and environmental context, and social structure factors. These dimensions help identify the values, beliefs, and practices that shape a particular culture’s health care needs and preferences (McFarland & Wehbe-Alamah, 2019). Leininger believed that by recognizing and respecting these cultural factors, health care professionals can deliver culturally congruent care that meets the unique needs of individuals, families, and communities. The dimensions of the sunrise model include the following:
- Worldview is the cultural lens through which individuals perceive the world and their health. It includes spirituality, religion, and ethics, which significantly impact health care decisions and practices. Understanding a client’s worldview allows nurses to provide care that aligns with their cultural and spiritual beliefs.
- Cultural and environmental context considers a cultural group’s physical, social, economic, and political aspects, acknowledging the influence of the wider cultural and environmental factors on health and health care practices. By recognizing these contextual influences, nurses can adapt their care to better address the cultural nuances and challenges that clients face.
- Social structure factors reflect a culture’s family roles, gender roles, and social hierarchies. These factors shape health care decision-making processes and expectations. Understanding the social structure factors allows nurses to provide care that considers the dynamics and hierarchies within a culture.
Culture care theory may be used in practice. For example, Nguyen et al. (2019) described how a culturally sensitive intervention was developed and implemented to improve the health outcomes of Vietnamese American women with type 2 diabetes. The intervention was developed based on the principles of Leininger’s Culture Care Theory and included cultural care accommodation and negotiation. Cultural care accommodation was used to adapt the intervention to the cultural beliefs and practices of Vietnamese American women. For example, the intervention included a nutrition education component incorporating traditional Vietnamese foods and recipes. The intervention also included group exercise sessions held in a community center, a familiar and comfortable environment for the women. Cultural care negotiation addressed cultural conflicts and facilitated communication between the health care providers and the Vietnamese American women. For example, the health care providers worked with the women to develop a shared understanding of the importance of blood sugar control and the benefits of taking medication. The providers also discussed the potential side effects of medication and worked with the women to find a medication regimen that was acceptable to them.
The study found that the culturally sensitive intervention led to improvements in the participants’ health outcomes, including better blood sugar control and improved quality of life. The authors suggest that using Leininger’s culture care theory can help nurses and other health care providers develop culturally sensitive interventions that improve the health outcomes of diverse client populations (Nguyen et al., 2019).
Giger and Davidhizar Transcultural Assessment Model
In 1988 Giger and Davidhizar developed the transcultural assessment model , introduced in Cultural Influences on Health Beliefs and Practices, to address the need for nursing students to provide care for clients from diverse cultural backgrounds. This model is designed to help health care providers identify and understand cultural differences in clients and to provide culturally competent care.
According to this model, every culture shares six dimensions: communication, space, social organization, time, environmental control, and biological variation (Figure 22.3) (Giger & Davidhizar, 2002).
- Communication : This dimension acknowledges that communication patterns and language differ among cultures and that health care professionals should be aware of these differences to provide culturally competent care.
- Space : This dimension refers to the physical and personal space individuals require in different cultures. For instance, some cultures prefer to have more physical space between themselves and others, while others prefer to be in closer proximity to others. Understanding a client’s space expectations can help health care providers create a comfortable care environment, which is crucial for building trust, rapport, and communication with the client. Additionally, space expectations can influence how clients respond to treatments or procedures; for example, some clients may feel more comfortable if a family member is present during a medical examination, while others may feel uncomfortable with the same arrangement.
- Social Organization : This dimension is the way a culture structures itself around the family group and/or community, including the way communication, decision making, and role distribution occur within and among groups.
- Time : This dimension is “a cultural specific orientation to the past, present, and future.” Inquiries about the perception of time can help health care providers understand how clients view the timing of events, the importance of punctuality, and the value of time concerning health and illness.
- Environmental Control : This dimension is defined as the perception of an individual’s ability to control nature and the environment, including the use of natural resources, cultural sanctions, and technology.
- Biological Variation : This dimension is defined as the factors such as race, body structure, genetic variations, nutritional preferences, and psychological characteristics that need to be considered when assessing a client’s cultural foundation to avoid stereotypes and discrimination.
One strength of the Giger and Davidhizar transcultural assessment model is its holistic approach to cultural assessment (Albougami et al., 2016). The model looks at multiple dimensions of culture and how they interact with health and illness in order to provide nurses with a comprehensive understanding of clients’ experiences. However, the model has its limitations. Some critics argue that the model does not consider the diversity within cultures and assumes that all individuals from a particular culture will have the same beliefs or practices. For instance, if a nurse assumes that all people who identify as Hispanic have the same culture, they may make incorrect assumptions about an individual client, which may lead to cultural misunderstandings that affect the client’s care.
