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September
2010- Volume 4, Issue 2
Transcultural
Competency in the Curricula of Nursing
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Ebaa
M Felemban
School of Health Science
Discipline of Nursing and Midwifery
RMIT University
Melbourne,
Australia
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INTRODUCTION
Globalization and immigration are
causing a rapid growth of culturally diverse populations,
therefore, now more than ever, health care providers must
become more aware of and sensitive to the culturally diverse
meanings of health, illness, caring, and healing practice.
Personal background, heritage, and language have a direct
impact on both the way patients or clients reach and respond
to health care services and the way health care providers
practice within the system (Lowe & Archibald, 2009).
In this context, it is essential to fully acknowledge, appreciate,
and understand the terms "Cultural Evolution" and
"Cultural Revolution". Cultural Evolution refers
to the process of growth and change within a society, while
Cultural Revolution, on the other hand, is the effort to embrace
the evolution of a broader worldview (Jeffreys, 2006). Both
of these concepts are central in the career of a nurse. Clinical
practice areas can be in institutional settings, such acute
and long-term care settings; community-based settings, such
as nurses' practitioners and doctors' offices; and lastly,
public health and occupational settings, such as, clinics,
schools and universities. A health care facility may be considered
one of the most ethnically and culturally varied environments;
it includes intimate interaction among both patients and other
multidisciplinary staff workers, each of whom has their own
diverse beliefs and practice. Culture and ethnicity usually
determine one's view of health and illness, including types
of acceptable treatments and follow ups, guardianship for
decision making, and patient's reactions and behaviours.
This paper reviews the implications of cultural and ethnic
diversities on the health care system and explores the dimensions
of the term "Cultural Competence" in relation to
nursing practice and education. Moreover, it critically explores
the four major theories developed on cultural competency:
specifically, those of Leininger (1991), Purnell and Paulanka
(1998), Giger and Davidhizar (2004), and Campinha-Bacote (2007).
In addition, it provides an overview of the models' application
in the current literature and presents suggested and current
standards for a curriculum that enables culturally competent
nurses to face key issues, concerns, and new challenges in
the health care profession today and in the future.
2. Definition
Culture
Internationally Recruited Nurses (IRNs) are valuable resources
to tackle predicted and existing nursing shortage in many
countries, including Australia, the United States, the United
Kingdom, and Canada. They account for more than sixty percent
of the nursing work force in some health care organisations.
Once employed, many IRNs face difficulties due to differences
in culture and language in their new country of practice.
Unlike language, culture is more difficult to define due to
its complexity and constantly changing dynamic nature (Hearnden,
2008).
Over the years, culture has been
seen in many different ways and therefore has a variety of
definitions. Leininger (1991) defined culture as "the
learned, shared, and transmitted beliefs, values, norms, and
life experiences of a certain group that that are generally
transmitted intergenerationally to direct their thinking,
decisions, and actions in mannered ways." He defines
cultural competence, on the other hand, as involving "systems,
providers, and agencies with the capability of responding
to the certain needs of populations whose cultures are different
from the dominant one." Kramsch (1998) defines culture
as membership in a discourse community that shares a common
social space and history and common imagination. Even when
they have left that community, its members may retain, wherever
they are, a common system of standards for perceiving, believing,
evaluating, and acting. These standards are what are generally
called their "culture". Sully and Dallas (2005),
on the other hand, said "it is useful to think of culture
as generally concerning organisations, professions, and groups
that have shared assumptions and beliefs which link the shared
values held. These values in turn produce shared norms that
govern patterns of behaviour." Davidhizar, Giger, and
Hannenpluf (2006) define culture as a patterned behavioral
response that develops over time as 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 ethnic group.
Culture guides our thinking, doing, and being and becomes
patterned expressions of who we are. These patterns expressions
are passed down from one generation to the next.
2.1 Clashes of Cultures
Culture can be either learnt or transmitted by family and
other social organisations, and it is shared by the majority
of the group to which one "belongs". This will affect
one's worldview, self-worth, self-esteem, and guide one's
decision-making. Culture varies within and between members
and generations in a single cultural and ethnic group. Cultural
evolution is driven by the rapid growth in the world's migration,
changes in the demographic patterns, changes in fertility
rates, increasing numbers of multiethnic and multiracial individuals,
and advanced technological breakthroughs associated with health
care. Further. As defined by Purnell and Paulanka (2003),
cultural diversity refers to variety in race, ethnic orientation,
and beliefs; thus, nurses need to deliver culturally appropriate
and competent care to culturally diverse patients and their
families.
