Theories of transcultural nursing with established clinical approaches to clients from varying cultures are relatively new. According to Madeleine , who founded the field of transcultural nursing in the mid-1960s, the education of nursing students in this field is only now beginning to yield significant results. Today, nurses with a deeper appreciation of human life and values are developing cultural sensitivity for appropriate, individualized clinical approaches. Transcultural nursing concepts are being incorporated into the curricula for student nurses in the United States and Canada.
The Transcultural Nursing Society, founded in 1974, is promoting interest in transcultural concepts and the education of transcultural nurses at the graduate level ( ; ). Since its inception, the society has promoted such efforts at annual transcultural nursing conferences in different worldwide locations. The society also implemented the first certification plan in transcultural nursing. Through the efforts of the society, a number of U.S. and Canadian nurses have received certification. Other international conferences, such as that supported by the Rockefeller Foundation in October 1988 in Bellagio, Italy, have sought to promote international health care management. The society also publishes the Transcultural Nursing Society Newsletter and the Journal of Transcultural Nursing . In addition, other transcultural publications include the International Journal of Nursing Studies and the International Nursing Review . Although the literature on patient approaches in culturally diverse situations is mushrooming and nurses are beginning to perform transcultural research studies, up to now relatively few theories on transcultural nursing have provided a systematic method for comprehensive nursing assessment ( ; ; ; ; ; ).
Culture Defined
Culture is a patterned behavioral response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations. Culture is also the result of acquired mechanisms that may have innate influences but are primarily affected by internal and external environmental stimuli. Culture is shaped by values, beliefs, norms, and practices that are shared by members of the same cultural group. Culture guides our thinking, doing, and being and becomes patterned expressions of who we are. These patterned expressions are passed down from one generation to the next. Other definitions of culture have been offered by , , , and . According to and , culture is the values, beliefs, norms, and practices of a particular group that are learned and shared and that guide thinking, decisions, and actions in a patterned way. contends that culture is a metacommunication system based on nonphysical traits such as values, beliefs, attitudes, customs, language, and behaviors that are shared by a group of people and are passed down from one generation to the next. According to , culture represents a unique way of perceiving, behaving, and evaluating the external environment and as such provides a blueprint for determining values, beliefs, and practices. Regardless of the definition chosen, the term culture implies a dynamic, ever-changing, active, or passive process.
Cultural values are unique expressions of a particular culture that have been accepted as appropriate over time. They guide actions and decision making that facilitate self-worth and self-esteem. postulates that cultural values develop as a direct result of an individual’s desirable or preferred way of acting or knowing something that is often sustained by a culture over time and that governs actions or decisions.
The Need for Transcultural Nursing Knowledge
It is believed that demography is destiny, demographic change is reality, and demographic sensitivity is imperative. The United States is rapidly becoming a multicultural, pluralistic society. In 2010, 72.4% of the population in the United States was White of European descent; 14%, African-American; 17.3%, Hispanic-American; 4.8%, Asian American; and 0.9%, American Indian ( ). It is projected that by the year 2020, only 53% of the U.S. population will be White of European descent. It is further projected that by the year 2021, the number of Asian Americans and Hispanic-Americans will triple, and the number of African-Americans will double ( ).
If the 2010 census data on fertility, birth, and mortality are correct, conceivably it will be almost impossible to isolate and identify a “pure” race of Whites of European descent by the year 2070 ( ). In light of these statistical data, it is imperative that the nursing workforce rapidly adapt itself to a changing, heterogeneous society.
Providing culturally appropriate and thus competent care in the twenty-first century will be a complex and difficult task for many nurses. In many professional health career programs, such as nursing, medicine, and respiratory therapy, students are rarely taught culturally appropriate and competent care techniques. Thus, when these individuals encounter clients from culturally diverse backgrounds in the clinical setting, they are often unable to accurately assess and provide the kinds of interventions that are culturally appropriate.
The burden of teaching nurses culturally competent care techniques will rest not only with the individual programs of practice development but also with the health care agency itself. Regardless of who is responsible for this task, nurses must develop an understanding about culture and its relevance to competent care.
