Models of transcultural care

This section offers an introduction to the different models of transcultural care. It is not intended to be a complete, comprehensive critique of each one. Further reading is essential and sign posting of recommended reading material has been provided throughout.

 

Introduction

There are many theories and models of nursing (Aggleton & Chalmers, 2000). Some of these you will be familiar with, for example, Roper, Tierney and Logan’s Activities of Living (Roper et al., 1996) and Orem’s Self-Care (Orem, 1995). Most of these theories consider the four main elements – that is, Health, Environment, Person and Nursing care. Some of these sources have considered nursing models from a transcultural perspective. However, none of them go into sufficient detail about the cultural aspects of care that is required to address culturally competent care.

Eddins & Riley-Eddins (1997) – Watson’s Theory of Human caring; Hardin (1997) – Roger’s Science of Unitary Human Beings; Morgan (1997) – Roy’s Adaptation Model;Villarruel & Denyes (1997) – Orem’s Self-Care Deficit Theory of Nursing.

Models of transcultural care have emerged over the last three decades. As with other models of nursing, they have been constructed with concepts that are already found in the biological, behavioural and human sciences. Dobson (1991) provides outlines of the main concepts that have been used to construct frameworks or models by different theorists, and contrasts these in view of developments in transcultural nursing.  In this resource, Campinha-Bacote’s Model of Cultural Competence, Madeleine Leininger’s Cultural Care Diversity and Universality Theory, Giger and Davidhizar’s Model of Transcultural Nursing, Purnell’s Model of Transcultural Health Care and Ramsden’s Cultural Safety model are briefly introduced. The model of cultural competence by Papadopoulos, Tilki and Taylor (1998) is briefly described. The key elements of each are described, and the applications and limitations of each are outlined.

However, before we examine the models of transcultural care, you will note that for the purpose of framing nursing care, the four stages of the nursing process – assessment, planning, implementation, and evaluation, remain the foundation on which transcultural care is formulated.

Analysis Of Theories

It is not the intention here to give a definitive critical evaluation of the theories but to introduce this framework to facilitate further discussion among students and practitioners as to the contribution of these theories to practice.

Marriner-Tomey (1994) suggests that the theories ‘provide knowledge to improve practice by describing, explaining, predicting, and controlling phenomena’ (p.3). Knowledge empowers health care professionals to practice with autonomy and confidence. Understanding and application of theories facilitate the development of knowledge, analytical skills, value clarification, and challenge assumptions and advance practice. Marriner-Tomey (1994) adopts an approach that considers the following areas when examining theories: the source of the theory and its development, use of data-based evidence to support its assertions, major concepts and assumptions, the theoretical assertions, the logical form, and acceptance by the professions, and its further development.

Theories evolve over time. Theorists often revise their thinking and formulations, and seek validation through application and testing. Marriner-Tomey (1994, p 6-7.) provides a framework for the analysis and evaluation of nursing theories. The main criteria are: (1) Clarity and Simplicity; (2) Generality; (3) Empirical Precision, and; (4) Derivable Consequences.

1. Clarity And Simplicity

Marriner-Tomey (1994) suggests that the development of the theory should follow a logical process, and should be consistent its underlying goals. In order to achieve this, concepts and sub-concepts should be clearly described and defined, without any ambiguity but always with consistency. Where words may have multiple meanings, caution should be exercised in defining and making their meanings precise, particularly when they are borrowed from across disciplines. The relationships between concepts should be made explicit, and where diagrammatic outlines are used to illustrate these relationships, again consistency should be apparent.

Simplicity is necessary to allow for understanding without making concepts unnecessarily complex and their comprehension difficult. It should not however be at the risk of losing the depth and breadth of concepts and their interrelationships. Simplicity will allow for easy translation into application and practice.

2. Generality

This relates to the scope of the theory. When both concepts and goals are limited, the theory may have less generality. However, the significance of the theory is not dependent solely on the breadth and narrowness of its scope, since it is recognised that the simplicity and complexity of concepts add to the theory.