Within the nursing literature, cultural diversity, changes,
and the need to have culturally congruent nursing care was
repeatedly reported in various countries (Davidhizar, Giger
& Hannenpluf, 2006; Jeffreys, 2006). Another aspect arising
from the diversity of cultures is Health Disparity, which,
according to the National Institute of Health is defined as
"the differences in the incidence, prevalence, mortality,
and burden of disease and other adverse health conditions
that exist among specific population groups". Atrash
and Hunter (2006) define the factors contributing to these
disparities, including uneven levels of education, salaries
and incomes, environmental and economic conditions, specific
health attitudes and lifestyles, access to care, and quality
of service provided. It should be noted, however, that delivering
culturally competent care will not necessarily decrease or
prevent health disparities.
3. Cultural Competency Overview
Transcultural competency Background
Cultural competence is described as a multidimensional process
that aims to achieve culturally congruent health care. Although
this concept is fundamentally important and is obviously applicable
to the contemporary issues faced nowadays, cultural competence
is considered new in the nursing literature and it is only
in the last five decades that nurses have begun to value the
need to integrate culturally appropriate practice into daily
nursing care for clients. Moreover, as stated by Narayanasamy
and White (2005, p.103), transcultural health care is defined
as the "formal areas of study and practice in the cultural
beliefs, values and life ways of diverse cultures and the
use of knowledge to provide culture-specific or culture-universal
care to individuals, families and groups of particular cultures".
Transcultural nursing models provide the nurse with the foundations
needed to become knowledgeable about the various cultures
faced on the practice setting. These models continue to develop
and refine to become materials of guidance to be used internationally.
Dr. Madeline Leininger has provide the basic concept for cultural
competency in nursing practice and today there different models
and theories to be followed, including those of Leininger
(1991), Purnell and Paulanka (1998), Giger and Davidhizar
(2004), and Campinha-Bacote (2007) (Dayer-Berenson, 2010).
4. Transcultural Theories Related
to Nursing
4.1 Leininger Model (1991)
Dr. Madeline Leininger first developed her theory, "Cultural
Care, Diversity, and Universality," from both anthropological
and nursing perspectives in 1984. She defined transcultural
nursing as a "humanistic and scientific area of formal
study and practice in nursing, which is focused on the comparative
study of cultures with regards to differences and similarities
in care, health, and illness patterns based on cultural values,
beliefs, and practices in the world, and the use of knowledge
to provide culturally specific and/or universal nursing care
for people". The purpose of this theory is to expand
transcultural nursing knowledge and practice to achieve culturally
congruent nursing care whether the patients are culturally
diverse or similar. The foundation of Leininger's theory is
that cultures exhibit both diversity and internationalization.
It was her intention to let nurses try and step into the patients'
shoes and look at things from their perspectives (Davidhizar,
Giger & Hannenpluf, 2006; Engebretson, Mahoney & Carlson,
2008; Dayer-Berenson, 2010)).
Leininger express the need to expand the definition of nursing
from just involving its four traditional metaparadigms, (i.e.
the concept of self, environment, health, and nursing, to
caring. Caring, according to Leininger, is unique to nursing
and essential for life, survival, and human development. Transcultural
nursing is a branch of nursing that is learned by comparing
and analyzing studies of different cultures as they apply
to nursing and health-illness practice, beliefs, and value.
Transcultural competence was first developed in the mid1960s
by Madeline Leininger, when she (and other nursing scholars)
wished to obtain doctoral degrees and become nurse anthropologists.
In her first course on transcultural nursing, she stated that
this concept was created in response to nurses having increased
exposure to diverse groups of patients. This increased exposure
was the result of the changing demographics in the United
States during that period as well as the leadership of the
States in health care delivery, resulting in many people from
different countries coming to America to seek medical care.
Furthermore, due to the nurses' direct contact with patients
when providing care, it was crucial to understand how to work
effectively within a culturally diverse atmosphere and transcend
cultural boundaries (Andrews & Boyle, 2008; Dayer-Berenson,
2010).
4.2 Purnell and Paulanka Model
(1998)
Unlike other theories about cultural competency, Purnell and
Paulanka's model extend some of the categories under which
the concepts are organized. This model consists of two sets
of factors: macro-aspects and micro-aspects. In the diagrammatic
representation of the model, Purnell and Paulanka use concentric
circles to identify the macro-aspects and micro-aspects. The
macro-aspects form the wider outer circles and the micro-aspects
the inner circle, all constituting segments of the whole.