A nurse who does not recognize the value and importance of culturally appropriate care cannot possibly be an effective care agent in this changing demographic society. If nurses do not recognize that the intervention strategies planned for an African-American client with diabetes are uniquely different from those planned for a Vietnamese American, an Italian American, and so forth, they cannot possibly hope to change health-seeking behaviors or actively encourage the wellness behaviors of this client or any client. When nurses consider race, ethnicity, culture, and cultural heritage, they become more sensitive to clients. This is not to suggest that there is a cookbook approach to delivering care to clients by virtue of race, ethnicity, or culture. There is as much variation within certain races, cultures, or ethnic groups as there is across cultural groups. When the informed nurse considers the significance of culture, clients are approached with a more informed perspective.
The time to learn differing perspectives about culture is at hand. As professional health care providers, nurses will be asked to step forward to provide the leadership to ensure that all people have equal access to high-quality, culturally appropriate, and culturally competent health care. This task can be accomplished only through culturally diverse nursing care.
Cultural Assessment
Using Non-nursing Models
In a pluralistic society, nurse practitioners need to be prepared to provide culturally appropriate nursing care for each client, regardless of that client’s cultural background. To provide culturally appropriate nursing care, nurses must understand specific factors that influence individual health and illness behaviors ( ). According to , cultural assessment can give meaning to behaviors that might otherwise be judged negatively. If cultural behaviors are not appropriately identified, their significance will be confusing to the nurse.
Although transcultural nursing theories have appeared in the literature ( ; ), adequate nursing assessment methods to accompany these theories have not been provided consistently. One of the most comprehensive tools used for nursing cultural assessment is the Outline of Cultural Materials by ; however, this tool was developed primarily for anthropologists who were concerned with ethnographic descriptions of cultural groups. Although the tool is well developed and contains 88 major categories, it was not designed for nurse practitioners and thus does not provide for systematic use of the nursing process. Another assessment tool is in Community, Culture, and Care: A Cross-Cultural Guide for Health Workers . Brownlee’s work is devoted to the process of practical assessment of a community, with specific attention given to health areas. The work deals with three aspects of assessment: what to find out, why it is important, and how to do it. Brownlee’s assessment tool has been criticized as being too comprehensive, too difficult, and too detailed for use with individual clients. Although this tool was developed for use by health care practitioners, it is not exclusively a nursing assessment tool.
Using Nursing-Specific Models
Transcultural nursing is defined by ; ) as a “humanistic and scientific area of formal study and practice which is focused upon differences and similarities among cultures with respect to human care, health (or well-being), and illness based upon the people’s cultural values, beliefs, and practices.” According to , the ultimate goal of transcultural nursing is use of relevant knowledge to provide culturally specific and culturally congruent nursing care to people. From this theoretical perspective, ; ) provides a comprehensive transcultural theory and assessment model. For more than 30 years, this model has helped nurses discover and understand what health care means to various cultures. Leininger’s sunrise model symbolizes the rising of the sun (care). The model depicts a full sun with four levels of foci. Within the circle in the upper portion of the model are components of the social structure and worldview factors that influence care and health through language and environment. These factors influence the folk, professional, and nursing systems or subsystems located in the lower half of the model. Also included in the model are levels of abstraction and analysis from which care can be studied at each level. Various cultural phenomena are studied from the micro, middle, and macro perspectives ( ). Leininger’s model has served as the prototype for the development of other culturally specific nursing models and tools ( ; ; ; ).
An Analysis of Culturally Specific Models and Tools
, in one of the first studies of its kind, analyzed selected culturally appropriate models and tools to determine whether the models significantly differed. They concluded that most cultural assessment guides are similar because they all seek to identify major cultural domains that are important variables if culturally appropriate care is to be rendered. Nine culturally appropriate models or guides were analyzed: , , , , , , , , and . In analyzing the models, concluded that the same two limitations existed in each guide. The first limitation was the tendency to include too much cultural content, ultimately negating the “heart of the matter,” which is the process itself. The second limitation was that it is often impossible to separate client-specific data from normative data.