3. Empirical Precision

Empirical precision relates to the idea that objective testing of the theory should be possible. In other words, the theory should lend itself to generating knowledge based on observed and tested relationships between concepts. It therefore follows that unless theories lend themselves to testing, they are less likely to be accepted as guides to informing practice.

4. Derivable Consequences

This refers to the potential of the theory to have a sustained impact and continuing influence on further developing new ideas, professional practice and research.

Marriner-Tomey’s approach to the analysis of nursing theory is but one of many that may be used.

Further Reading

Aggleton P and Chalmers H (2000) Nursing models and nursing practice 2nd ed. Basingstoke: Macmillan Press

Hancock B (2000) Are nursing theories holistic? Nursing Standard 14:91

Marriner-Tomey A (1994) Introduction to analysis of nursing theories in: A Marriner-Tomey (ed.) Nursing Theorists and Their Work 3rd ed. St. Louis: Mosby

Orem DE (1995) Nursing: concepts of practice 5th ed. St Louis: CV Mosby

Roper N, Logan W and Tierney A (1996) The elements of nursing 4th ed. Edinburgh: Churchill Livingstone

Transcultural Care

The concepts of care and caring have been described as both models and theories. The main focus of transcultural care is the study and analysis of cultural values, beliefs and practices, and their influence in shaping the beliefs and practices with respect to health, illness and care.

The aim of transcultural care is to provide care that is culturally in keeping with the expectations of the person’s cultural values, beliefs and practices.Transcultural theory has been criticised for not addressing issues of sociological or political inequalities that face minority ethnic groups with respect to the power relationships in society (Culley, 1996). A major limitation of transcultural nursing models is their lack of consideration of the relationship between power and knowledge, and the analysis of prejudice and discrimination (Mulholland, 1995). Talabere (1996) has suggested that in its usage the term cultural diversity itself is ethnocentric in the sense that it implies a worldview of the other person being different from oneself rather than how one is different from the other. The risk being that the ‘white’ ethnic group is viewed as the norm against which comparisons of other ethnic groups (non-whites) are made. This has wide-reaching implications for how we question and respond to our own assumptions about others, and our knowledge of the deep-rooted historical, political, religious, cultural and socio-economic origins of the issues that impact on developing culturally competent nursing care.

Cultural Competence

Introduction

There are different ways of formulating cultural competence. In defining cultural competence, Giger and Davidhizar (1999) state that it is ‘a dynamic, fluid, continuous process whereby an individual, system, or health care agency finds meaningful and useful care-delivery strategies based on the knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care’ (Giger & Davidhizar, 1999, p.8).

Purnell and Paulanka (1998) view cultural competence in developmental terms and as a conscious process that is not linear. Campinha-Bacote Model Of Cultural Competence

The following provides a summary of Campinha-Bacote’s framework for organising cultural competence (Campinha-Bacote, 1994; Campinha-Bacote, Yahle & Langenkamp, M., 1996; Campinha-Bacote, 1999; Campinha-Bacote & Campinha-Bacote, 1999).

In order to demonstrate cultural competence, individuals as well as organisations and institutions should first show an intrinsic motivation that is cultural desire, to engage in the process of cultural competence. This concept, one of five within the framework, is perhaps the most crucial in the process of developing cultural competence. The five elements are now described. A diagrammatic representation of Campinha-Bacote’s model of cultural competenceA diagrammatic representation of Campinha-Bacote’s model of cultural competence. (Modified from Campinha-Bacote, 1999).

Cultural Awareness

The nurse becomes sensitive to the values, beliefs, lifestyle and practices of the patient/client, and explores her/his own values, biases and prejudices. Unless the nurse goes through this process in a conscious, deliberate and reflective manner there is always the risk of the nurse imposing her/his own cultural values during the encounter. Cultural imposition is the tendency to impose one’s own cultural values, beliefs and patterns of expected behaviour upon others of a different culture to one’s own. During the cultural awareness phase, the nurse becomes aware of her/his own ethnocentric position and the stereotypes that they hold. Gradually, they should become more sensitive to the cultural diversity and modify their attitudes and beliefs.