From the outermost circle moving inwards to the centre, the
concentric circles are made up of the 'global society', the
community, the family and the person.
One of the unique features in the Purnell and Paulanka model
is its flexibility, which allows it to be applied for all
health care members. It includes the recognition of biocultural
ecology and workforce problems and the impact they have on
a culturally diverse patient. Purnell and Paulanka identify
a number of benefits to the use of their model. First of all,
the model provides a framework for health care providers to
learn about the inherent concepts and characteristics of new
cultures. This model links between historical perspectives
and their impact on one's cultural international view. It
also links the central relationships of culture so that congruence
can occur and facilitate the delivery of culturally competent
care. Moreover, the model provides a framework for nurses
to reflect on and consider each patient's unique characteristics,
such as, motivation, intentionality, and conceptions of illness
and health care. Further, it provides a structure for analyzing
cultural data, and it allow the nurse to view the individual,
family, or group with its own unique cultural environment
by considering communication strategies to overcome identified
barriers. The Purnell and Paulanka model has an organizing
framework of twelve domains that are common to all cultures.
These twelve domains are essential for assessing the enthnocultural
attributes and they include the individual, family, or group,
the inhibited localities and topography, communication, family
role and organization, workforce issues, biocultural ecology,
high risk health behaviours, nutrition, pregnancy and child
bearing practice, death rituals, spirituality, and health
care practice and health care practitioners (Dayer-Berenson,
2010).
4.3 Giger and Davidhizar Model
(2004)
Giger and Davidhizar state that, although all cultures are
different, there are several organizational factors that are
common to all, including communication, space, social organization,
time, environmental control, and biologic variations. However,
this model does not presume that every person within an ethnic
or cultural group will behave or act in the same manner; therefore,
according to this model it is essential to view each individual
as culturally unique and that they be assessed according to
the six identified phenomena in this model (Dayer-Berenson,
2010). Giger and Davidhizar's six organisational factors will
be discussed thoroughly later in this paper. The model also
explores the variables affecting the caregiver's response
and the recipients' perspective in relation to cultural diversity
(Davidhizar, Giger & Hannenpluf, 2006).
This model was first developed in 1988 to help undergraduate
nursing students assess and provide health care to those of
different cultures. In the present form, the model provides
a framework that systematically assesses the role of culture
on illness and health and has been used in a variety of settings
and by different disciplines. However, in 1993, both Purnell
and Paulanka's, and Giger and Davidhizar's models were combined
and utilized in other health care facilities, like medical
imaging, dentistry, education, and healthcare administration.
This combined theory has been the theoretical framework for
dissertations and other researches (Dayer-Berenson, 2010).
4.4 Campinha-Bacote Model (2007)
Campinha-Bacote first developed this model in 1991, and by
1998 it was revised to become known as the process of "Cultural
Competency in the Delivery of Healthcare Services". The
aim of this model is to look at cultural competence as a process
rather than an end result, where the nurse is required to
strive to achieve effective and optimum care with individuals
(Dayer-Berenson, 2010). Cultural competency is defined as
"the process in which the health care provider continuously
strives to achieve the ability to work effectively within
the cultural context of a client, individual, family, or community
(Kardong-Edgren & Campinha-Bacote, 2008). The focus of
this model is on the process of cultural competence (rather
than being culturally competent), utilizing the five components
of this model, as discussed below (Engebretson, Mahoney &
Carlson, 2008).
Campinha-Bacote's model of care is based on five main components:
cultural awareness, cultural skills, cultural knowledge, cultural
encounters, and cultural desire. Cultural awareness is the
process of self-examination of one's own biases towards others
and the in-depth exploration of one's culture and background.
It also involves one's awareness of documented racism and
other "isms" in the health care system. Cultural
skill is the ability to conduct cultural and physical assessment
to collect data regarding the client's presented problem.
Cultural knowledge, on the other hand, is defined as the process
where the healthcare professional seeks and obtains information
about the worldview of different cultures and ethnic groups,
as well as biological variations and different understandings
of illness and health. Cultural encounter is the process that
encourages the healthcare professional to engage in cultural
interactions to modify existing beliefs about culturally diverse
groups and avoid possible stereotyping. Lastly, cultural desire
is the motivation of health care professional to be engaged
in the process of being culturally aware, knowledgeable, skilled,
and competent, and seeking cultural encounter (Dayer-Berenson,
2010; Law & Muir, 2006).
