Definitions of culturally competent nursing

An American Academy of Nursing monograph defines culturally competent nursing care as being sensitive to issues related to culture, race, gender, sexual orientation, social class and economic situation (Davis et al. 1992; Meleis et al. 1992). In reconsidering this definition we would add disability as an aspect of diversity (Lipson & Rogers 2000). Recently, the US Office of Minority Health (2000) developed a national definition:

How does culturally ‘competent’ care differ from nursing care that is culturally compatible, culturally appropriate, culturally sensitive, culturally responsive or culturally informed? Most of these phrases may or may not imply knowledge, interpretation of behaviour, attitudes, communication or other skills, nursing roles and actual interventions. Some argue that ‘culturally competent care’ is used too loosely—a health provider cannot be culturally ‘competent’ in a second culture unless he or she grew up in it or is at least fluent in the language. However, the advantage of the word ‘competence’ over terms like sensitivity is that it implies more than awareness, it implies the ability to intervene.

Another definitional issue is transcultural nursing versus cross-cultural nursing. Based in anthropology, Brink (1999) describes transcultural as referring to concepts that transcend cultural boundaries, that are universal, and found in all cultural groups, e.g. healing and caring. Cross-cultural refers to describing cultural groups that are first examined as case studies, focusing on similarities and contrasts. She cautions nurses to be careful about using definitions of such topics as caring or social support that apply only to North American cultures without first validating them with cross-cultural information.

The organisational perspective

Culturally competent care in a health care organisation or agency includes:

accessibility—being free of barriers due to geography, administration, money, culture and language;

accountability—high quality and satisfying care delivered ethically with an efficient use of resources;

sustained partnership—based on a trusting, continuing, respectful and responsible relationship between the patient and clinician;

a family context—provided in the context of the patient’s living conditions, family background, and cultural values; and

a community context—provided within the context of shared values, e.g. culture, ethnic heritage, religion, neighbourhood, geopolitical boundaries (Rorie et al. 1996).

Multicultural California developed criteria for publicly-funded, managed care that included guaranteed language access through telephone language services or on-site interpreters in areas where there are at least 3000 eligible patients indicated a preferred language other than English; community advisory committees of consumers, advocates and traditional ‘safety net’ providers; and needs assessment to identify the language and cultural needs of small groups of individuals who speak a primary language other than English. These were used as a model to develop national guidelines recently finalised by the Office of Minority Health. (See Appendix A.)

A cultural competence continuum (Cross et al. 1989) can be applied to either agencies or individual nurses. It includes the following levels:

cultural destructiveness: incidents reflecting negative attitudes such as prejudice, (e.g. remarks, shunning) or discrimination (e.g. behaviour that blocks opportunities);

cultural incapacity: a biased authoritarian system that cannot foster growth in culturally diverse groups;

cultural blindness: based on the belief that culture and race make no difference in how services are provided (e.g. ‘we are all human’);

cultural precompetence: ‘cultural sensitivity’ is the desire and attempt to deliver services in a manner respectful of cultural diversity. Awareness of cultural beliefs and behaviour of a particular group may be evident;

cultural competence: acceptance of and respect for cultural norms, beliefs and differences. Self-assessment regarding degree of cultural competence, adaptation of services, and interplay between policy and practice; and

cultural proficiency: motivation to add to the knowledge base of culturally competent practice, develop culturally therapeutic approaches and hire staff who are specialists in cultural competence.

The individual perspective

There has always been an overemphasis on cultural knowledge as underlying culturally competent care. However, early studies of nurse characteristics facilitating competence focused on ethnicity, attitudes and/or personality variables, e.g. open-mindedness, prejudice, authoritarianism, cultural relativism or intolerance of ambiguity. Such studies assumed that attitudes towards other groups are central to cultural sensitivity and that knowledge is connected to behaviour, e.g. skills in applying this knowledge. Meleis (1999) stated that culturally competent individuals value diversity at all levels and in all areas of their lives, being ‘energised’ by variations and challenged by teaching, researching or caring for people who are different from themselves, as well as awareness of how being different from the norm can be marginalising.

