Reflection and Learning

Chapter 22: Theories Focused on Caring

Joanne R. Duffy

INTRODUCTION

Caring is an evolving human science ( Watson, 2012 ), a relational process ( Duffy, 2013 ), a “nurturing way to relate to a valued other” ( Swanson, 2016 ), and a way of being human ( Roach, 1987 ) that enhances personhood ( Boykin & Schoenhofer, 2001a ). According to  Duffy (2009 ,  2013 ), when practiced authentically, caring relationships lead to feeling “cared for,” an antecedent to optimal patient, nurse, and system outcomes. It has been the subject of much focus in nursing for the last 30 years, having formerly been described as the “moral ideal of nursing” ( Watson, 1985 , p. 29) and used by many to guide research, design measurement tools, lead, educate, and practice professional nursing. Some have contended that caring is the essence of nursing ( Leininger, 1984 ;  Watson, 1979 ,  1985 ), while others have asserted that caring is not solely the purview of nursing ( Boykin & Schoenhofer, 2015 ). Within the disciplinary interpretation of nursing, however, caring has been a central tenet not only for theorists, but also for students and nursing educators, and is deeply reflected in the American Nurses Association’s Code for Nurses With Interpretive Statements ( Boykin & Schoenhofer, 2015 ).  Duffy (2013)  contends that in the larger context of healthcare systems, when relationships among patients, families, nurses, and the entire healthcare team are of a caring nature, intermediate consequences occur, enabling forward progress or advancement.

Caring is a universal phenomenon that occurs in all societies and cultures ( Leininger, 1978 ,  1991 ). In fact,  Watson (2012)  views human caring as a process that is “connected to universal human struggles and human tasks” (p. x). It is manifested most noticeably in many families. For example, in the parent–child relationship, parents can be observed delivering physical, emotional, and educative actions that enhance safety, promote physical growth, and encourage emotional and cognitive development in their children. According to Mayerhoff (1970), caring is essential for the attainment of such human goals. Thus, caring relationships are transforming in that they facilitate human change, growth, and forward movement, adding significantly to the evolution of human life. In the parent–child relationship, parental caring actions are founded on a loving bond or connection between parent and child that assumes expanded potentials and future advancement in the children. In the patient–nurse relationship, caring actions are founded on disciplinary values and the use of relational strategies that provide the context for specific nursing interventions that ultimately engender advancement (in terms of improving health outcomes) in recipients.

In the context of health care, the vulnerability of persons of all ages and backgrounds creates an unusual dependency on healthcare providers (in this case, professional nurses) for behaviors, skills, and attitudes that help protect patients from harm, enable the delivery of high-quality services, preserve human dignity, instill confidence, enable participation in care processes and decisions, promote comfort, uphold hope, and advance general well-being. As patients and families try to negotiate the complex healthcare system and discover the meaning of their illness experience, professional nurses who cultivate and sustain caring relationships with them enable the positive emotion of feeling cared for ( Duffy, 2013 ). It is this optimistic emotion that often energizes patients and families to participate, learn, follow through, interact, and persist in meeting their health goals. Furthermore, nurses also benefit from caring relationships with patients and families in that such relationships provide the needed feedback about the important work they do, affording meaning that may, in fact, facilitate increased work satisfaction. Caring in this instance is not viewed as simply kind words or courteous acts, but rather a cohesive blending of disciplinary values, knowledge-based actions, skilled approaches, and affirmative attitudes that, taken together, guide the human-to-human patient–provider relationship. It is within this caring relationship that the uniqueness of the patient becomes known to the nurse and the meaning of the illness experience can be fully appreciated by the patient. Caring relationships, therefore, are the medium for healthcare decisions, interventions, and, ultimately, healing and health.

Since caring, along with its explicit knowledge, specialized skills, and attitudes, provides the conduit for healthcare delivery, health services grounded in caring are vital in the delivery of safe, high-quality services. Such services are the basis for ongoing interactions, accurate gathering and reporting of pertinent assessment data, establishment of relevant diagnoses, provision of effective interventions, and continuous improvement. Numerous frameworks have advanced the knowledge of how caring contributes to health and healing (for both the care provider and the care recipient). To better appreciate the phenomenon of caring, four theories are presented in this chapter: (1) the Nursing as Caring Theory, (2) the Theory of Human Caring Science, (3) the Theory of Caring and Healing, and (4) the Quality–Caring Model.

THE NURSING AS CARING THEORY (ANNE BOYKIN AND SAVINA SCHOENHOFER)

The Nursing as Caring Theory is considered a grand theory ( Boykin & Schoenhofer, 1993 ) and was heavily influenced by Mayerhoff’s (1970) and Gaut’s (1984) philosophical and theoretical discussions of caring,  Roach’s (1987)  five C’s (compassion, competence, confidence, conscience, and commitment), and  Paterson and Zderad’s (1988)  humanistic views of nursing. While considering the curricular infrastructure at Florida Atlantic University,  Boykin and Schoenhofer (1990 ,  1993 ) carefully analyzed existing work on caring using an organizing framework that helped identify common themes and unique stances among several caring scholars. Their resulting theory was intended to be a practice theory that honors the special nature of all persons as caring. The central assumption of the theory—that all persons are caring by virtue of their humanness—underlies its major concepts: personhood, the nursing situation, calls for nursing, and nursing as caring.

Personhood is “a process of living grounded in caring” (Schoenhofer & Boykin, 1993, p. 83) and is enhanced in “nurturing relationships with caring others” (p. 83). The nursing situation is the lived experience between a patient and a nurse that affects one’s personhood. Each nursing situation is unique and dynamic. In this situation, the nurse brings his or her caring self and comes to know the other person as a caring human. In this nursing situation, calls for nursing that request specific forms of caring can be heard by the nurse. As the nurse responds to these calls, the other’s unique experience and personal growth can be enhanced. In this theory, the focus of nursing is living caring and growing in caring. As such, caring is the body of knowledge from which professional nurses uniquely respond through specific expressions of caring nurturance ( Boykin & Schoenhofer, 2015 ). Finally, intentionality of the nurse, defined as “consistently choosing personhood as a way of life and the aim of nursing” (Schoenhofer, 2002, p. 39), generates commitment and fuels resulting nursing actions.

The major assumptions of the Nursing as Caring Theory are summarized here:

· Persons are caring by virtue of their humanness.

· Persons are caring from moment to moment.

· Persons are whole or complete in the moment.

· Personhood is a way of living grounded in caring.

· Personhood is enhanced through participating in nurturing relationships with caring others.

· Nursing is both a discipline and a profession. ( Boykin & Schoenhofer, 2015 )

Boykin and Schoenhofer (2015)  do not view caring as the unique province of nursing, but rather as a central value that focuses the profession.  Boykin, Schoenhofer, Smith, St. Jean, and Aleman’s (2003)  view of all persons as whole or complete just as they are does not incorporate the nursing process because it assumes some modification or change in persons is needed. Rather, these authors see nursing as “coming to know persons as caring” (Aleman, 2003, p. 224) and creating caring responses that advance personhood. They view nursing as both a discipline and a profession, with practice guided by the theory entailing intention, formal study, and reflection on experience. The use of storytelling of the nursing situation as a form of evidence of nursing as caring as well as other methodologies, such as interpretive phenomenology, have characterized their approach to the study of caring (Schoenhofer, 2002).