5. DISCUSSION
In their paper, Law and Muir (2006) explored the complexity
of the internationalisation of the nursing curriculum by discussing
its manifestation within a British university during a short
student exchange program. Various models were explored and
critiqued for their efficiency, including Leininger's cultural
care diversity and universality theory. This theory was criticised
for ignoring structural and political process, assuming that
knowledge of different cultures will result in providing better
care, and that focusing on cultural diversity will lead to
the reinforcement of stereotyping and maintain the sense of
inequality between nurses and patients. Further, it was stated
that Talabere (1996) has gone so far as to argue that the
term "cultural diversity" is itself seen to be ethnocentric
and that it's use entails major issues of discrimination,
racism and a lack of equality of opportunity. For example,
Leininger's model ignores the view of diversity within cultures,
such as between age and youth, rich and poor, and urban and
rural. While criticism and limitation of transcultural nursing
theories are present, their importance in forming vital curriculum
components for nursing students must be acknowledged. Students
may find, for example, Leininger's model (1991) a simple way
to explore societal and professional culture and Ginger and
Davidhizar's (1999) six components of human diversity useful
to assist in observations and reflections. Nonetheless, it
was Campinha-Bacote's model (1999) that was used in the student
exchange program between the U.S., the U.K., and other European
countries for addressing cultural competence in health care,
by achieving cultural desire within students. Thus, leading
to the development of cultural awareness, knowledge, skills,
and competence (Law & Muir, 2006).
Another model used for nursing education
is the Giger- Davidhizar Transcultural Assessment Model (GDTAM),
which, as stated by Davidhizar, Giger and Hannenpluf (2006),
is a modern, yet simple, extension of Dr, Leininger's model
that had been used widely in nursing schools as an assessment
tool and a way to gain appreciation for diverse cultures.
GDTAM offers an assessment umbrella that includes the aforementioned
six elements to assure provision of culturally sensitive care
(communication, space, social organisation, time, environmental
control, and biological variations).
The first phenomenon is communication. Communication includes
the whole process of human interaction and behaviour. It is
the means by which culture is transmitted and preserved though
written, verbal, and non- verbal methods. Communication variables
include dialect, language, style, volume of speech, touch,
context of words or emotional tone, and kinesics. Due to the
variations in theses variables within and between different
cultures, communication can present a barrier between nurses
and patients, as well as their families. Thus, it is crucial
for nurses to appreciate different approaches of communication
to provide more culturally sensitive care.
The second of the six phenomena is space, which is defined
as "the distance and intimacy techniques that are used
when relating verbally or non- verbally to others. Like those
of communication, spatial needs vary according to the cultural
orientation and the setting in which the individual is raised
in. Dayer-Berenson (2010) stated that Giger and Davidhizar
(2004) identified four aspects of behaviour patterns related
to space that should be assessed to enhance a healthy interaction.
These aspects include, proximity to others, attachment with
objects in the environment, body posture, and movement in
the setting. Physical proximity between patient and caregiver
is based on the level of intimacy and trust. Nurses should
be sensitive to patients who may feel that their personal
space is being violated by nurses' actions. Anxiety may be
created as a result of such behaviour.
The third phenomenon to be discussed
is social organisation. Social organisation is the manner in
which a cultural group organises itself around the family group,
structure, and organisation, beliefs and religion values, and
role assignment. "Enculturation" is the process of
learning social behaviours and it, too, differs according to
the cultural setting surrounding the individual. Matters like
rules of decision making, male and female orientation, and the
use of titles, are important for the nurse to be aware of by
assessing the unique and personal behaviours of patients and
their families associated with respect to avoid offending.
The fourth phenomenon is time and it, like the other phenomenon
discussed, is affected by family and cultural upbringing in
relation to whether an individual is "clock- or socially-
oriented". Clock orientation is a feature valued by most
Westerns, where individuals are usually oriented to past, present,
or future, and appointments tend to be kept at the prescribed
time and not doing so is considered rude. Other cultures focus
on the present person and place rather than on social time,
where activities start only when a previous social event is
completed; this is known as being socially oriented. Further,
time can be perceived differently to different cultures and
this affects the delivery of health care directly, where the
orientation of different time phases are needed to effect preventive
health measures and increase compliance with medication regimen
or required health screenings.