Cultural Knowledge

Cultural knowledge is the process whereby the nurse finds out more about other cultures and the different worldviews held by people from other cultures. Understanding of the values, beliefs, practices and problem-solving strategies of culturally / ethnically diverse groups enables the nurse to gain confidence in her/his encounters with them. Cultural knowledge will include aspects of demography, epidemiology, socio-economics and political factors, and nutritional practices and preferences, and other data that are meaningful in understanding variations across cultural/ethnic groups.

Cultural Skill

Cultural skill as a process is concerned with carrying out a cultural assessment. Based on the cultural knowledge gained, the nurse is able to conduct a cultural assessment in partnership with the client/patient. Interpersonal skills, acceptance, trust, respect, empathy, clinical and diagnostic skills informed by cultural knowledge demonstrates itself through reflective practice. Cultural skill represents the ability to systematically collect culturally relevant information about the client’s health, and interpret these for the purpose of culturally congruent interventions.

Cultural Encounter

Cultural encounter is the process which provides the primary and experiential exposure to cross-cultural interactions with people who are culturally/ethnically diverse from oneself. Exposure leads to further reflection and integration of the learning about culturally congruent care and its delivery.

Cultural Desire

Cultural desire is an additional element to the model of cultural competence (Campinha-Bacote, 1999). It is seen as a self-motivational aspect of individuals and organisations to want to engage in the process of cultural competence. The willingness and desire has to come from within. It is an intrinsic and positive factor that does not have to be imposed or brought about through regulatory mechanisms.

Cultural Assessment

‘A cultural assessment is needed on every client, for every client has values, beliefs and practices that must be considered when rendering health care services. Therefore, cultural assessments should not be limited to specific ethnic groups, but rather conducted with each individual’ (Campinha-Bacote et al, 1996, p61). Cultural assessment should not imply a simplistic notion that it only refers to people in relation to a limited view of cultural diversity. In our resource, the broadest sense of cultural diversity is being implied, although it is not possible to make this explicit on every occasion.

It is worth noting that cultural assessment can be carried out using the frameworks provided by any of the models that we describe below.

Further Reading

Campinha-Bacote J (1994) Cultural competence in psychiatric mental health nursing. A conceptual model Nursing Clinics of North America 29 (1): 1-28.

Campinha-Bacote J (1999) A model and instrument for addressing cultural competence in health care Journal of Nurse Education 38 (5): 203- 207.

Campinha-Bacote J and Campinha-Bacote D (1999) A framework for providing culturally competent health care services in managed care organisations Journal of Transcultural Nursing 10 (4): 290-291.

Campinha-Bacote J, Yahle T and Langenkamp M (1996) The challenge of cultural diversity for nurse educators The Journal of Continuing Education in Nursing 27 (2): 59-64.

Leininger’s Model

Leininger’s Cultural Care Diversity and Universality Theory and the Sunrise Model are perhaps the most written about to date (Sources: Reynolds & Leininger, 1993).

The theory draws from anthropological observations and studies of culture, cultural values, beliefs and practices. It derives from nursing and anthropological concepts and methods of enquiry. Some concepts are described as they pertain to the theoretical development. The orientational definitions are explained. Leininger has defined concepts as they apply to nursing. The development of the theory of transcultural nursing is based on the defining and redefining of concepts to give them a focus that emphasise the essence of care in its cultural context, with both the culture specific and universal issues being considered. Leininger claims that the theory of cultural care diversity and universality is holistic.

Leininger considers cultural blindness, culture shock, culture imposition, ethnocentrism and cultural relativism as barriers to developing knowledge about other’s culture.

Applications

The model has been used in a wide range of nursing specialisms.

 

Critical Overview

As many of the concepts are abstract in nature together with the layered way in which it is constructed, the theory is complex and requires an understanding of how these interrelate. Many of these concepts are prefixed by the adjective ‘cultural’, pointing to the emphasis placed by Leininger on the cultural perspective. The theory is holistic and seeks to encompass both the diversity and universality of concepts in nursing care. This is because Leininger also recognises the comparative aspects of caring within and between cultures, hence the acknowledgement of similarities as much as differences in caring in diverse cultures. The broad concepts and their qualitative dimensions make the theory relatively comprehensive and applicable in some contexts of multicultural care settings. The theory of transcultural nursing has been researched using the qualitative approach. The rigour of the approach has been demonstrated primarily through the criteria of credibility and confirmability of data in the studies. The theory has implications for how we assess, plan, implement and evaluate care of people from diverse cultural backgrounds. (A detailed critical overview can be found in Marriner-Tomey, 1994, Chapter 28, pp. 423-444).