Additionally, the model may not be as useful for clients from cultures not well-represented in the model’s dimensions (Albougami et al., 2016). Let’s say that a nurse is caring for a client from a small, remote tribe in Africa. The tribe has unique cultural beliefs and practices that are not well-represented in the Giger and Davidhizar Transcultural Assessment Model’s dimensions. The nurse may struggle to understand the client’s cultural needs and be unable to provide culturally sensitive care using the model alone. The tribe may have specific beliefs around illness and healing that are not captured in the transcultural assessment model’s dimensions. The nurse may not be aware of these beliefs and may not be able to provide care that aligns with the client’s cultural practices. This can lead to a breakdown in trust between the client and the nurse and may result in the client receiving suboptimal care. Nurses should be aware of the limitations when using the model to provide culturally sensitive care. The example below provides a case example using the Giger and Davidhizar transcultural assessment model.
In a diverse community health setting, Lou, a nurse, provides care for 70-year-old Mrs. Sato, who recently emigrated to the United States from Japan. Mrs. Sato has been experiencing symptoms of depression and anxiety since her arrival. Lou recognizes the importance of applying transcultural nursing principles and utilizes the Giger and Davidhizar transcultural assessment model to understand and address Mrs. Sato’s unique needs.
Step 1: Gathering Data
Lou creates a safe and nonjudgmental environment for Mrs. Sato to share her experiences.
Mrs. Sato’s cultural background: Japanese
Length of time living in the United States: 6 months
Primary language spoken: Japanese
Perceived support systems: Limited social connections in the new community
Physical health conditions: No significant medical issues reported
Previous experiences with the health care system: Limited exposure to Western medicine
Step 2: Assessing Six Cultural Phenomena
| 1. Communication | Mrs. Sato relies on her son to communicate in English, which may hinder effective communication with health care providers. |
| 2. Space | Mrs. Sato values personal space and may feel uncomfortable with certain physical examinations or procedures. |
| 3. Social Organization | Mrs. Sato has limited social support in the new community, which may contribute to her feelings of isolation and depression. |
| 4. Time | Mrs. Sato may have different perceptions of time, which may affect her adherence to appointment schedules or medication regimens. |
| 5. Environmental Control | Mrs. Sato may have different beliefs regarding control over her health decisions, which could influence her level of engagement in care. |
| 6. Biologic Variations | Mrs. Sato’s genetic and physiological makeup may differ from those of individuals from other cultures, impacting her response to treatment and medications. |
Step 3: Analyzing the Data
The nurse develops an understanding of the potential influences of cultural factors on Mrs. Sato’s mental health and overall well-being.
Step 4: Planning and Implementing Culturally-Sensitive Care
| 1. Communication | Lou arranges for a qualified interpreter fluent in Japanese to ensure accurate communication during health care visits. |
| 2. Space | Lou explains the physical examinations and procedures in a culturally sensitive manner, allowing Mrs. Sato to express any discomfort or concerns. |
| 3. Social Organization | Lou connects Mrs. Sato with community resources, such as local cultural organizations or support groups, to foster social connections and reduce feelings of isolation. |
| 4. Time | Lou discusses appointment timings with Mrs. Sato, taking into consideration her cultural understanding of time to enhance adherence and punctuality. |
| 5. Environmental Control | Lou involves Mrs. Sato in her care decisions, respecting her cultural views on health care and encouraging her to take an active role in managing her health. |
| 6. Biologic Variations | Lou collaborates with the health care team to assess Mrs. Sato’s genetic variations that may impact medication response to personalize her treatment plan. |
Purnell Model for Cultural Competence
The Purnell model for cultural competence is based on the belief that culture affects every aspect of human life, including health and illness (Purnell, 2002). The model offers a framework for health care providers to develop cultural competence and improve client outcomes. Figure 22.4 illustrates the model, and Table 22.2 presents a client example incorporating the 12 domains of the model.