The fifth phenomenon in the GDTAM is environmental control,
which is defined as internal and external feelings of control
in the patients' social psychology. People with different cultures
have different beliefs about the cause of health and wellness
and the treatment of illness.
The last phenomenon is biological orientation. Biological variation
may be considered the least understood feature in the cultural
diversion. An investigation known as "biocultural ecology"
started in 1975, and with development it revealed the presence
of many biological variations between races. Modern DNA mapping
provides a wider understanding of the prevalence of some diseases
among different populations and, therefore, provides more appreciation
of many aspects of care including drug's pharmacokinetics, including
absorption, metabolism, distribution, and elimination, and drug's
pharmacodynamics, which is the mechanism of action and affect
on the target. It also reveals factors related to pain, such
as pain tolerance, nutritional preferences and deficiency, and
tendency for illness to aggravate (Davidhizar, Giger & Hannenpluf,
2006; Lipson & Desantis, 2007; Dayer-Berenson, 2010).
Another study conducted by Kardong-Edgren
and Campinha-Bacote (2008) evaluates four different nursing
program curricula in developing culturally competent new graduates.
Two programs utilise a theory or a model by recognised transcultural
nursing theorists, including Leininger and Campinha-Bacote.
One program utilises an integrative approach, where no specific
model is employed, while another program utilises a free-standing
two credit culture course within the curriculum. It was argued
that using an integrative approach may allow programs to avoid
problems associated with adding cultural content in the curricula,
which is seen to some as a soft science compared to other
biomedical components. Although some may argue that nursing,
as the diagnosis and treatment of human illness, should preclude
the need of teaching cultural competency; this approach reduces
the sociological and economic factors in which health encounters
occur and health decisions are made.
By using a version of Campinha-Bacote's Inventory for Assessing
the Process of Cultural Competency Among Healthcare Professionals-Revised
(IAPCC-R), it was concluded that no curricular strategy is
clearly better and more effective than another. As a result,
more questions than answers were raised due to the final outcomes
of that study. Questions such as "Is cultural awareness
a more realistic goal for graduating nursing students?"
imply that faculty are to expect the presence of cultural
competency to occur after graduation. Another question was
"What are the qualifications of faculty currently teaching
cultural competence?" and "Is the self-report evaluation
tool is the best way to assess cultural competency?"
Campinha-Bacote (2006) suggests that only less than 75 nurses
internationally are currently certified in transcultural nursing.
Consequently, it is clear that more studies are required to
answer these enquiries.
Another model used to apply transcultural
competence in practice is Purnell's model, which has been classified
by a number of nursing theorist as a holographic and complexity
theory because it involves an organisational framework that
enable its usage by all healthcare providers in different disciplinary
settings (Larry, 2005). It is stated by Lipson and Desantis
(2007) that the Purnell model is most often used at the bachelor
level in communication and health assessment courses. Dr Purnell
mentioned Excelsior College as an example of the success of
this model among some 17,000 culturally diverse students. The
Purnell model is a circle [Appendix 1] with an outlying frame
representing global society, a second frame representing community,
a third frame representing family, and an inner frame representing
the person. The interior of the concentric circles is divided
into twelve cultural domains and their concepts, where they
all interrelate to one another.
The first in the twelve domains is overview and heritage, which
includes concepts related to the country of origin, the effects
of the geography of the country of origin, and current residence,
politics, economics, educational status, and occupation. The
second domain is the concepts related to communication, which
include the dominant language and dialects, contextual use of
the language, paralanguage variations, nonverbal communication,
and spatial distancing. The third domain is family roles and
organization, which includes concepts related to the head of
the household and gender roles; family roles, priorities; and
developmental tasks of children and adolescents. Social status
and views toward alternative lifestyles such as single parenting,
sexual orientation, childless marriages, and divorce are also
included in this domain. The fourth area includes workforce
issues that are related to autonomy, acculturation, assimilation,
gender roles, ethnic communication styles, individualism, and
health care practices from the country of origin or residence.
Next are the biocultural ecology factors that include manifestations
variations in ethnic and racial origins, such as skin coloration
and other physical differences.