The Nursing as Caring Theory has been applied both in curricular design and in various implementation and research projects. For example,  Boykin, Schoenhofer, Smith, Jean, & Aleman (2003) , together with hospital-based investigators, reported the results of a project in which an 18-bed telemetry unit in a 350-bed for-profit hospital implemented the theory. Through the use of dialogue and specific practice strategies, patient and nurse satisfaction in this unit improved. A lesson learned through this project included that returning to fundamental nursing values created transformation. Another innovative application of the theory is detailed by Bulfin (2005). A partnership between a university (Florida Atlantic University) and a community hospital (Boca Raton Community Hospital) used the Nursing as Caring Theory to frame a professional practice model. Through four phases (education, understanding self, storytelling, and specific practice strategies), the model was evaluated using pre- and postintervention patient satisfaction measures. Postsatisfaction scores improved, although significance testing was not described. Qualitative approaches, such as patient letters, were also used in the evaluation of the project.

Another acute care unit project was evaluated after implementation of the Nursing as Caring Theory ( Dyess, Boykin, & Bulfin, 2013 ). In this participatory action project, nurses clearly expressed a commitment to caring. In a systems implementation of the model ( Pross, Hilton, Boykin, & Thomas, 2011 ), the process of transforming ways of relating was described as an important foundation for sustained change. Likewise, integrating caring theory into education and practice was explained through an academic service partnership where faculty members, staff, and students were exposed to and expected to practice caring together ( Dyess, Boykin, & Riggs, 2010 ). Thus, the Nursing as Caring Theory has been applied by nurses, nurse educators, and nurse leaders in a variety of settings. The authors’ most recent text, Health Care System Transformation for Nursing and Health Care Leaders: Implementing a Culture of Caring ( Boykin, Schoenhofer, & Valentine, 2014 ), challenges current health system practices and offers a person-centered, caring framework upon which to transform health care.

Although progress is being made in terms of showcasing Nursing as Caring practice and gathering evidence related to the value of the theory, more systematic evaluation of its benefits to both patients and nurses is warranted. Future research using multiple methods will aid in this effort. For example, specific qualitative methods might elicit richer descriptions of caring situations and their consequences from both nurses’ and patients’ perspectives. Descriptive studies examining relationships between patients who receive nursing care on the basis of the theory and nursing-sensitive outcomes are needed as well. Finally, developing and testing specific nursing interventions grounded in the theory in varying populations would provide further validation.

THE THEORY OF HUMAN CARING SCIENCE (JEAN WATSON)

From a strong foundation in educational counseling and psychology, Jean Watson first developed the Theory of Human Caring while designing an integrated baccalaureate curriculum in a large school of nursing ( Watson, 1979 ). Watson’s goal was to present nursing as a distinct entity, a profession, a discipline and science in its own right, separate from, but complementary to, medicine.

The Theory of Human Caring was more formally articulated in 1985, when Watson authored the book Nursing: Human Science and Human Care. In this text, Watson elaborated on the caring occasion, the transpersonal nature of caring, the 10 carative factors, phenomenal fields, the influence of time (past, present, and future), and human growth—all of which are major concepts in the theory. In this theory, all persons are considered to be unique and to have a life history, social norms, and experiences that generate a subjective reality or phenomenal field. A caring occasion occurs whenever the nurse and another person come together with their unique subjective realities, seeking to connect to each other in the present. During this moment, with the carative factors authentically present, the interaction is considered to be transpersonal (unified body, mind, and spirit; collective consciousness; one with the universe). This transpersonal caring relationship conveys deep connections to the spirit of another that transcend time, space, and physicality, ultimately affecting the consciousness field as a whole, generating endless possibilities, facilitating human growth, learning, and development. Thus, both the care provider and the one being cared for evolve from the encounter ( Watson, 1985 ).

Later, more spiritual and energy-related aspects of caring were incorporated in the theory, with heightened awareness of the nurse’s intentionality and own personal evolution ( Watson, 1999 ). Likewise, a more sacred dimension of nursing’s work with a philosophical–ethical–moral dimension was presented in  Watson’s (2006)  book Caring Science as Sacred Science. Moreover, Watson has showcased her evolving views on caring resulting from personal experiences, fresh perspectives on the convergence of transpersonal caring and unitary science theories ( Watson & Smith, 2002 ), and metaphysical orientations. In doing so, Watson has suggested that caring is a foundational framework of caring–healing professions and laid the groundwork for a revised edition of her first book, Nursing: The Philosophy and Science of Caring, Revised Edition ( Watson, 2008 ). In this revised text, Watson first presents caritas nursing as the more mature perspective of nursing and transitioned the 10 carative factors to 10 caritas processes.

In 2012, Watson authored Human Caring Science: A Theory of Nursing. This text includes a more expanded worldview of universal cosmology (human connectedness) that affirms human caring science as the “disciplinary foundation for the nursing profession” ( Watson, 2012 , p. xi). It showcases a more unitary-transformative grand theory of evolving consciousness that includes a global worldview of connectedness to all. In this revision Watson clarifies the 10 caritas processes.

Caritas comes from the Greek word meaning “to cherish”; it connotes something that is very precious. Watson’s evolving path to this way of thinking highlights the connections between caring, spirituality, and human love. The connectedness of caring and love allows for deeper transpersonal and healing relationships, enriching for both the patient and the nurse ( Watson, 2015 ). Working within this expanded caring consciousness allows deeper connections between the human condition and universal love. Related to this evolving theoretical stance on caring,  Watson (2015)  posits that this direction becomes a “converging paradigm for nursing’s future” (p. 325).

A major concept in this evolved theory is the caritas field, which is described as a conscious healing presence founded on caring and love that profoundly changes the relational experience for nurses and patients alike ( Watson, 2012 ). Thus, the more evolved clinical caritas processes reflect spirituality and love for others.

The evolution of Watson’s Theory of Human Caring Science is a valuable example of the practical side of theory development. Changing worldviews, new insights and experiences, and emerging evidence provided the background for new or revised concepts and relationships over the course of the theory’s development. In an effort to expand the study of caring, Watson collated and critiqued 22 instruments for assessing and measuring the concept ( Watson, 2003 ,  2009 ) and participated in the development of the Watson Caritas Patient Score ( Brewer & Watson, 2015 ). Many of these instruments have been subsequently used to evaluate how nurses and patients perceive caring, how caring relates to other health concepts (e.g., patient experiences), nurses’ perspectives of manager caring, caring in nursing education, and multisite benchmarking studies.

Numerous health systems have incorporated the theory into their professional practice models as they prepare for Magnet recognition. For example, using Watson’s model as the foundation, some health systems have integrated the theory into various patient care delivery systems ( Watson & Foster, 2003 ), while others have demonstrated their commitment to the theory through documentation systems ( Rosenberg, 2006 ), creating healing spaces for nurse time-outs, instilling centering practices into nursing workflow, and performing caring-based rounds ( Watson, 2015 ). Furthermore, schools of nursing have used the model for curricular planning, teaching–learning strategies, and course content ( Beck, 2001 ;  Cook & Cullen, 2003 ), while others have studied caring within a broader educational context (Sitzman, 2015,  2016 ). Some have tested interventions on the basis of the caring theory or used the theory as the study’s conceptual foundation ( Arslan-Özkan, Okumus¸, & Buldukoǧlu, 2014 ; Erci, 2003;  Smith, Kemp, Hemphill, & Vojir, 2002 ;  Suliman, Welman, Thomas, & Omer, 2009 ), albeit the Theory of Human Caring Science as it was originally conceptualized. According to  Watson (2006) , research in caring embraces inquiries that are both reflective and subjective, as well as objective–empirical.