Using Nursing Diagnoses
The relative significance of culturally appropriate health care cannot be understood if the nurse does not understand the value of culturally relevant nursing diagnoses. reported a study to determine the applicability of the North American Nursing Diagnosis Association (NANDA) taxonomy as a culturally appropriate assessment tool for use with diverse populations. In the study, three nursing diagnoses were analyzed to validate their cultural appropriateness: (1) impaired verbal communication, (2) social isolation, and (3) noncompliance in culturally diverse situations. Participants in the study ( n = 245 nurses) were experts in the field of transcultural nursing and were members of either the Transcultural Nursing Society or the American Nurses Association Council on Cultural Diversity ( ). Findings from this study also indicate that nursing diagnoses tend to (1) focus on the client rather than the provider and therefore do not acknowledge the existence of other culturally relevant viewpoints (such as those expressed by the provider); (2) be generalized and, as a result, increase the likelihood, when applied in diverse cultural settings, for stereotyping and victimization because so-called non-Western medical models are believed to be “abnormal” and thus require necessary interventions; and (3) involve mislabeling phenomena, which in actuality arise as expressions of cultural dissonance rather than expressions of political, social, psychological, or economic factors.
In a classic, but relevant, study reported by , the NANDA nursing diagnosis of “impaired communication, verbal, related to cultural differences” is an excellent example of a client-oriented diagnosis that does not recognize linguistic cultural differences. The study concludes that the NANDA diagnosis of “impaired verbal communication” connotes that the client’s verbal communication and ability to understand and use language are impaired in some way. This diagnosis does not consider the causative factors creating the impairment ( ). It is apparent that individuals who speak a language different from that used by health care providers or nurses may be very capable of both use and comprehension of a specific language when interacting with persons fluent in that language ( ). According to , if the client in this situation is “verbally impaired,” the nurse is equally impaired. Geissler also concludes that the NANDA diagnosis of “impaired verbal communication” does not adequately address the issue of nonverbal communication, which was identified in the earlier nursing literature as an essential assessment factor ( ).
According to , nursing diagnoses related to social isolation and noncompliance need further defining characteristics for use with culturally diverse populations. Rather than use the term noncompliance, suggests that the term nonadherence may be more appropriate because this term may more accurately reflect behavior resulting from cultural dissonance. At the same time, the use of nonadherence may remove the stigma of guilt experienced by the health care recipient who is inappropriately labeled noncompliant.
Giger and Davidhizar’s Transcultural Assessment Model
In response to the need for a practical assessment tool for evaluating cultural variables and their effects on health and illness behaviors, a transcultural assessment model is offered that greatly minimizes the time needed to conduct a comprehensive assessment in an effort to provide culturally competent care. The metaparadigm for the Giger and Davidhizar Transcultural Assessment Model includes (1) transcultural nursing and culturally diverse nursing, (2) culturally competent care, (3) culturally unique individuals, (4) culturally sensitive environments, and (5) health and health status based on culturally specific illness and wellness behaviors.
Transcultural Nursing Defined
In the context of , transcultural nursing is viewed as a culturally competent practice field that is client centered and research focused. Although transcultural nursing is viewed as client centered, it is important for nurses to remember that culture can and does influence how clients are viewed and the care that is rendered.
Every individual is culturally unique, and nurses are no exception to this premise. Nonetheless, nurses must use caution to avoid projecting on the client their own cultural uniqueness and worldviews if culturally appropriate care is to be provided. Nurses must carefully discern personal cultural beliefs and values to separate them from the client’s beliefs and values. To deliver culturally sensitive care, the nurse must remember that each individual is unique and a product of experiences, beliefs, and values that have been learned and passed down from one generation to the next.
According to , nursing as a profession is not “culturally free” but rather is “culturally determined.” Nurses must recognize and understand this fact to avoid becoming grossly ethnocentric ( ). Because there is a contingent relationship between cultural determination and the delivery of culturally sensitive care, the transcultural nurse must be guided by acquired knowledge in the assessment, diagnosis, planning, implementation, and evaluation of the client’s needs based on culturally relevant information. This ideology does not presuppose that all individuals within a specific cultural group will think and behave in a similar manner with relative predictability. The astute nurse must remember that there is as much diversity within a cultural group as there is across cultural groups. Nonetheless, the goal of transcultural nursing is the discovery of culturally relevant facts about the client to provide culturally appropriate and competent care.
Although transcultural nursing is becoming a highly specialized field of specially educated individuals, every nurse, regardless of academic or experiential background, must use transcultural knowledge to facilitate culturally appropriate care. Regardless of preparation in the field of transcultural nursing, every nurse who is entrusted with care of clients must make every effort to deliver culturally sensitive care that is free of inherent biases based on gender, race, or religion.