The sixth domain includes high-risk behaviours that should be
considered by health care providers, such as smoking, the use
of alcohol and recreational drugs, lack of physical activity,
and sexual practices. The seventh area involved is nutrition,
which includes the meaning of food: food choices, rituals; and
how food and food substances are used health promotion, treatment
and wellness. The eighth domain is pregnancy and childbearing,
including fertility practices; methods for birth control; and
attitudes toward pregnancy, birthing, and postpartum treatment.
There are also the death rituals that include how individuals
and their culture view death, rituals and behaviours to prepare
for death, and burial practices. This is connected to the next
domain, which is spirituality, which encompasses religious practice,
prayer, and any practices that bring peace and meaning to life.
Health care practice is the eleventh domain and it focuses on
traditional, religious, and biomedical beliefs, self medicating
practices, and views regarding mental illness and organ donation
and transplantation. The final domain of Parnell's model is
health care practitioner concepts, including the status, function,
and perceptions of traditional, religious, and allopathic biomedical
health care providers. All health care providers in any practice
setting can use this model including nurses, physicians, and
physical and occupational therapists in practice, education,
administration, and research in Australia, Belgium, Canada,
Central America, Great Britain, Korea, South America, and Sweden
and thus shows promise for becoming a major contribution to
transcultural nursing and health care (Larry, 2005).
6. Transcultural Competence in
the Curricula of Nursing
One of the biggest issues facing nursing education in recent
times is the effort to develop more culturally sensitive graduates.
Although theory and literature are sufficient to introduce
cultural concerns, problems such as the most effective applications
of these skills are limited by the nature of the clinical
experience and patients' populations students may face and
treat. In Europe, there have been several reforms in nursing
education, especially different processes trying to harmonise
its approach. Nevertheless, the nursing education system still
lacks conformity on these issues (Salminen, et al. 2010).
Consequently, educators strive to turn students into culturally
sensitive practitioners, where cultural content and experience
are thought of within the curriculum to develop improved cultural
competence (Halloran, 2009). Thus, many schools require a
specific course that focuses on transcultural nursing, cultural
concepts in health, health and culture, or more recently,
health disparities. These courses tend to apply medical anthropology
topics to nursing practice or combine medical anthropology
with cross-cultural nursing. Faculty members usually use the
nursing literature and models to develop their own method
of including cultural content; this is known as the integrative
approach (Lipson & Desantis, 2007).
6.1 Standards for Culturally
Competent Curricula for Nursing
A multidisciplinary teaching model is essential to develop
a pilot course for students to gain knowledge and skills in
providing diverse clients with culturally appropriate services
during field and clinical experience. According to this model,
in order to develop culturally sensitive graduates, the curriculum
should include five components, which are cultural awareness,
knowledge, desire, encounter, and skills. Campinha-Bacote's
Inventory for Assessing the Process of Cultural Competency
Among Healthcare Professionals-Revised (IAPCC-R) provides
twenty-five items to measure these cultural constructs (Kardong-Edgren
& Campinha-Bacote, 2008, p.39; Munoz, DoBroka & Mohammad,
2009). Moreover, in their book, Ring et al. (2008) interweave
the health care curricula with the Accreditation Council for
Graduate Medical Education (ACGMA) and Association of American
Medical Colleges (AAMC) requirements for medical education
in culture. The curriculum covers six major units, including
introduction to culture and cultural competence, which involves
defining contemporary diverse terms and their implications
in health care. Another unit covers the key concepts in cultural
competence, which include the value of social determinants,
describing historical models of common health beliefs, and
the value of curiosity, empathy, and respect in patient care.
The third area of discussion is bias, stereotyping, culture,
and clinical decision-making. Self assessment has an important
role in the quality of care provided; thus, these issues must
be recognised and evaluated for their effects upon interaction
with patients, families, and community. Another area in the
curriculum is concerned with the definition and contribution
of health and healthcare disparities and the factors involved
that have an impact on them, such as historical, political,
environmental, and institutional factors. The fifth unit covers
the discussion of cultural competence in patient care, including
models of effective cross-cultural communication and theories
of assessment. Finally, the curriculum addresses factors that
influence community actions towards cultural competence are
disclosed including the population's health criteria, social
mores, cultural beliefs and needs.
These units are presented with attention to Culturally and
Linguistically Appropriate services (CLAS) [Appendix 2], where
the office of Minority Health developed standards to offer
health care providers with guidance to promote and support
the attitudes, behaviours, knowledge, and skills necessary
to work respectfully and effectively with patients and each
other in a culturally diverse environment (Spector, 2009;
Cuellar, Brennan, Vito & Siantz, 2008).