Watson’s Theory of Human Caring Science has played a major role in helping professional nurses honor their unique and distinct values and has influenced the scholarship of countless others, including the theorists reviewed in this chapter.  Boyd (2008)  contended that the theory is especially useful for those with mental illness (p. 71); however,  Frisch and Frisch (2011)  cautioned that some patients (on the basis of their illness) may not easily enter this form of mutuality. The theory, with its current “caritas consciousness” concept, represents an authenticity of person that transcends the biomedical and bureaucratic nature of most health systems, sometimes presenting practical challenges for nurses’ work in the acute care environments. That being said, many U.S. acute care hospitals have embraced Watson’s theory as a component of their professional practice models!

In 2007, Watson established the Watson Caring Science Institute, a nonprofit that was recently transitioned to the University of Colorado as the Watson Caring Science Center ( University of Colorado, n.d. ). In this newly developed center, human caring knowledge, ethics, and clinical practice are advanced through educational programs (including a focused caring science PhD track), partnerships, research, and international collaboration. Watson has made extraordinary contributions to the discipline of nursing over the last four decades and continues her work guiding health professionals in this transforming and evolving human caring science. Ongoing evaluation of the theory in terms of its measurement, authentic application, and potential value to patients, families, health professionals, and the larger health system are warranted.

THE THEORY OF CARING AND HEALING (KRISTEN SWANSON)

Kristen Swanson’s middle-range theory of caring was developed through inductive methods while studying three groups of women. In this theory, caring is defined as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” ( Swanson, 1991 , p. 162). Using data from women who miscarried, neonatal intensive care unit caregivers (both parents and professionals), and at-risk mothers, five caring processes—maintaining belief, knowing, being with, doing for, and enabling—were described. Swanson maintains that while caring is not unique to nursing, it informs those relationships central to nursing.

Maintaining belief demonstrates faith in the capacity of others and provides nurses with the foundation for the commitment to serve (both society in general and individual patients). Knowing refers to understanding how others’ lives have meaning; it avoids assumptions and focuses on the one being cared for in order to better comprehend the client’s lived reality. Being with incorporates emotional presence. It conveys to clients that they matter and assures them that their reality is appreciated. It includes physical presence as well as ongoing availability. Doing for involves nursing behaviors that preserve another’s wholeness. It includes comforting, anticipating, protecting, maintaining confidentiality and dignity, interpersonal listening, teaching, coaching, referring, supporting and guiding, providing feedback, and validating the other’s reality. Enabling implies facilitating another’s capacity through providing information, being present and sharing, and assisting behaviors.

In 1993, Swanson structured these processes such that they were ordered to influence the intended outcome—namely, client well-being. Later, Swanson completed a meta-analysis of the state of caring research. In this review, although 130 empirical studies were identified, 18 of those provided evidence of the consequences of caring and noncaring both for nurses and for patients. More importantly, she highlighted the clear significance of caring knowledge to current nursing practice and identified its implications for the nursing practice of the future ( Swanson, 1999 ).

Using knowledge of caring and the inductively developed theory of caring, Swanson set out on a program of research that focused on responses to miscarriage and interventions to promote healing subsequent to early pregnancy loss. After completion of the meta-analysis, Swanson tested an intervention in a study of 242 women who had miscarried ( Swanson, 1999 ). Using a caring-based counseling intervention, she conducted a randomized trial with a Solomon four-group design to test the intervention on several outcomes. Findings revealed that the caring intervention had a positive effect on disturbed mood, anger, and level of depression. In addition, a majority of the patients reported satisfaction with the caring intervention. Monitoring caring as delivered in the miscarriage study involved both qualitative and quantitative (including the development of the Caring Professional Scale [ Swanson, 2002 ]) methods. Items on this instrument were derived from the five caring processes, and preliminary psychometric properties were evaluated.

A follow-up intervention-focused study using 341 couples compared three types of couples-focused interventions to no treatment, with the goal being to identify strategies to help men and women resolve depression and grief during the first year after a miscarriage ( Swanson, Chen, Graham, Wojnar, & Petras, 2009 ). Through this rigorous experimental design, findings revealed that overall, while participation in any of the three intervention arms accelerated women’s grief resolution, their resolution of depression was best enhanced by the three nurse-led and caring-based counseling sessions. Women who received three nurse counseling sessions were three to eight times more likely to see a faster decline in their symptoms of depression than were women who received similar but limited help or no such help.

Despite the limitations imposed by the predominantly White and heterosexual samples, Swanson was able to demonstrate the benefits of caring interventions in terms of decreased depression, improved mood, decreased anger, and intervention satisfaction for persons who had experienced a pregnancy loss. Swanson and her students followed up with a conceptual model of miscarriage (Wojner, Swanson, & Adolfsson, 2011), a secondary analysis ( Huffman, Schwartz, & Swanson, 2015 ), and development of the meaning of miscarriage scale ( Huffman, Swanson, & Lynn, 2014 ). Further and extended evidence of her work is found in the empirical literature related to parents’ experiences with children undergoing congenital heart surgery ( Wei Roscigno, Hanson, & Swanson, 2015 ;  Wei et al., 2016 ).

Recently, Swanson supplemented her theory by presenting a connection between caring and healing ( Swanson, 2015 ), maintaining that “when a provider takes the time to know, be with, do, enable, and maintain belief in the other, the recipient feels a sense of wholeness” (p. 530). While some would classify Swanson’s Theory of Caring and Healing as a practice or situational theory (since it was developed as an outcome of studying a limited patient population), others have used it beyond pregnancy loss to guide professional practice and curricula. For example, the theory was implemented in a large health system in the Southeast, and improvements were noted in patient and nurse satisfaction levels, patient pain, and response to call lights (Tonges & Ray, 2011). Swanson continues to work with students and faculty members in her role as Dean at the University of Seattle and with health systems as they implement cultures of caring. Swanson’s persistence in observing, applying, validating, and refining the Caring and Healing Theory provides an exemplary model of the relationship between theory and research.

THE QUALITY–CARING MODEL© (JOANNE R. DUFFY)

Developed to fill a perceived practice and research void in the late 1980s, the Quality–Caring Model was initially informed by Duffy’s involvement in quality improvement and clinical experiences with acute hospitalized patients who, when asked about their dissatisfaction with care, verbalized, “no one cares.” In these encounters with acutely ill hospitalized adults, Duffy observed that the fundamental patient–nurse caring relationship (a deeply held disciplinary value) was frequently marginalized from the often routine task-oriented nature of nursing work. This incongruity between professional values and work behaviors was considered serious because, as Duffy began to investigate, nurses linked it to work dissatisfaction and patients linked it to poorer health outcomes, both important indicators of healthcare quality.