| Domain | Name | Description | Example: Mr. Rodriguez, a 45-year-old male seeking health care in a community clinic |
|---|---|---|---|
| 1 | Overview and heritage | This domain includes the client’s ethnic and racial background, as well as their country of origin and primary language. |
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| 2 | Communication | This domain includes the client’s language proficiency, nonverbal communication, and other cultural communication patterns. |
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| 3 | Family roles and organization | This domain includes the client’s family structure, gender roles, and family values. |
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| 4 | Workforce issues | This domain includes the client’s employment status, occupation, and education level. |
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| 5 | Biocultural ecology | This domain includes the client’s physical and environmental factors that affect their health, such as diet and exercise habits. |
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| 6 | High-risk behaviors | This domain includes the client’s behaviors, such as smoking or substance use, that may lead to negative health outcomes. |
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| 7 | Nutrition | This domain includes the client’s dietary habits, food preferences, and beliefs about food and health. |
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| 8 | Pregnancy and childbearing | This domain includes the client’s beliefs and practices related to pregnancy and childbirth. |
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| 9 | Death rituals | This domain includes the client’s beliefs and practices related to death and dying. |
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| 10 | Spirituality | This domain includes the client’s beliefs and practices related to spirituality and religion. |
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| 11 | Health care practices | This domain includes the client’s beliefs and practices related to health care, including beliefs about illness and treatment. |
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| 12 | Health care access | This domain includes the client’s access to health care services, including insurance coverage and transportation. |
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Community health nurses using the Purnell model would consider factors such as communication styles, family dynamics, health care practices, and dietary preferences within specific cultural groups. For instance, when working with a Hispanic community, a community health nurse using the Purnell model would recognize the importance of language and might utilize interpreters to facilitate effective communication. The nurse would also understand the significance of family involvement in health care decisions and involve family members in the care process. Additionally, the nurse would consider traditional Hispanic food preferences and cultural beliefs around nutrition, incorporating culturally appropriate dietary advice.
Strengths of the Purnell model include its comprehensive nature and emphasis on understanding each client’s unique cultural background. It provides a structured framework for nurses to assess, plan, and implement care tailored to each client’s cultural needs. The model has also been revised and updated to reflect changes in health care practices and incorporate new research findings.
Limitations of the Purnell model are its complexity and that it may be too time-consuming to apply in a busy clinical setting. This is because the model involves a detailed assessment of all 12 domains of an individual’s culture, including beliefs, values, traditions, and practices. The model also requires nurses and other health care providers to be knowledgeable about a wide range of cultures. Additionally, the model focuses primarily on individual clients and may not adequately address the cultural needs of families or communities.
Campinha-Bacote’s Process of Cultural Competence in the Delivery of Healthcare Services
Campinha-Bacote’s model of cultural competence in the delivery of healthcare services is a framework that helps health care providers become more culturally competent in their care delivery. This model is based on five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire (Campinha-Bacote, 2018). Within these constructs, cultural competence and cultural humility are not alternative approaches. Instead, they work together to define a process that not only is a lifelong reflective process but also places importance on cultural encounters and learning to increase cultural competence.
- Cultural awareness is the first construct and refers to nurses’ self-awareness of their own cultural values and beliefs.
- Cultural knowledge refers to nurses’ understanding of different cultures and their values, beliefs, and practices.
- Cultural skill refers to nurses’ ability to adapt their skills to meet the needs of clients from different cultures.
- Cultural encounter s are nurses’ direct engagement with clients from different cultures.
- Cultural desire refers to nurses’ motivation to become culturally competent.
- Cultural competemility refers to the synergistic relationship between cultural competence and cultural humility.
One of the strengths of this model is its emphasis on the importance of the nurse’s self-awareness and motivation to become culturally competent. It recognizes that cultural competence is not just about acquiring knowledge or skills but also about a nurse’s commitment to providing culturally sensitive care. Both are critical for providing culturally sensitive care to clients from diverse backgrounds.
There are also some limitations to Campinha-Bacote’s model of cultural competence. Some critics argue that this model does not clearly define cultural competence and does not offer specific strategies for health care providers to become more culturally competent (Albougami et al., 2016). Additionally, this model may not be as useful for clients from cultures not well-represented in the model’s constructs. For example, consider a nurse who is working with a client from a culture that places a high value on community and collective decision making. While the Campinha-Bacote model includes the construct of cultural encounters, which emphasizes the importance of interacting with individuals from diverse cultural backgrounds, it may not fully prepare the nurse to understand and respect the client’s cultural values around decision making. In this case, the nurse may need additional resources or training to address the client’s cultural background and values. This could involve consulting with a cultural expert or community leader or seeking out literature or other resources that provide insights into the client’s culture. Table 22.3 presents a client example incorporating the constructs of this model.
Fifty-five-year-old Mr. Ivan Petrov, who recently emigrated to the United States from Russia, presents to a community health clinic with symptoms of depression. His primary language is Russian. The nurse caring for Mr. Petrov speaks Russian and has completed a Qualified Bilingual Staff (QBS) Assessment for general communication; additional assessment would be needed for medical interpretation.