A document recently issued by the American Academy of Nursing
has listed twelve recommendations of Expert Panel on Cultural
Competence to assist the process of having culturally sensitive
health care providers, nurses in particular [Appendix 3] (
Joyce, et al. 2007). Another contribution to the transcultural
competency curricula is the Cultural Competence and Confidence
(CCC) model [Appendix 4], designed by Jeffreys (2006), which
aims to interrelate aspects that explain, describe, affect,
and/ or predict the process of learning and developing cultural
competence with incorporation of the construct of transcultural
self-efficacy as a major influencing factor. "Transcultural
self-efficacy" is the perceived confidence in performing
or learning general cross-cultural nursing skills among a
culturally diverse population. Although standards and competencies
have shifted to more formal approaches and increasingly developed
within the nursing curricula and regulatory frameworks, it
is crucial to identify the minimal required level of performance
in each competency (Chiarella, Thoms & Mclnnes, 2008).
Salminen, et al. (2010) provide rrecommendations to target
challenges in future nursing education, including recognising
the importance of demonstrating competency categories for
nursing students and registered nurses in curricula, which
must be more specific with regards to content, learning strategies,
and evaluation of learning outcomes. This entails the need
for integration of theoretical studies, clinical practice
in health care settings, and research skills relating to the
culturally diverse population's needs. Further, the quality
of nursing education should be evaluated in local, national,
and international networks, and thus provide the optimum standards
for culturally sensitive health care providers. A substantial
increase in the conditions for students' and educators' mobility
is required, where knowledge about cross-cultural activities
and willingness to understand diverse populations are a necessity.
7. Conclusion
The main aim of having transcultural desire, awareness, knowledge,
skill, and competence in the curricula of nursing is to provide
optimum patient care that is framed with respect, appreciation,
and understanding to the culturally diverse nature of each
individual involved in the process. Four major cultural competence
models and theories, including those of Leininger (1991),
Purnell and Paulanka (1998), Giger and Davidhizar (2004),
and Campinha-Bacote (2007) are discussed thoroughly in relation
to the current nursing literature. Leininger's Model illustrates
the major components and interrelationships of cultural care,
diversity, and universality. When using her theory in caring
for patients, nurses should consider the presence of cultural
mismatch and develop awareness of each individual's style
of interaction (Dayer-Berenson, 2010). On the other hand,
Davidhizar, Giger and Hannenpluf (2006) argued the need to
use the (GDTAM) to assess patients in order to provide culturally
sensitive and competent care. Purnell and Paulanka's model
is considered flexible because it can be applied for all healthcare
members using the macro- and micro-factors for individuals
involved (Larry, 2005). However, Campinha-Bacote's model of
care added new dimensions to the process of cultural sensitivity
by identifying the five main components (which are cultural
awareness, cultural skills, cultural knowledge, cultural encounters,
and cultural desire). Nonetheless, there are no articles in
the literature clearly identifying a certain model to be better
than another. Although theory and literature are sufficient
to introduce and address cultural concerns to some extent,
effective application of these skills is problematic, where
current practices are not solving problems nursing faces,
where evaluating cultural competency of graduating nursing
students is not yet established, and further studies in that
area are required (Kardong-Edgren & Campinha-Bacote, 2008;
Law & Muir, 2006).
7. Appendix
Appendix
1 (click to view)
Appendix 2
National
Standards for Culturally and Linguistically Appropriate
Services in Health Care (CLAS)
1. Health care organizations should ensure that patients/consumers
receive from all staff member's effective, understandable,
and respectful care that is provided in a manner compatible
with their cultural health beliefs and practices and preferred
language.
2. Health care organizations should implement strategies
to recruit, retain, and promote at all levels of the organization
a diverse staff and leadership that are representative
of the demographic characteristics of the service area.
3. Health care organizations should ensure that staff
at all levels and across all disciplines receive ongoing
education and training in culturally and linguistically
appropriate service delivery.
4. Health care organizations must offer and provide language
assistance services, including bilingual staff and interpreter
services, at no cost to each patient/consumer with limited
English proficiency at all points of contact, in a timely
manner during all hours of operation.
5. Health care organizations must provide to patients/consumers
in their preferred language both verbal offers and written
notices informing them of their right to receive language
assistance services.
6. Health care organizations must assure the competence
of language assistance provided to limited English proficient
patients/consumers by interpreters and bilingual staff.