Corroborated by the consequences of noncaring as reported in the literature ( Reiman, 1986 ), Duffy first set out to narrow the gap between disciplinary values and behaviors and current professional practice by studying the linkage between nurse caring relationships and quality, with the ultimate intention of demonstrating how nurse caring contributes to improved patient outcomes. After developing the Caring Assessment Tool (CAT) to measure patients’ perceptions of caring, Duffy used this instrument to conduct the original study that significantly associated nurse caring to patient satisfaction ( 1990 ,  1992 ). The CAT was later adapted to assess student nurses’ perceptions of faculty caring (via the CAT-edu) and staff nurses’ perceptions of nurse managers’ caring (via the CAT-adm); findings demonstrated a positive relationship between nurse manager caring behaviors and staff nurse satisfaction ( Duffy, 1993 ,  2008 ). Continued development and evaluation of the CAT instruments are ongoing. For example, an exploratory factor analysis of the CAT in 2007 and again in 2010 pointed to a one-factor solution and assisted with item reduction ( Duffy, Brewer, & Weaver, 2010 ;  Duffy, Hoskins, & Seifert, 2007 ). A factor analysis of the CAT-adm was recently completed, and new instruments, namely, patient perceptions of team caring, the caring intention scale, and the caring capacity scale, are presently under development or evaluation. Graduate students, individual researchers, nursing faculty members, and health systems throughout the world routinely use these instruments for assessment of caring relationships in varying contexts.

With valid and reliable instruments now available, Duffy continued her program of research but was struck by the lack of attention in the literature to the quality–caring link. In collaboration with Lois Hoskins, she developed the Quality–Caring Model in 2003. The model is considered middle range and deductive, drawing heavily on the works of  Watson (1979 ,  1985 ,  1999 );  King (1981) ;  Donabedian (1966) ;  Mitchell, Ferketich, and Jennings (1998) ; and  Irvine, Sidani, and Hall (1998) . It supports the connections between nurse caring and quality health outcomes, “exposing the hidden value of nursing” ( Duffy & Hoskins, 2003 , p. 78)

Originally, the model depicted a linear process, but due to the complex, evolving, and interdependent nature of health systems, Duffy revised the model in 2009 ( Duffy, 2009 ) and again in 2013 ( Duffy, 2013 ), incorporating aspects of complexity theory ( Holland, 1992 ,  1999 ). Assumptions and propositions of the model are available in these texts and in the later revision (2013). Some components of the model are reworded and presented in the larger context of health systems. The revised model identifies four evolving complex relationships that humans experience as they live and encounter the health system: relationships with self, community, patients and families, and other health professionals. In this way of thinking, relationships are central to human progress, including the improvement of health; when enacted in caring ways, relationships naturally lead to advancement or forward movement, even in challenging conditions. This overarching concept, humans in relationships, refers to the multidimensional relational nature of humans as they exist in society. The relationship with self includes embracing the thoughts, feelings, and experiences one holds, especially as they relate to nursing work. Regular attention to such emotions allows for accessing the inner wisdom drawn from practice and using this guidance to know and value the self as a prerequisite for engaging in caring interactions with others. Caring relationships within larger communities (such as neighborhoods or practice groups) raises the capacity of citizens and employees to address challenges and contribute to the welfare and development of members, including nurses themselves. When nurses are involved professionally in their broader communities, not only do communities benefit greatly, but nurses themselves express added meaning from their work.

Relationship-centered professional encounters include those independent relationships that nurses enjoy with patients and families as well as the interdependent collaborative relationships they establish with members of the entire healthcare team. During healthcare encounters, nurses’ relationships with patients and families are considered to be primary and independent, delivered autonomously, and for which nurses are solely held accountable. Using caring behaviors, nurses cultivate mutually reciprocal human caring interactions with patients and families that inform future interactions and contribute to health outcomes. It is also theorized that caring relationships with patients and families benefit nurses in terms of the latter’s professional growth, ongoing motivation, engagement, and work satisfaction. Collaborative relationships, in contrast, are multidisciplinary in nature and include those activities and responsibilities that nurses share with other members of the healthcare team. Collaborative relationships are enhanced when mutual caring relationships exist among the various professionals and are focused on the best interests of patients and their families. Such relationships are considered essential to the revised model, given that high-quality outcomes are enhanced when multiple healthcare providers work together as cohesive teams ( Brandt, Lutfiyya, King, & Chioreso, 2014 ). In this way, continuity is enhanced and patients and families, as well as team members, feel cared for.

According to Duffy, caring relationships are grounded in specific behaviors and attitudes labeled caring behaviors. The caring behaviors—namely, mutual problem solving, attentive reassurance, human respect, encouraging manner, healing environment, appreciation of unique meanings, affiliation needs, and basic human needs—are fundamental to the concept of relationship-centered professional encounters because they are the visible, perceptible, quantifiable evidence of caring interactions that recipients can recognize, identify, and distinguish. Caring behaviors require specialized knowledge, attitudes, and behaviors that are directed toward health and healing. The behaviors, when applied expertly and over time, result in the recipient “feeling cared for” ( Duffy, 2009 , p. 196).

“Feeling cared for” is an important, positive emotion that is associated with contentment, met needs, acceptance, and validation ( Duffy & Hoskins, 2003 ). As individuals perceive being cared for by their healthcare providers, they experience ease, understanding and connection, enhanced self-confidence, an awareness of being valued, comfort, and an optimistic outlook. In this affirmative state, “a sense of security develops that makes it easier to learn new things, change behaviors, take risks, and follow guidelines” ( Duffy & Hoskins, 2003 , p. 83). The feeling of being cared for is considered an antecedent to advancement, particularly related to nursing-sensitive patient outcomes such as increased knowledge, safety, decreased self-reported pain, decreased anxiety, maintenance of human dignity, increased participation (engagement), and positive experiences of care.

Self-advancing systems, defined as dynamic positive progress that enhances a system’s well-being ( Duffy, 2009 , p. 196), is closely related to quality or value because this concept is dynamic and indicates some benefit or advantage. As caring relationships are cultivated with others over time, small changes or differences begin to emerge that can grow exponentially into longer-term positive outcomes that transform. Self-advancement is manifested individually, among groups, or even in large health systems as behavior changes, improvements, higher levels of health, maturation, learning, gains, or expansions.

Consideration of quality health outcomes as a consequence of the unique caring relationships central to daily nursing practice represents a practical, contemporary approach that showcases nursing’s contribution and provides a useful way to generate evidence ofits value. The model emphasizes the centrality of caring relationships, shifting the primary focus of professional nursing work to the more relational aspects of the practice.

The Quality–Caring Model has been adopted as a disciplinary framework for numerous U.S. health systems’ professional practice models; used to ground experiential learning activities, including a graduate-level relationship-centered caring course and a relationship-centered leadership course; and used to provide the theoretical foundation for research projects, dissertations, scholarly projects, and theses. Additionally, it was used in the following efforts:

· To develop and evaluate the effect of a caring-based intervention on heart failure patients’ quality of life and 30-day readmission rates ( Duffy, Hoskins, & Dudley-Brown, 2005 )

· To assess caring competencies of graduating seniors ( Duffy et al., 2005 )

· To evaluate its influence on patient, nurse, and system outcomes in two national demonstration projects conducted by the Health Resources and Services Administration (Relationship-Centered Caring in Acute Care, and Advancing Safety and Quality in Vulnerable Acute Care Patients Through Interprofessional Collaborative Practice)

· To generate valid and reliable measurements (previously cited)

· To pilot-test hospitalized older adults’ electronic participation in assessing patient-centeredness ( Duffy, 2013 )

· To create the enabling conditions for an academic–service partnership that increased research productivity at year 1 ( Duffy, Culp, Sand-Jecklin, Stroupe, & Lucke-Wold, 2015a ;  Duffy, Culp, Sand-Jecklin, Stroupe, & Yarberry, 2015b )

· To assess the feasibility of measuring patient perceptions of caring in a multisite collaboration study ( Duffy & Brewer, 2011 )

In the context of advanced nursing practice, the Quality–Caring Model accounts for the complexity of healthcare systems and honors the vital role that caring relationships play in advancing patient-centeredness and creating value in health systems. These characteristics offer a strong basis for practice that can assist in the development of relevant organizational processes and procedures. The doctor of nursing practice graduate may be involved in translating model concepts into clinical practice, use the model to guide clinical decision making, generate and evaluate evidence of the model’s value (in terms of patient outcomes), implement clinical innovations (derived from the model) that change practice, and work with others in caring ways (use the caring behaviors) to alter individual and team behavior or impact organizational-level change. For example, advanced practice nurses may create an innovative method for improving patient engagement (drawing on model concepts) that could be evaluated for its success in reducing 30-day readmission rates and improving adherence.