The model with its emphasis on cultural sensitivity and cultural congruence has been criticised on the grounds that it assumes that knowledge of different cultures will improve care and services (Culley, 1996; Culley, 1997; Culley, 2000). The culturalist approach fails to account for the structural and political aspects of the inequalities of minority ethnic people (Mulholland, 1995). And, by focusing on cultural differences and deficits, makes the culture the problem, and gives rise to a ‘victim blaming’ stance. The cultural analysis is based on the notion of cultural differences as cultural deficits, and may reinforce stereotypes, and perpetuate the power distance between care professionals and patients. From the perspective of cultural safety, the power relationship between the patient and the care professional is an important one, and it has been argued that not to take into account the structural and political issues that affect people from minority ethnic groups is to diminish and disempower, making the care less than culturally safe (Coup, 1996).

Further Reading

Leininger MM (1995) Transcultural nursing: concepts, theories, research and practices 2nd ed. New York: McGraw-Hill

Bruni N (1988) A critical analysis of transcultural nursing Australian Journal of Advanced Nursing 5, 3: 26-32.

Reynolds CL and Leininger M (1993) Culture care diversity and universality theory Newbury Park: Sage Publications

Giger And Davidhizar’s Model Of Transcultural Nursing

(Giger & Davidhizar, 1999)

Giger and Davidhizar’s model focuses on Assessment and Intervention from a transcultural perspective. In this model, the person is seen as a unique cultural being. Thus 3 concepts underpin the unique cultural being: Culture, Ethnicity, and Religion.

From the wider literature on cultural values, beliefs and practices, Giger and Davidhizar have extracted and explained in their model six areas of human diversity and variations.

Communication Time

Space Environmental control

Social organisation

Biological variations

Communication

Communication is a theme that recurs all the time whenever we are interacting with others or the environment. Communication is the essence of being, and therefore a very important aspect of our professional skills. In order to understand the person as a unique cultural being, detailed assessment and intervention aim to provide care that is culturally competent. Giger & Davidhizar (1999) present communication in the context of the uniqueness of the individual, and support this with the literature. The factors that influence communication can be seen as universal to everyone. However, the culture specific influences are associated with verbal, non-verbal, and the personal aspect of communication. Among the factors affecting verbal communication, the importance of the use of language in assigning meanings to the inner and outside worlds in different cultures is highlighted. Some of linguistic features of verbal communication that are detailed include vocabulary, names, and grammatical structure. The socio-cultural and personal aspects of verbal communication, such as voice qualities, rhythm, speed, pronunciation are explained, whilst the meaning of silence in different cultures is outlined with some useful examples. The meanings of touch in communication, and cultural differences and sensitivities are considered with respect to facial expressions, eye movement or eye contact and body posture. Personal qualities such as warmth and humour are also discussed.

The influences of cultural values, beliefs, practices on communication styles and skills, and the knowledge of these in the cultural care of individuals and families are beneficial to outcomes of care.

Giger & Davidhizar (1999) provide a set of guidelines for communicating and relating to patients from different cultures (p.34). The central role of communication in establishing rapport and a therapeutic relationship requires the health professional to adapt communication approaches to meet the cultural needs of patients in a non-threatening manner. Erroneous perceptions of roles and power, particularly when the patient is vulnerable, can hinder effective communication. The patient who speaks a different language, or is unwilling to discuss issues about health that may be culturally sensitive, needs communication approaches that meet with the cultural expectations of the patient.

Giger & Davidhizar (1999) suggest ways of enhancing communication in the care of patients from different cultures.