Cultural competence of nurses as individuals is the effect of our own cultural and socioeconomic backgrounds. There is a common assumption that nurses who represent ethnic minorities are naturally better equipped to give good care to patients of that group than nurses who do not. Indeed, in the mid-1970s to the early 1980s, there was disagreement between ‘ethnic nurses of colour’ and nurse-anthropologists about whether we should focus on people who are ‘visibly’ part of a politically or economically marginalised group, e.g. African-Americans, American Indians, or on the ‘cultural’ backgrounds of all patients, including ‘privileged’ European-Americans. Despite having moved beyond this issue to ‘valuing diversity’, nurses bring to patient care their own values, biases and communication styles, which may strongly affect quality of care. Nurses as individuals vary widely in the strength of their ethnic identity, commitment to their communities and respect for differences. Indeed, just as nurses from the dominant culture vary, ethnic minority nurses range from the most competent to the least competent, e.g. judgmental towards ethnic peers who represent a different social class. We must examine our own cultural baggage to see whether and how it may be offending our patients or otherwise interfering with good care.

Leininger

Any discussion of transcultural nursing must start with Madeleine Leininger, who began developing her theories in the 1970s and has been the most prolific writer in this area since then. She calls her theory ‘Culture care diversity and universality’ (Leininger 1991). She published the Sunrise model, which contains nine domains of culture and relates them to client actions. These domains, arranged in a half-circle under cultural and social structure dimensions, include technological factors, religion and philosophical factors, kinship and social factors, cultural values and life paths, political and legal factors, economic factors, and educational factors. These are influenced by care expressions, patterns, practices, wellbeing and nursing care decisions and actions. A very useful part of the Sunrise model is the three major modalities that guide nursing decisions and actions to provide cultural congruent care: cultural care preservation and/or maintenance; cultural care accommodation and/or negotiation; and cultural care re-patterning or restructuring.

Giger and Davidhizar

Giger and Davidhizar’s framework is similar to the Leininger model in that it includes a number of domains that are important for client and family assessment (Giger & Davidhizar 1999). One of its strengths is its emphasis on both the uniqueness of individual clients and potential similarities due to their cultural backgrounds. In the centre of this somewhat bull’s eye-shaped model is a circle depicting the ‘client: unique cultural being’. Surrounding the inner circle is another circle containing three segments: culture, religion and ethnicity. The outer circle contains six segments: communication, space, time, biological variations, environmental control and social organisation.

The focus is on knowledge in each of these major domains, based on the assumption that if nurses have this knowledge they can use it to provide culturally competent care. This popular book includes chapters on many groups that have not been described in other cultures and nursing books in the past, such as East Indian Americans, Irish Americans, Jewish Americans, and French Canadians.

The Purnell model

Purnell’s (2000) model is the newest of the popular models used in the United States. Originally devised as an organising framework for cultural assessment, it resembles the previous two models in that it includes important domains of culture and health, contained in a diagram. Arranged in a series of concentric circles, the outermost circle represents the global society, followed by the community, then the family, and people in the centre. Within the inner circle are twelve pie-shaped divisions representing multiple concepts in the following areas: heritage, communication, family roles and organisation, workforce issues, biocultural ecology, high-risk behaviours, nutrition, pregnancy/childbearing practices, death rituals, spirituality, health care practices, and health care practitioner concepts. At the bottom is a continuum often used in diversity training, ranging from ‘unconsciously incompetent, consciously incompetent, consciously competent, to unconsciously competent’ (p.42). While Purnell asserts that culturally competent health care providers must be aware of their own existence, thoughts and environment, the emphasis is mainly on knowledge to allow providers to adapt care to be congruent with the client’s culture. Purnell has included an even wider array of cultural groups in his book (Purnell & Paulanka 2002), including Iranian-Americans, Turkish Americans, Polish-Americans, and so on.

Campinha-Bacote

Campinha-Bacote’s model proceeds beyond knowledge about the culture of a patient or community to health provider skills and the ability to act on this knowledge. She conducts training workshops based on three objectives: defining cultural competence, discussing five components of this concept, and identifying cultural interventions. The five components are cultural awareness (e.g. recognising ethnocentric beliefs about health care delivery), cultural knowledge (beliefs and practices of a variety of groups), cultural skill (e.g. culturological assessment), cultural encounters (emphasising face to face interactions), and cultural desire (motivation to achieve cultural competence). She views competence as a journey, not a state to be achieved (Campinha-Bacote 1998).

Lipson

Lipson’s framework (Lipson & Steiger 1996) is a guiding perspective rather than a model, a way to think through the complexity of any cross-cultural nursing care encounter. Like Campinha-Bacote, she insists that culturally competent nursing care is more than focusing on knowledge about a patient or group. To capture the complexity, this perspective views care in three different ways:

the context—a focus on the culture of the health care system and the social, political and economic systems and how they affect health care providers, patients, families and communities;

the ‘objective’ component—a focus on patient/community cultural and socioeconomic characteristics, as well as how any individual or family expresses them, including variations; and

the subjective component—a focus on nurses themselves based on the premise that we must examine our own cultural values, biases and communication patterns in order to recognise their influence on nursing care, and to be able to shift our communication to improve care.