Family and friends should not be used to provide interpretation
services (except on request by the patient/consumer).
7. Health care organizations must make available easily
understood patient-related materials and post signage
in the languages of the commonly encountered groups and/or
groups represented in the service area.
8. Health care organizations should develop, implement,
and promote a written strategic plan that outlines clear
goals, policies, operational plans, and management accountability/oversight
mechanisms to provide culturally and linguistically appropriate
services.
9. Health care organizations should conduct initial and
ongoing organizational self-assessments of CLAS-related
activities and are encouraged to integrate cultural and
linguistic competence-related measures into their internal
audits, performance improvement programs, patient satisfaction
assessments, and outcomes-based evaluations.
10. Health care organizations should ensure that data
on the individual patient's/consumer's race, ethnicity,
and spoken and written language are collected in health
records, integrated into the organization's management
information systems, and periodically updated.
11. Health care organizations should maintain a current
demographic, cultural, and epidemiological profile of
the community as well as a needs assessment to accurately
plan for and implement services that respond to the cultural
and linguistic characteristics of the service area.
12. Health care organizations should develop participatory,
collaborative partnerships with communities and utilize
a variety of formal and informal mechanisms to facilitate
community and patient/consumer involvement in designing
and implementing CLAS-related activities.
13. Health care organizations should ensure that conflict
and grievance resolution processes are culturally and
linguistically sensitive and capable of identifying, preventing,
and resolving cross-cultural conflicts or complaints by
patients/consumers.
14. Health care organizations are encouraged to regularly
make available to the public information about their progress
and successful innovations in implementing the CLAS standards
and to provide public notice in their communities about
the availability of this information.
The National Center for Complementary
and Alternative Medicine (NCCAM)
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Appendix 3
Comprehensive Recommendations
of Expert Panel on Cultural Competence of the American
Academy of Nursing (AAN)
1. The AAN, through its publications, mission statements,
and yearly conferences, must make an explicit commitment
to quality, culturally competent care that is equitable
and accessible by targeting four groups: (a) health care
consumers, (b) health care providers, (c) health care
systems, and (d) communities.
2. The AAN will collaborate with other organizations and
communities in developing guidelines.
3. The AAN shall develop mechanisms to synthesize existing
theoretical and research knowledge concerning nursing
care of ethnic/minorities and other vulnerable populations.
4. The AAN, through its expert panels and commissions,
must create an interdisciplinary knowledge base that reflects
health care practices within various cultural groups,
along with human communication strategies that transcend
interdisciplinary boundaries to provide a foundation for
education, research, and action.
5. The AAN, through its expert panels and commissions,
must identify, describe, and examine methods, theories,
and frameworks appropriate for utilization in the development
of knowledge related to health care of minority, stigmatized,
and vulnerable populations.
6. The AAN shall seek resources to develop and sponsor
studies to describe and identify principles used by organization
magnets that (a) provide an environment that enhances
knowledge development related to cross-cultural, ethnic
minority/stigmatized populations, and (b) attract and
retain minority and other vulnerable students, faculty,
and clinicians.
7. The AAN, through its various structures, must identify
health care system delivery models that are the most effective
in the delivery of culturally competent care to vulnerable
populations and develop mechanisms to promote the necessary
changes in the U.S. health care delivery system toward
the identified models.
8. The AAN must collaborate with other organizations in
establishing ways to teach and guide faculty and nursing
students to provide culturally competent nursing care
practices to clients in diverse clinical settings in local,
regional, national, and international settings.
9. The AAN must collaborate with racial/ethnic nursing
organizations to develop models of recruitment, education,
and retention of nurses from racial/ethnic minority groups.
10. The AAN will collaborate with other organizations
in promoting the development of a document to support
the regulation of content reflecting diversity in nursing
curricula. In addressing regulations, specific attention
needs to be given to the NCLEX examinations, continuing
education, and undergraduate curricula.
11. The AAN must take the lead in promulgating support
of research funding for investigation with emphasis on
interventions aimed at eliminating health disparities
in culturally and racially diverse groups and other vulnerable
populations in an effort to improve health outcomes. The
AAN must take a more proactive stance to encourage policy
makers to create policies that address the elimination
of health disparities and ultimately improve health outcomes.
12. The AAN must encourage funding agencies' requests
to solicit proposals focusing on culturally competent
interventions designed to eliminate health disparities.
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Appendix
4 (click to view)
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