Space

We perceive space through our senses with the help of the biological structures that make up our body. We perceive environments that are internal and external to our body in terms of space. Perceptions involve very complex mechanisms at different levels of our biological and mental functioning. The interpretations of what we see, hear, smell, taste and feel are however given meaning through what we have learned these to mean during our socialisation. The meanings we give to our perceptions are important factors in determining our responses to the cues in the space external to our body. For example, those with all their senses intact, combine their sense of touch with their sense of distance to manoeuvre to sit in a chair.

Giger and Davidhizar’s model considers the relationships between visual and tactile space from a cross-cultural perspective. Touch assumes specific significance of purpose and meanings in the context of the activity, and relationship with others. As such, there are cultural implications for our perceptual worlds. How we perceive shape, size, distance, and depth are to some extend influenced by our cultures. Giger and Davidhizar consider the cultural aspects of spatial behaviour and their implications. The notion of territoriality is explored and explained in terms of personal space and proximity to others, material objects in the external environment, and body movement or position.

Spatial behaviour of patients and health professionals as well as the internal structural designs of hospital wards and departments convey needs that reflect cultural influences.

When assessing patients, observation of the response to body contact, patterns of behaviour within the ward or department, or during examination, response to the presence of other patients, proximity with family members, and other emotional reactions may reveal the cultural meanings attached to space.

Social organization

Under the social organisation theme, Giger and Davidhizar (1999) recognise that their culture should be considered in its totality. They suggest that in order to understand culture-specific behaviours, ‘culture must be viewed and analysed as a totality – a functional, integrated whole whose parts are interrelated yet interdependent. The components of culture such as politics, economics, religion, kinship, and health systems, perform separate functions but nevertheless mesh to form an operating whole’ (p. 65).

Under social organisation, Giger and Davidhizar include for consideration family groups as systems, with structures and characteristics, which in turn reflect their function at different levels. They adopt three criteria to examine and explain family systems: kinship, function, and location. Each one of these criteria serves the purpose of identifying differences and similarities within and across cultures. Religious affiliation is linked to social systems.

In general, the influences of social organisation systems on individuals and groups of people cannot be underestimated. With respect to life opportunities in a multicultural context, social organisation systems may discriminate against certain groups on the basis of ethnicity, religion, politics and socio-economic status.

Understanding of the social organisation systems and their impact on the lives of people in culturally diverse communities can enable us to deliver care and services that is empowering and sensitive to needs.

Time

Time is perceived, measured and valued differently across cultures. Giger & Davidhizar discuss the concept of time with reference to the lifespan in terms of growth and developments, perception of time in relation to duration of events, and time as an external entity, outside our control.

The measurement of time is discussed with respect to the clock and other astronomical concepts. Practical aspects of measurements are considered, and the lunar calendar should be added to the concepts of tropical time such as seasonal events, solar time, and the Gregorian calendar. The timing of Ramadan according to the lunar calendar is an example. See lifespan, within this resource.

Cultural variations in the perception of social time and clock time are explained, as are the implications of time in human interactions. Cultures also vary in their emphasis and orientation to the past, present and future. These differences may influence interactions as the worldview of time itself may impact on the values placed on relationships with others, and oneself and the environment.

Environmental control

Giger and Davidhizar (1999) adopt a broad definition of the concept of environment, suggesting that it is more than just the place where one lives, and involves systems and processes that influence and are influenced by individuals and groups. These theorists think of environmental control as ‘the ability of an individual or persons from a particular cultural group to plan activities that control nature’ (p.115). The human systems and processes interact with the environment. The relationship between the individual or human groups is a dynamic one, each influencing the other in terms of beliefs and practices about health and illness. The environments that cultural groups have lived in have influenced their beliefs about disease and illness, and the remedies that have evolved in those environments.

Giger and Davidhizar (1999) include health practices, values that influence these health care practices and the locus of control as one of these values across cultures.

Folk medicine and models or systems of health care that have relevance to particular cultural groups have emerged over generations, and are part of the groups’ means of exercising environmental control in illness. Alternative therapies vary across cultures. Some of these have found expression in different cultures and exist alongside the medical model of treatment and care.