The Quality–Caring Model, on the basis of its unique concepts and propositions, could also be used in advanced practice as the foundation for research or evaluation projects. For example, using the CAT ( Duffy, Brewer, & Weaver, 2010 ), advanced practice nurses might correlate its scores with nursing-sensitive outcome indicators in their institutions, or the longitudinal success of Quality–Caring-based professional practice models, even benchmarking their organizations with others to improve performance. Considering that the CAT was piloted successfully with hospitalized older adults ( Duffy, Kooken, Wolverton, & Weaver, 2012 ), using this method to assess caring relationships in real time might accelerate more actionable patient-centered practice changes. In fact, this measure could easily be incorporated into user-friendly information systems to promote rapid improvement activities.

In the direct care role, a nurse with advanced education may use the Quality–Caring Model to role-model self-caring; complete systematic and holistic assessments of individuals, communities, or systems; cultivate and sustain caring relationships with patients, families, and health team members; help problem solve with patients and families; make clinical decisions on the basis of evidence; and advance professional nursing practice. The model provides a guide for self-caring that includes remaining more aware (or mindful) as a particularly healthy way to work that deepens a nurse’s ability to be present for patients, families, and team members. In fact, health professionals need to acknowledge and allow themselves to experience the feelings associated with their work, including suffering. Duffy asserts that this form of self-caring may be a necessary antecedent to caring for others. When role-modeled by advanced practice nurses, others may begin to incorporate such practices of their own.

Despite the success of the Quality–Caring Model as a foundation for professional practice, and on the basis of national consultations, Duffy has recently observed varying levels of “uptake” of professional practice models, which recently led to the authorship of Professional Practice Models in Nursing: Successful Health System Integration  (2016) . In this text, Duffy asserts that the benefits of such models may not yet be realized due to limited system integration. The text emphasizes a systematic process of system integration and dissemination so that the full impact of professional practice models (and nursing’s contribution to health care) can be more fully appreciated.

Duffy continues her research on caring relationships, most recently designing an intervention to improve the delivery of patient-centered care in hospitalized older adults through real-time data and group reflection. Duffy’s consultation work, particularly at the executive and board levels in health systems throughout the United States, continues to advance patient-centeredness and inspire quality–caring work cultures. More research on the benefits of the Quality–Caring Model is needed in diverse populations with larger multisite samples.

SUMMARY

No one universal theoretical approach to caring in nursing exists. In fact, two of the theories presented in this chapter use a philosophical/ethical approach (Boykin and Schoenhofer; Watson), one was developed inductively (Swanson), and one was developed deductively (Duffy). Each of these theories incorporates unique worldviews and concepts, yet all share commonalities to some extent. Specifically, the relational nature of caring, patient well-being or healing, nurses’ ability to connect with others, and a disciplinary focus for nursing are features found in all of the theories reviewed in this chapter.

Professional practice models founded on caring theories are now incorporated on a widespread basis, albeit in varying degrees, and healthcare professionals at all levels are being exposed to them. Advanced practice nurses are now in positions where they can evaluate the consequences of these disciplinary perspectives (in terms of creating value for patients, families, and health systems). Assessments of barriers and facilitators to their implementation, as well as cost–benefit analysis, and evaluation of specific approaches that can accelerate, change, improve, and sustain the use of caring theories are also needed. Practicing nurses, educators, other health professionals, and those in leadership and policy positions are beginning to appreciate the relational aspect of health care and are demanding approaches that incorporate caring relationships to advance high-value health outcomes. Advanced practice nurses are key to crafting this future!

Chapter 23: Models and Theories Focused on Culture

Larry Purnell

INTRODUCTION

This chapter provides an overview of selected cultural models and theories commonly used in nursing practice, education, administration, and research. Although the main focus of this chapter is the Purnell model for cultural competence, other models and theories are briefly described. Some of these cultural models are not intended for research, but they have value when used in education, practice, and administration. Advanced practice nurses (APNs) have preparation in all of these areas and use cultural models, theories, and approaches accordingly. Exemplars are provided for cultural models and theories that have been used in nursing and healthcare research.

OVERVIEW OF CULTURAL MODELS AND THEORIES

Many differing definitions and meanings of theory exist, both within and outside of the nursing profession. Theory is not reality; it is abstract and complex and must be so that research can be generated to guide practice. According to  Fawcett and DeSanto-Madeya (2012) , theory is one or more relatively concrete and abstract concepts that are derived from a conceptual model, the propositions that describe those concepts, and the propositions that state specific relationships between two or more of the concepts. A theory can be grand or middle range, depending on its level and scope. Moreover, a theory must have (1) a purpose; (2) concepts that are systematically linked and defined and that interconnect the ideas of the theory; and (3) explicit and implicit assumptions. Nursing theory, of which there are four levels—metatheory, grand theory, middle-range theory, and practice theory—comprises either one or a combination of the following four types:

1. Descriptive theory identifies properties and components of a discipline, identifies meaning and observations, and describes which elements exist.

2. Explanatory theory identifies how the properties and components relate to one another and accounts for the functions of the discipline.

3. Predictive theory conjectures the relationships between the components of a phenomenon and predicts under which conditions the phenomena will occur.

4. Prescriptive theory addresses therapeutics and consequences of interventions ( Fawcett & DeSanto-Madeya, 2012 ).

Because there is no agreement in the scientific community regarding the definitions of a conceptual model, conceptual framework, theoretical model, and theoretical framework, these terms are used interchangeably in this chapter. A conceptual model can be represented by words, diagrams, or pictures. Each theoretical/conceptual model or theory is evaluated on the basis of its clarity, simplicity, generality, empirical precision, and derivable consequences. Clarity is concerned with the logical and adequate arrangements of constructs and concepts. Simplicity is concerned with the number and complexity of concepts in the model. Generality is concerned with how the model or theory can be useful to APNs. Empirical precision is concerned with the ability of the model or theory to hold up over time. Derivable consequences refer to how practical and useful the theory or model is in relation to achieving important health outcomes ( Purnell, 2000 ; StudyBlue, 2016).

Given the increasing complexity of culture in the United States, faculty in continuing education and schools of nursing are frequently looking for resources for teaching culture along with evidence-based materials. A few resources are the Jeffreys textbook Teaching Cultural Competence in Nursing and Health Care: Inquiry, Action, and Innovation  (2010) ; the American Association of Colleges of Nursing’s (AACN’s) Toolkit for Cultural Competence in Master’s and Doctoral Nursing Education (2011); and the Purnell textbook websites. In addition, the American Academy of Nursing, along with members of the Transcultural Nursing Society, established a task force to develop Guidelines for Implementing Culturally Competent Nursing Care ( Douglas et al., 2014 ).