Culturally Diverse Nursing Care
Culturally diverse nursing care refers to the variability in nursing approaches needed to provide culturally appropriate and competent care. Nurses need to use transcultural knowledge in a skillful and artful manner to render culturally appropriate and competent care to a rapidly changing, heterogeneous client population. Culturally diverse nursing care must take into account six cultural phenomena that vary with application and use, yet are evident in all cultural groups: (1) communication, (2) space, (3) social organization, (4) time, (5) environmental control, and (6) biological variations ( Figs. 1-1 and 1-2 ).
Culturally Competent Care Defined
As a heightened awareness of transcultural health care has been espoused, so too has the widened use of the term cultural competence . There are as many varying definitions for this term as there are for the term culture . note that cultural competence is the act whereby a health care professional develops an awareness of one’s existence, sensations, thoughts, and environment without letting these factors have an undue effect on those for whom care is provided. Further, they conclude that cultural competence is the adaptation of care in a manner that is congruent with the client’s culture. In this sense, cultural competence is a conscious process and as such cannot be necessarily viewed as linear ( ).
According to , cultural competence is a continuous process of awareness, knowledge, skill, interaction, and sensitivity that is demonstrated among those who render care and the services they provide. Smith concludes that cultural competence requires continuous seeking of skills, practices, and attitudes that enable nurses to transform interventions into positive health outcomes, such as improved client morbidity and mortality, as well as augmenting client and professional levels of satisfaction.
Cultural competence is a dynamic, fluid, continuous process whereby an individual, system, or health care agency finds meaningful and useful care-delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care. To develop cultural competence, it is essential for the health care professional to use knowledge gained from conceptual and theoretical models of culturally appropriate care. In addition, cultural competence connotes a higher, more sophisticated level of refinement of cognitive and psychomotor skills, attitudes, and personal beliefs. Attainment of cultural competence can assist the astute nurse in devising meaningful interventions to promote optimal health among individuals, regardless of race, ethnicity, gender identity, sexual identity, or cultural heritage. It is interesting to note that in searching for an adequate definition for cultural competence , , writing in a seminal text by , used the cultural competency definition proposed by Giger and Davidhizar.
took a major lead along with colleagues from the American Academy of Nursing’s Expert Panel on Cultural Competence (2007) to develop an important consensus paper that addressed ways to eliminate health disparities using culturally competent care techniques. This Expert Panel made 12 consensus recommendations to assist health care professionals in the endeavor to not only eliminate health disparities across racial/cultural groups but to do so using culturally competent care techniques appropriate to that particular group.
Culturally Unique Individuals
To provide culturally appropriate and competent care, it is important to remember that each individual is culturally unique and as such is a product of experiences, cultural beliefs, and cultural norms. Cultural expressions become patterned responses and give each individual a unique identity (see Fig. 1-2 ). Although there is as much diversity within cultural and racial groups as there is across and among cultural and racial groups, knowledge of general baseline data relative to the specific cultural group is an excellent starting point to provide culturally appropriate care.
Culturally Sensitive Environments
Culturally diverse health care can and should be rendered in a variety of clinical settings. Regardless of the level of care—primary, secondary, or tertiary—knowledge of culturally relevant information will assist the nurse in planning and implementing a treatment regimen that is unique for each client.
In response to the apparent lack of practical assessment tools available in nursing for evaluating cultural variables and their effects on health and illness behaviors, this text provides a systematic approach to evaluating the six essential cultural phenomena to assist the nurse in providing culturally appropriate nursing care. Although the six cultural phenomena are evident in all cultural groups, they vary in application across cultures. Thus, an individualized assessment of these areas is necessary when working with clients from diverse cultural groups ( Fig. 1-3 ).
Development and Refinement of Giger and Davidhizar’s Transcultural Assessment Model
Clinical and Educational Application
Since its introduction in 1991, Giger and Davidhizar’s Transcultural Assessment Model has been applied to the care of clients in a variety of clinical specialties, including the maternity client ( ), the operating room client ( ), the psychiatric client ( ), and others.
In 1993, Spector illustrated the model’s utility by combining it with the Cultural Heritage Model. The combination of these two models ( Fig. 1-4 ), which appears in Potter and Perry’s Fundamentals of Nursing textbook, is unique because it provides a holistic method of providing culturally competent care. In addition, using Giger and Davidhizar’s six cultural phenomena, although in a different hierarchical arrangement, created a unique quick-reference guide for cultural assessment of people from a variety of racial and cultural groups ( Table 1-1 ).