Religious beliefs and experiences influence beliefs about healing and the power of healing. Religious systems influence the everyday lives of people. A wide range of rituals and taboos can be observed across religious groups. Religious considerations influence the perception of the individual and the natural environment, food, clothing, and medical interventions such as blood transfusion among others.

Giger and Davidhizar (1999) construct the assessment of individual or persons around the cultural beliefs and practices that mark events such as pregnancy, birth, and responses to illness through the lifespan.

Biological Variations

Giger and Davidhizar (1999) outline biological variations across ethnic groups. The need to understand the biological variations is necessary in order to avoid generalisations and stereotyping people. They argue that knowledge of biological variations can enable the nurse to provide care that is culturally competent and non-harmful.

They also outline these biological variations in terms of dimensions such as body structure, body weight, skin colour, internal biological mechanisms such as genetic and enzymatic predisposition to certain diseases, drug interactions and metabolism.

Some of the categories they list are questionable, since they do not take into consideration the full extent of the interactive relationship between environmental and biological factors in determining human characteristics.

Applications

The model provides a comprehensive structure and organisation of the six broad areas of human thinking, beliefs and activities where cross-cultural similarities and differences may be observed. These six areas enable individual and group characteristics to be understood and explained without losing sight of the diversity and universality that exists within and across ethnic and cultural groups. The six areas are further subdivided to accommodate concepts that are specific to cultural discourse.

The model proposes a framework that facilitates that assessment of the individual. A set of questions is constructed under each of the six areas to generate information that assist planning of care that is congruent with the individual’s needs.

The model also represents a learning tool that can be utilised to explore issues about any of the six broad areas in practice. It encourages flexibility and the involvement of the patient as an equal partner in the cultural assessment of needs. It can facilitate explanatory models of health and illness. The use of the model has been reported in various studies, some of which are cited in the references related to this model at the end of this section.

Critical Overview

The six areas are easy to relate to as they represent themes that can be understood at several levels, individual and groups, cultural and societal. There are concepts incorporated under each of these areas that could be categorised differently under separate categories. For instance, under social organisation, religious groups are introduced. From a transcultural perspective, religious beliefs determine and influence a number of practices that are related not just to religious observance, but also how they influence health and illness behaviours. Religion and spirituality, and their cultural expressions, can be a separate theme.

The six areas borrow from a wide range of biomedical and social science disciplines. The breadth and depth of understanding of the concepts may not lend themselves to application, unless one is fully conversant with the area of knowledge. For instance, the idea of time and its meanings in different cultural contexts may not be fully appreciated.

Assessment and intervention require previous knowledge of the cultural heritage and values, beliefs and practices of the patient. Limitations of individual nurses may be exposed, however the need to learn may act as an incentive.

 

Further Reading

Giger J and Davidhizar R (1990) Culture and space Advances in Clinical Care 8: 8-11.

Giger JN and Davidhizar RE (1999) Transcultural nursing. Assessment and interventions 3rd ed. St Louis: CV Mosby.

Bechtel GA and Davidhizar R (1999) A cultural assessment model for ED patients Journal of Emergency Nursing 25 (5): 377-380.

Purnell’s Model Of Transcultural Health Care

(Purnell & Paulanka, 1998)

In the literature, the model is generally referred to as Purnell’s model. However, Purnell and Paulanka (1998) are the editors of the textbook in which the model has been described and its applications illustrated through the contributions of other authors. Hence, this resource refers to Purnell’s model when addressing issues directly related to the model, and Purnell and Paulanka (1998) when referring to the book as a source.

Purnell and Paulanka (1998) conceptualise the development of cultural competence along an upward curve of learning and practice. An increasing level of achievement of competence characterises the model that views the practitioner moving through the following 4 levels:

The practitioner moving from a stage of unconscious incompetence.

Conscious incompetence

Conscious competence

Finally, unconscious competence.

These are described in great detail and take into consideration the experiences and knowledge of the practitioner. Purnell and Paulanka (1998) also suggest that it may be possible to devise criteria to measure these levels of competence.

The Model

The concepts that make up Purnell’s model of cultural competence are not unlike those found in Leininger’s, and Giger and Davidhizar’s models. However, Purnell’s model extends some of the categories under which the concepts are organised.