The content of this chapter is not focused on the numerous simplistic approaches that use acronyms as a guide for cultural assessment. Although some of these simplistic techniques can be used for collecting initial interview data, they do not work well with all ethnic and cultural groups, nor are they comprehensive. Two examples of acronymic approaches are BATHE and LEARN. The LEARN approach includes the following guidelines: Listen to your patients from their perspectives; Explain your concerns and your reasons for asking for personal information; Acknowledge your patients’ concerns; Recommend a course of action; and Negotiate a plan of care that considers cultural norms and personal lifestyles ( Berlin & Fowkes, 1983 ). The BATHE acronym stands for Background information, Affect [sic] the problem has on the patient, Trouble the problem causes for the patient, Handling of the problem by the patient, and Empathy conveyed by the healthcare provider ( U.S. Department of Health and Human Services, n.d. ).

ESSENTIAL TERMINOLOGY RELATED TO CULTURE

Many different definitions exist for culturally related terms. The definitions used in this chapter are adapted from the American Nurses Association’s Nursing: Scope and Standards of Practice, Standard 8  (2015) ; the Expert Panel on Cultural Competence of the American Academy of Nursing ( Giger et al., 2007 ); and Guidelines for Implementing Culturally Competent Nursing Care ( Douglas et al., 2014 ). These definitions were developed in an attempt to reach a standard worldwide consensus and thereby decrease confusion related to the inconsistent definitions of culture-related terms. The confusion arises because a variety of terms and definitions that describe cultural awareness, cultural sensitivity, and cultural competence are used interchangeably in the literature. They have been presented in several international conferences. A few of these definitions are listed here:

· Cultural awareness is being knowledgeable about one’s own thoughts, feelings, and sensations and having an appreciation of diversity in terms of the objective (material) culture, such as arts, clothing, foods, and other external signs of diversity.

· Cultural sensitivity is experienced when neutral language, both verbal and nonverbal, is used in a way that reflects sensitivity and appreciation for the diversity of another. Cultural sensitivity is conveyed through words, phrases, and categorizations that are intentionally avoided, especially when referring to an individual who may interpret them as impolite or offensive.

· Cultural imposition intrusively applies the majority cultural view to individuals and families. For example, prescribing a special diet without regard to a person’s culture and limiting visitors to immediate family border on cultural imposition. In this context, healthcare providers must be careful in expressing their cultural values too strongly until cultural issues are more fully understood.

· Cultural imperialism is the practice of extending the policies and procedure of one organization—usually the dominant one—to disenfranchised and minority groups. Proponents of cultural imperialism appeal to universal human rights values and standards. Opponents posit that universal standards are a guise under which the dominant culture seeks to destroy or eradicate traditional cultures by setting worldwide public policy.

· Cultural relativism is the belief that behaviors and practices of people should be judged only in the context of their cultural system. Proponents argue that issues such as abortion, euthanasia, female circumcision, and physical punishment in childrearing should be accepted as cultural values without judgment from the outside world. Opponents argue that cultural relativism may undermine condemnation of human rights violations and that family violence cannot be justified or excused on a cultural basis.

· Ethnocentrism is a universal tendency to believe that one’s own worldview is superior to another’s worldview. It is often experienced in the healthcare arena, in particular when the healthcare provider’s own culture or ethnic group is considered superior to another.

· A stereotype is a simplified and standardized conception, opinion, or belief about a person or group. A healthcare provider who fails to recognize individuality within a group is jumping to conclusions about the individual or family.

· Generalization begins with assumptions about the individual or family within an ethnocultural group but leads to further information seeking about the individual or family.

· Race is a viable term that relates to biology but also has sociological implications. Members of a particular race share distinguishing physical features such as skin color, bone structure, or blood group. Race as a social construct can limit or increase opportunities, depending on the setting.

· Racism refers to feelings of prejudice against persons of another race or group of people. Racist practices lead to interpersonal tension, isolation, discrimination, and overt anger.

· An ethnic group is a group of people whose members have different experiences and backgrounds from the dominant culture in terms of status, background, residence, religion, education, or other factors that functionally unify the group and act collectively in their effects.

· Stigma is a characteristic or trait that puts a strain on or reproaches a group’s or individual’s reputation or being.

· Culture is a learned, patterned behavioral response acquired over time that includes implicit versus explicit beliefs, attitudes, values, customs, norms, taboos, arts, and life ways accepted by a community of individuals. Culture is primarily learned and transmitted through the family and other social organizations, is shared by the majority of the group, includes an individualized worldview, guides decision making, and influences self-worth and self-esteem.

CULTURAL SELF-AWARENESS

Culture has a powerful unconscious impact on both patients and health professionals ( Purnell, 2013 ). Each clinical encounter with an APN adds a unique dimension to the complexity of providing culturally competent care. The way APNs perceive themselves as competent is often reflected in the way they communicate with clients. Thus, it is essential for APNs to take time to think about themselves, their behaviors, and their communication styles in relation to their perceptions of different cultures.

Before addressing the multicultural backgrounds and unique individual perspectives of their patients, APNs must first address their own personal and professional knowledge, values, beliefs, ethics, and life experiences in a manner that optimizes assessment of and interactions with clients who come from cultures different from those of the APN. Self-awareness in cultural competence is a deliberate and conscious cognitive and emotional process of getting to know oneself; one’s own personality, values, beliefs, professional knowledge, standards, and ethics; and the effects of these factors on the various roles one plays when interacting with individuals who are different from oneself. The ability to understand oneself sets the stage for integrating new knowledge related to cultural differences into the APN’s knowledge base and perceptions of health interventions ( Purnell, 2013 ).

SELECTED CULTURAL MODELS AND THEORIES

The limited space available here does not permit an exhaustive description of the numerous models and theories centered on culture. A brief description of the models most commonly used in practice, education, administration, and research follows. A more thorough description of the Purnell model for cultural competence is described in detail in the next section.

The Campinha-Bacote Model

The Campinha-Bacote model is a practice model that was originally developed in 1991. It has been revised several times since then. It focuses on the process of cultural competence in the delivery of healthcare services. This model, which is currently referred to as a volcano model (Campinha-Bacote, 2015), is used primarily in practice and education; it does not have an accompanying organizational framework. Included is a Biblically based model of Cultural Competence in the Provision of Health Care Services. A literature review did not reveal any research using the Campinha-Bacote model.

According to Campinha-Bacote (2015), individuals, as well as organizations and institutions, begin the journey to cultural competence by first demonstrating an intrinsic motivation to engage in the process of cultural competence. The five concepts in this model are described as follows:

1. Cultural awareness: The nurse becomes sensitive to the values, beliefs, lifestyle, and practices of the patient, and explores his or her own values, biases, and prejudices. Unless nurses go through this process in a conscious, deliberate, and reflective manner, there is always the risk of nurses imposing their own cultural values during the encounter.

2. Cultural knowledge: Cultural knowledge is the process through which nurses find out more about other cultures and the different worldviews held by people from other cultures. Understanding the values, beliefs, practices, and problem-solving strategies of culturally/ethnically diverse groups enables nurses to gain confidence in their cultural encounters.

3. Cultural skill: Cultural skill as a process is concerned with carrying out a cultural assessment. On the basis of cultural knowledge, nurses are able to conduct an assessment in partnership with patients.

4. Cultural encounter: Cultural encounter is the process that provides the primary and experiential exposure to cross-cultural interactions with people who are culturally/ethnically diverse from oneself.