A simple version to guide nursing interventions is similar to Leininger’s suggestions to evaluate the benefits or risks of supporting the patient’s cultural practices. If the belief or practice is beneficial for health and wellbeing, or at least neutral, it can and should be reinforced. If the belief or practice is potentially risky, the patient and nurse need to discuss their different views on the practice and negotiate a compromise. The nurse might support the patient’s belief but suggest a more beneficial practice related to that belief. If a health practice is clearly potentially harmful, the nurse might take a stronger stand in explaining the risks and help the patient to substitute a healthier practice. Of course, we must always acknowledge that it is ultimately the patient’s choice.

Strengths and limitations of frameworks

In summary, these frameworks focus on different elements of culturally competent care. All include the importance of cultural knowledge in a broad variety of areas to improve care. Some focus on obtaining a large amount of culturally specific information seems to assume that knowing cultural details leads to the ability to act on this knowledge. Campinha-Bacote and Lipson emphasise a more general approach that includes skills as well as knowledge. Both focus on nurses as cultural beings whose identities and values impact on relationships with patients and families. They also emphasise working in partnership with patients, families and communities, rather than dictating care. These assumptions depend heavily on self-awareness and recognition of the social, economic and political environment.

Each framework has strengths and limitations, but none manages to capture the whole complexity of the cultural, socioeconomic and political reality context within which nursing care is practised. None adequately handles bi-culturalism or diversity within cultural groups. At issue here is whether a general model, relatively devoid of cultural group description, is more or less effective than a model which asks nurses to consider specific cultural group information. While knowledge-based models can provide rich guidelines for culturally competent care, they may tempt culturally unsophisticated nurses to ‘fill in the blanks’ or stereotype their patients, the so-called ‘laundry list’ or reductionist approach. The general models provide a context for interpreting what one sees in a patient or family in order to allow them to ask the right questions. Specific cultural facts are very important as a starting point, as long as they are used with the understanding that every belief and behaviour has both a cultural and an individual base.

Stereotyping or generalising

Stereotyping is an outcome of having some information about a cultural group and using it in a ‘cookbook’ manner. It is applying cultural ‘facts’ indiscriminately to a patient of a particular cultural group. Publishers’ space limitations and reader time often result in brief descriptions of cultural groups that do not emphasise variation within the group. Readers with little familiarity with intragroup variation may tend to assume that individuals will match the description, and end up depersonalising a patient/client. Stereotyping is making an assumption based on group membership without critically assessing whether or not the individual fits all of the assumptions and patterns of response. In generalising without stereotyping, one begins with a cultural pattern, then seeks further information to see whether the assumptions and patterns of responses fit the individual, e.g. whether the patient considers himself or herself to be typical or different from others in their cultural group and/or the effects of age, education, personality or geographic origin on how individuals express their culture.

Ethnocentrism versus cultural relativism

Ethnocentrism is the conviction that the way one does things in one’s own cultural group is the best or only correct way. Everyone exhibits some degree of ethnocentrism in the context of group identity. It is usually unquestioned until one confronts a situation that forces them to think differently with regard to one or more groups of people. For example, nurses commonly exhibit ethnocentrism with regard to the biomedical model, assuming that we know more about what is good for patients’ health than patients do. We are not always right, of course. With regard to other cultural groups, an ethnocentric stance is usually based on believing that one’s world view is the only reality because it has not been challenged by familiarity with other cultural systems. Sometimes it is based on feelings of superiority. Ethnocentrism can be expressed verbally, or non-verbally in facial expressions or posture, either of which can demonstrate bias or condescension.

Cultural relativism, a concept from anthropology, is the ability to view each cultural group as unique, with its own set of values and practices that should not be judged against one’s own culture as being either ‘good’ or ‘bad.’ In other words, what is ‘good’ is what is ‘socially approved’ in a given culture. Because there is no universal set of morals or laws against which to measure those of any particular culture, cultural relativists attempt to appreciate other cultural practices not as ‘wrong’ but simply different.

The question is where culturally competent care lies along the continuum from ethnocentrism to cultural relativism. Either extreme is potentially damaging, and each specific situation needs to be considered in its sociocultural and political/economic contexts. However, ‘Ultimately, culturally competent care is about acknowledging difference, advocacy for the marginalised, and intolerance of inequity and stereotyping’ (Meleis 1999, p.12) while, at the same time, refusing to go along with a cultural group’s potentially damaging health practices or beliefs as being simply ‘part of their culture’ in the name of cultural relativism.