Purnell’s model of cultural competence consists of 2 sets of factors that are described as the macro aspects and micro aspects. In the diagrammatic representation of the model, Purnell and Paulanka use concentric circles to locate the macroaspects and microaspects. The macroaspects form the wider outer circles and the microaspects 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. Purnell and Paulanka (1998, p.8-9) suggest that the model is informed by a range of fields of inquiry that include ‘biology, anthropology, sociology, economics, geography, history, ecology, physiology, psychology, political science, pharmacology, and nutrition as well as communication, family development, and social support’. They go on to say that ‘the model can be used in clinical practice, education, research, and the administration and management of health-care service’.

Global Society

Global society is described with reference to the wider world, politics, communication systems, commerce and economies, technologies and events, and the impact of these in shaping the individual’s or persons’ worldviews.

Community

The community is described in terms of a group of people living in the same locality and sharing interests and a common identity.

Family

The family is described as two or more people, emotionally involved, living together or not, but close. Family structure and roles vary.

The Person

The person is conceptualised as ‘a biopsychosociocultural human being who is constantly adapting’ (Purnell & Paulanka, 1998, p. 9).

Health is viewed as permeating aspects of culture, and defined at different levels, global, national, regional, local and individual. Health is also defined, and takes on board the ethnocultural perspective of the people, and relates to the physical, mental, spiritual states in the context of the people and their interactions with the family, community and the wider world.  The microaspects are represented by segments that make up the 12 domains:Inhabited localities and topography

Communication

Family roles and organisation

Workforce issues

Biocultural ecology

High-risk health behaviours

Nutrition

Pregnancy and child bearing practices

Death rituals

Spirituality

Health-care practices

Health-care practitioners

These domains are interrelated and provide for a comprehensive view of the individual. They include concepts that are common to the other models. The descriptive details this model reflects are to a large extent those that have been described earlier in Giger and Davidhizar’s model.

However, the domains of Purnell’s model allow for a more focused analysis. Purnell and Paulanka (1998) provide guidelines to facilitate the further exploration of issues under each of these domains.

Applications

Used with a framework for nursing assessment, intervention and evaluation, the model can provide useful insight into the aspects of the person’s cultural needs in relation to each domain. It can also provide explanatory models for health and illness across cultures.

Critical Overview

There may be overlap as a result of common elements being present in any two or more of the domains, as well as in the domains and the macro aspects.

The model tries to be all-inclusive. The risk is that it may not be appropriate to practitioners unless the breadth and depth of their knowledge and skills is matched with the requirements of health care users.

Further Reading

Purnell LD (1999) Panamanians’ practices for health promotion and the meaning of respect afforded them by health care providers Journal of Transcultural Nursing 10 (4): 331-339.

Purnell LD and Paulanka BJ (1998) Transcultural health care. A culturally competent approach Philadelphia: F A Davis Company

Ramsden’s Cultural Safety Model

The concept of cultural safety was developed in Aotearoa (New Zealand) in the late 80s. A group of Maori nurses developed the concept as a means of analysing nursing practice from the perspective of the indigenous people who are a minority (Ramsden, 1990; Ramsden, 1992). The concept is very much embedded in the redefinition of post-colonial identity, redistribution of power and resources. Although framed in the context of New Zealand, its European colonisation and the disenfranchisement of the indigenous Maori people, Ramsden contends that the idea of cultural safety is relevant for any environment where the power sharing and resources distribution between people of diverse background is unequal.

Ramsden (1993) has outlined the concept in further detail and argued for its place in nursing education. In nursing practice, the concept of ‘cultural safety’ emerged in response to transcultural care with respect in particular to Leininger’s model, which it was argued did not take into consideration the wider sociocultural and political issues in bicultural or multicultural environments of care. Ramsden argues that ‘Such a model does not allow for the diversity within cultures, for the differences between conservative and liberal, age and youth, urban and rural, rich and poor and gender interaction’ (Ramsden, 1993, p. 6). In developing the concept of cultural safety, Ramsden has been mindful of the nature of interactions that are bicultural in nature. Furthermore, participation in the assessment of service needs and the opportunity to influence service delivery are important aspects of cultural safety. In these processes, Ramsden argues that there exists an element of cultural risk. Cultural risk refers to the belief by a group of people from one culture that they are devalued and disempowered by the care delivery systems and the actions of people from another culture (Wood and Schwass, 1993, p.2). Culturally unsafe nursing practice includes ‘any actions which diminish, demean or disempower the cultural identity and well-being of an individual’ (Whanau Kawa Whakaruruhau, 1991, cited by Wood & Schwass, 1993, p. 5).