5. Cultural desire: Cultural desire is a self-motivational aspect of individuals and organizations that encourages them to want to engage in the process of cultural competence.

Campinha-Bacote has emphasized that a cultural assessment is needed for every client because every person has values, beliefs, and practices that must be considered when the nurse is delivering healthcare services. Therefore, cultural assessments should not be limited to specific ethnic groups, but rather conducted with each patient ( Campinha-Bacote, 2015 ). Although this model does not have an assessment guide, it does meet the criteria for simplicity, clarity, generality, and empirical precision. A graphical display and additional information about the Campinha-Bacote model can be found at the Transcultural C.A.R.E. Associates website ( http://transculturalcare.net/a-biblically-based-model-of-cultural-competence/ ).

The Giger and Davidhizar Model

The transcultural assessment model developed by Giger and Davidhizar ( Giger, 2012 ) focuses on assessment and intervention from a transcultural nursing perspective. In this model, each person is seen as a unique cultural being influenced by culture, ethnicity, and religion. The model has been used in education, practice, administration, and research. The six areas of human diversity and variation in the model are described as follows:

1. Communication: The factors that influence communication are universal, but they vary among culture-specific groups in terms of language spoken, voice quality, pronunciation, and use of nonverbal communication, including silence.

2. Space: People perceive physical and personal space through their biological senses. The cultural aspect of space reflects the degree of comfort one feels in proximity to others, in body movement, and in perception of personal, intimate, and public space.

3. Social orientation: Components of social organization vary by culture, with differences observed in what constitutes one’s understanding of culture, race, ethnicity, family role and function, work, leisure, church, and friends in day-to-day life.

4. Time: Time is perceived, measured, and valued differently across cultures. Time is conceptualized in reference to the life span in terms of growth and development, perception of time in relation to duration of events, and time as an external entity outside of an individual’s control.

5. Environmental control: Environment is more than just the place where one lives; it involves systems and processes that influence, and are influenced by, individuals and groups. Culture influences the understanding of how individuals and groups shape their environments and how environments constrain or enable individual health behaviors.

6. Biological variations: Biological variations include dimensions such as body structure, body weight, skin color, and internal biological mechanisms such as genetic and enzymatic predisposition to certain diseases, drug interactions, and metabolism.

The Giger and Davidhizar model proposes a framework that facilitates assessment of the individual. A set of questions is constructed under each of the six areas to generate information useful in planning care that is congruent with an individual’s cultural orientation and needs. The model also represents a learning tool that can be used to explore issues about any of the six broad areas in practice. For nurses, flexibility and the involvement of the patient as an equal partner in the cultural assessment of needs are encouraged. The Giger and Davidhizar model can be used to elicit general explanatory models of health and illness. It meets the criteria for clarity, simplicity, generality, empirical precision, and derivable consequences ( Giger, 2012 ).

The Papadopoulos, Tilki, and Taylor Model

The Papadopoulos, Tilki, and Taylor model—which focuses on the process of cultural competence in the delivery of healthcare services—was first published in 1998 and is used in education, practice, and administration. This model does not have an assessment guide or organizing framework. The four main components of this model are described as follows ( Intercultural Education of Nurses in Europe, 2016 ):

1. Cultural awareness: Cultural awareness represents the first step toward cultural competence. It incorporates self-awareness, cultural identity, cultural adherence, ethnocentricity, stereotyping, and ethnohistory.

2. Cultural knowledge: Cultural knowledge is the second step toward cultural competence. It includes health beliefs and behaviors; anthropological, sociopolitical, and biological understanding; similarities and differences among cultures; and health inequities.

3. Cultural competence: Cultural competence includes assessment skills, diagnostic skills, and challenging and addressing prejudice, discrimination, and inequalities.

4. Cultural sensitivity: Cultural sensitivity includes empathy, interpersonal communication skills, trust and respect, acceptance, appropriateness, and barriers to cultural sensitivity.

This model meets the criteria for clarity, simplicity, generality, and empirical precision. A graphical display of this model can be found through the  Leonardo da Vinci Partnership Project website (2012 ;  http://www.ieneproject.eu/download/Outputs/intercultural%20model.pdf ).

Leininger’s Cultural Care Diversity and Universality Theory and Model

Leininger’s cultural care diversity and universality theory and the sunrise model that depicts her theory are perhaps the most well known in nursing literature on culture and health ( McFarland & Wehbe-Alamah, 2015 ). The theory draws from anthropological observations and studies of culture and cultural values, beliefs, and practices. The theory of transcultural nursing promotes understanding of both the universally held and common understandings of care among humans and the culture-specific caring beliefs and behaviors that define any particular caring context or interaction. According to Leininger, this theory is intended to be holistic: Culture is the specific pattern of behavior that distinguishes any society from others and gives meaning to human expressions of care ( McFarland & Wehbe-Alamah, 2015 ).

The theory of cultural care diversity and universality is heavily used in education and research. It incorporates the following assumptions about care and caring as they relate to cultural competence ( McFarland & Wehbe-Alamah, 2015 ):

· Care (caring) is essential to curing and healing, for there can be no curing without caring.

· Every human culture has generic, folk, or indigenous care knowledge and practices and usually some professional care knowledge and practices that vary transculturally.

· Culture care values, beliefs, and practices are influenced by and tend to be embedded in the worldview, language, philosophy, religion and spirituality, kinship, social, political, legal, educational, economic, technological, ethno-historical, and environmental contexts of cultures.

· A client who experiences nursing care that fails to be reasonably congruent with his or her beliefs, values, and caring life ways will show signs of cultural conflict, noncompliance, stress, and ethical or moral concern.

· Within a cultural care diversity and universality framework, nurses may take any or all of three culturally congruent action modes: (1) cultural preservation/maintenance, (2) cultural care accommodation/negotiation, and (3) cultural care repatterning/restructuring.

According to Leininger, cultural care preservation/maintenance refers to assistive, supportive, facilitative, or enabling professional actions and decisions that help individuals, families, and communities of a particular culture retain and preserve care values so that they can maintain well-being, recover from illness, or face possible handicap or death. Cultural care accommodation/negotiation refers to assistive, supportive, facilitative, or enabling professional actions and potential decisions that help individuals, families, and communities of a particular culture adapt to or negotiate with others for satisfying healthcare outcomes with professional caregivers. Cultural care repatterning/restructuring refers to the assistive, supportive, facilitative, and enabling roles filled by nurses and other healthcare providers to promote actions and decisions that may help the person, family, or community change or modify behaviors affecting their life ways, thereby achieving a new and different health pattern ( McFarland & Wehbe-Alamah, 2015 ). These three action modes are sometimes used with other cultural theories and models.

Leininger recognized the comparative aspects of caring within and between cultures—hence the theory’s acknowledgment of similarities as much as differences in caring in diverse cultures. Her transcultural model has implications for how nurses assess, plan, implement, and evaluate care of people from diverse cultural backgrounds. The sunrise model and theory have clarity, but they are complex. The model has generality for nursing, empirical precision, and derivable consequences. It can be found on the Transcultural Nursing Society’s website ( http://www.tcns.org/Theories.html ).

Spector’s HEALTH Traditions Model

Spector’s health traditions model incorporates three main components: heritage consistency, HEALTH traditions, and Giger and Davidhizar’s theory ( Giger, 2012 ) about the cultural phenomena affecting health. Heritage consistency originally described the extent to which a person’s lifestyle reflected his or her tribal culture but has since been expanded to study a person’s traditional cultural background, such as European, Asian, African, or Hispanic. The values indicating heritage consistency exist on a continuum.