| Cultural Awareness | The nurse understands that Mr. Petrov’s recent emigration from Russia might influence his perceptions, health beliefs, and attitudes toward health care. The nurse acknowledges the potential challenges this client might face as an immigrant, such as language barriers and cultural adjustment. |
| Cultural Knowledge | The nurse researches Russian cultural values, health beliefs, and customs to gain insight into Mr. Petrov’s cultural background. The nurse learns about the importance of family, the potential stigma associated with mental health in Russian culture, and the role of traditional healing practices. |
| Cultural Skill | During the interaction, the nurse greets Mr. Petrov in Russian and uses culturally appropriate greetings, such as “Здравствуйте” (Hello). They introduce themselves by their name and role, explaining their purpose and the reason for their inquiry. The nurse ensures confidentiality and builds a rapport with Mr. Petrov to foster trust and comfort. |
| Cultural Encounters | The nurse engages in a therapeutic conversation with Mr. Petrov to understand his symptoms, concerns, and cultural background. The nurse asks open-ended questions to explore his experiences, considering any cultural factors that may impact his mental health. |
| Cultural Desire | The nurse demonstrates genuine interest in and respect for Mr. Petrov’s cultural background and experiences by expressing empathy and compassion, showing a desire to provide client-centered care that respects his autonomy and values. |
| Cultural Competence | The nurse collaborates with language interpreters or utilizes professional translation services to ensure effective communication and reduce language barriers. With Mr. Petrov’s consent, the nurse involves the client’s family in decision making and care planning, understanding the importance of family support in his health care journey. |
Strengths and Limitations of Transcultural Nursing Models
One strength of transcultural nursing models is their emphasis on culturally sensitive care. Culturally sensitive care involves respecting and incorporating clients’ cultural beliefs, practices, and values into health care delivery (Purnell, 2013). This approach can help health care providers better understand and address the unique health needs and concerns of clients from diverse backgrounds. Another strength of these models is their focus on trust-building and communication. Trust is a critical component of effective health care delivery, and it is often built through good communication and mutual respect between health care providers, including nurses, and clients. Campinha-Bacote (2002) emphasizes the importance of establishing trust and rapport with clients to facilitate effective communication and promote positive health outcomes. Collaborative care is another essential component of transcultural nursing models. It involves working with clients and their families to develop treatment plans that align with their cultural beliefs and values. Leininger’s sunrise model of transcultural nursing emphasizes the importance of collaboration between clients, families, and health care providers to ensure that care is culturally congruent.
However, despite these strengths, transcultural nursing models also have several limitations. For example, ethnocentrism , or the tendency to view one’s culture as the norm and superior to others, can lead nurses to lack understanding and respect for cultural differences. Nurses must be aware of their biases and work to overcome them to provide culturally sensitive care. Cultural imposition , or imposing one’s cultural beliefs and values on others, is another danger of transcultural nursing models, as it can result in cultural conflicts and misunderstandings. Nurses must be careful not to impose their own cultural views on clients and must work to understand and respect clients’ cultural beliefs and practices. Cultural essentialism can be a limitation of transcultural nursing models. This is the assumption that all members of a particular cultural group share a set of essential traits that define their identity. Nurses must be careful not to make assumptions about clients based on their cultural background and must work to understand and respect the unique needs and experiences of each client. Finally, clients may experience culture shock , another potential limitation of transcultural nursing models. Culture shock is the experience of personal disorientation when confronted with an unfamiliar way of life. Nurses must be aware of this phenomenon and work to understand and address the unique needs of clients experiencing culture shock. Table 22.4 compares the four transcultural models just discussed.
| Theory | Theory of Culture Care Diversity and Universality | Transcultural Assessment Model | Model for Cultural Competence | Process of Cultural Competence |
|---|---|---|---|---|
| Theorist | Leininger | Giger and Davidhizar | Purnell | Campinha-Bacote |
| Emphasis | The importance of understanding and respecting cultural differences in health care | The assessment of cultural characteristics and their impact on health and illness | The belief that culture affects every aspect of human life, including health and illness | The importance of cultural competence in nursing practice |
| Main Tenets | Cultural care is essential to nursing; providing culturally congruent care leads to better client outcomes. | Includes six cultural phenomena: communication, space, social organization, time, environmental control, and biological variations | Includes 12 domains of culture: communication, family roles and organization, workforce issues, health beliefs and practices, and biocultural ecology | Includes five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire |
| Purpose | To provide a framework for the delivery of culturally congruent care | To help nurses assess cultural factors that may affect client care | To help nurses develop the knowledge and skills needed to provide culturally competent care to clients from diverse backgrounds | To help nurses develop the knowledge, skills, and attitudes needed to provide culturally competent care |
In this short video, Assistant Professor of Nursing Carmen Alvarez describes why nurses should spend time asking clients questions to understand their needs and adapt their care.
Watch the video, and then respond to the following questions.
- Why is the first step in providing culturally sensitive care understanding your own limitations?
- What cultural assumption did Carmen make when caring for a client?
- Think of a time when you made a cultural assumption about another person. How might you prevent a similar situation from occurring in the future?