Thus, cultural safety ‘focuses on the elements in ethnicity ignored by transcultural theory. It makes clear the structural dimension in health care provision, that care is not simply provided for individuals but for members of groups whose care inevitably reflects the position of their groups as a whole within general society’ (Polaschek, 1998, p 456). The concept points to inequalities due to the power base of ethnic groups in their relationships, expressed in a range of inequalities and negative attitudes.

Polaschek (1998) outlines the development of the concept and contrasts it with other concepts used in culturally competent care:

Cultural safety is neither the same as cultural sensitivity nor is it about cultural practices.

Cultural safety is about the recognition and acknowledgement of the influences of the social structures in interactions between people of different cultural heritage, and the power relationships in service delivery.

Practice that is deemed culturally safe meets the needs, expectations and rights of people through actions that demonstrate recognition, respect and nurturing of their unique cultural identity.

Applications

The concept of cultural safety requires that the inequalities of power between groups and the within systems in society are taken into account when planning services and delivering care. Discrimination, racism, lack of equality of opportunity and stereotyping are issues that the concept assist in exploring.

Critical Overview

Polaschek (1998) has discussed the following:

 

Criticism about whether cultural safety has to do with attitudes and not behaviours of nurses.

There are ambiguities about the level at which cultural safety operates, that is whether it is focused at the individual level, or addresses issues mainly in relation to the collective identity of the minority ethnic group.

Confusion about the societal and personal dimension in its application

Does not address the societal dimension such as institutional racism

Limited methodological rigour

Culley (2000) has taken up some of these issues in relation to education and training for health care professionals. The critique of multiculturalism that has been put forward again reiterates the importance of not ignoring the economic, social and political factors that account for inequalities and less than culturally safe practice.

Further Reading

Huntington A, Gilmour J and O’Connell A (1996) Reforming the practice of nurses: decolonization or getting out from under Journal of Advanced Nursing 24 (2): 364-367.

Polaschek J (1998) Cultural safety: a new concept in nursing people of different ethnicities Journal of Advanced Nursing 27 (3): 452-457.

Ramsden I (1990) Cultural safety New Zealand Nursing Journal 83 (11): 18-19.

Ramsden I (1992) Teaching cultural safety New Zealand Nursing Journal 85 (5): 21-23.

Ramsden I (1993) Cultural safety in nursing education in Aotearoa (New Zealand) Nursing Praxis 8 (3): 4-10

Ramsden I and Spoonley P (1993) The cultural safety debate in nursing education in Aotearoa New Zealand Annual Review of Education 3: 161-174

Whanau Kawa Whakaruruhau (1991) Cultural safety Hui of the Whanau Kawa Whakaruruhau Apumoana Marae Rotura.

Wood P and Schwass M (1993) Cultural safety: a framework for changing attitudes Nursing Praxis 8 (1): 4-15.

Papadopoulos, Tilki and Taylor’s Model Of Cultural Competence

Papadopoulos, Tilki and Taylor (1998) have described an alternative model for the development of cultural competence. This model adopts key concepts from the model described earlier. The authors have reported on the application of the model which is currently being validated.

Conclusion

A number of concepts and models of transcultural care have been introduced. Whilst they engender considerable debate there are similarities in the conceptualisations and processes that lead to the development of cultural competence. These theories are not exhaustive as demonstrated in the literature relating to post colonialism theory ( e.g. Huntingon et al., 1996). The areas of knowledge and skills that are compatible for giving culturally congruent care may be explored in greater depth and breadth using the references and bibliography.