The HEALTH traditions model is based on the concept of holistic health and explores what people do to maintain, protect, or restore health. This model emphasizes the interrelationship between physical, mental, and spiritual health with personal methods of maintaining, protecting, and restoring health. To maintain physical health, for example, an individual may use traditional foods and clothing that have proven effective within the culture in the past. Protection of one’s mental health may be achieved by receiving emotional and social support from family members and the community. Religious rituals may be performed, with the belief that they will assist in restoring health ( Spector, 2013 ).

Spector also provides a Heritage Assessment Tool to determine the degree to which people or families adhere to their traditions. A traditional person observes his or her cultural traditions more closely. A more acculturated individual’s practice is less observant of traditional practices ( Spector, 2013 ). The model has clarity, simplicity, generality, and empirical precision.

THE PURNELL MODEL FOR CULTURAL COMPETENCE

The Purnell model for cultural competence has been classified as a grand, holographic, and complexity theory (StudyBlue, 2016) originated from education and practice. In 1989, Purnell took third-year nursing students to a community hospital that was not accustomed to having students. Soon after the clinical experience began, it became obvious that the students and staff needed additional knowledge concerning culture. The students primarily came from White families of middle socioeconomic and upper-middle socioeconomic classes, but most of the patients and staff came from lower socioeconomic backgrounds or had a heritage rooted in Appalachia. As part of postconferences, Purnell began having sessions with students and staff that centered on patients’, staffs’, and students’ cultures.

The next semester, Purnell had senior nursing students in five different emergency departments. Again, it became obvious that both students and staff could benefit from a cultural assessment guide, as well as from greater knowledge about the specific cultural groups to whom they were providing care.

The first step in formalizing the cultural educational experience was to develop a comprehensive organizing framework that was usable by both staff and students. The more APNs know about a specific ethnic or cultural group, the better their assessment of patients, which helps ensure culturally congruent care. For example, if APNs are not aware of the various traditional healthcare practitioners used by many Hispanic or Latino people (e.g., curanderos, sobadores, masajistas, y(j)erberos, espiritistas, sacerdotes), they will not know to ask about them ( Purnell, 2013 ).

Over the next few years, Purnell further developed the organizing framework and expanded the model to include holographic and complexity theory. Holographic simply means that the theory is not confined to one discipline, but rather has applicability across health-related disciplines. In complexity theory, there is usually an accompanying organizing framework to simplify the theory. Complexity theory, similar to chaos theory, is characterized by large numbers of similar but independent domains; continuous change in the phenomena of interest, leading to adaptation to the environment to ensure survival; and self-organization over time. The system never reaches equilibrium because societal events necessitate ongoing change in beliefs and values ( Rickles, Hawe, & Shiell, 2007 ).

This model has been used (1) in multiple practice sites; (2) in education as a guide to incorporate culture into baccalaureate, master’s, and doctoral programs; (3) in research in Australia, Brazil, Canada, Chile, China, the Czech Republic, Ethiopia, Korea, Spain, Turkey, the United Kingdom, and the United States; and (4) in administration. It also has been used by non-nursing disciplines, such as physical therapy ( Black-Lattanzi & Purnell, 2006 ), medicine ( Braithwaite, 2003 ;  Crandall, George, Marion, & Davis, 2003 ;  Purnell, 2003a ,  2003b ), and occupational therapy (Nayar & Tse, 2006). In addition, the model has been translated into Arabic, Czech, Flemish, German, Italian, Korean, Portuguese, Spanish, Swedish, and Turkish, testifying to its use on a worldwide basis. Purnell has also consulted and made presentations about cultural competence in nursing and health care at numerous universities and healthcare organizations in Australia, Belize, Belgium, China, Colombia, Costa Rica, Denmark, England, Hungary, Italy, Korea, Mexico, Panama, Portugal, Scotland, Spain, Sweden, Turkey, and the United States, testifying to its utility on an international scale.

Assumptions of the Purnell Model

The explicit assumptions upon which the model is based include the following:

1. All healthcare professions need similar information about cultural diversity.

2. All healthcare professions share the metaparadigm concepts of global society, family, person, and health.

3. One culture is not better than another culture; they are just different.

4. There are core similarities shared by all cultures.

5. There are differences within, between, and among cultures.

6. Cultures change slowly over time.

7. The variant cultural characteristics determine the degree to which one varies from the dominant culture.

8. If clients are coparticipants in their care and have a choice in health-related goals, plans, and interventions, their compliance and health outcomes will be improved.

9. Culture has a powerful influence on an individual’s interpretation of and responses to health care.

10. Individuals and families belong to several subcultures.

11. Each individual has the right to be respected for his or her uniqueness and cultural heritage.

12. APNs need both cultural-general and cultural-specific information to provide culturally sensitive and culturally competent care.

13. Caregivers who can assess, plan, intervene, and evaluate in a culturally competent manner will improve the care of clients for whom they care.

14. Learning culture is an ongoing process that develops in a variety of ways, but primarily through cultural encounters (Campinha-Bacote, 2015).

15. Prejudices and biases can be minimized with cultural understanding.

16. To be effective, health care must reflect the unique understanding of the values, beliefs, attitudes, life ways, and worldview of diverse populations and individual acculturation patterns.

17. Differences in race and culture often require adaptations to standard interventions.

18. Cultural awareness improves the caregiver’s self-awareness.

19. Professions, organizations, and associations have their own cultures, which can be analyzed using a grand theory of culture.

20. Every client encounter is a cultural encounter ( Purnell, 2013 ,  2014 ).

Variant Cultural Characteristics

Major influences that shape individuals’ worldview and the extent to which people identify with their cultural group of origin are called variant cultural characteristics and include the following: nationality, race, color, gender, age, religious affiliation, educational status, socioeconomic status, occupation, military experience, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (e.g., sojourner, immigrant, or undocumented status), length of time away from the country of origin, and hearing impairment. Moreover, immigration status also influences a person’s worldview. For example, people who voluntarily immigrate generally acculturate and assimilate into a new society more easily. Conversely, sojourners who immigrate with the intention of remaining in their new homeland for only a short time or refugees who think they may return to their home country may not have the need or desire to acculturate or assimilate. Additionally, undocumented individuals (illegal immigrants) may have a different worldview from those who have arrived legally ( Purnell, 2013 ). Some of these variant cultural characteristics change over time, while others do not. In addition, a stigma may occur for some, either the individual or the family, if they do change (e.g., changing religious affiliation from Judaism to Pentecostal).

Cultural Competence According to the Purnell Model

Cultural competence is multifactorial in nature. To be comprehensive, this term is defined as developing an awareness of one’s own existence, sensations, thoughts, and environment, without letting those factors have an undue influence on persons from other backgrounds. It incorporates the following aspects of care:

1. Demonstrating knowledge and understanding of the client’s culture, health-related needs, and culturally specific meanings of health and illness

2. Continuing to learn about the cultures of clients to whom one provides care

3. Recognizing that the primary and secondary characteristics of culture determine the degree to which clients adhere to the beliefs, values, and practices of their dominant culture

4. Accepting and respecting cultural differences in a manner that facilitates clients’ and families’ abilities to make decisions to meet their needs and beliefs

5. Not assuming that the healthcare provider’s beliefs and values are the same as the client’s

6. Resisting judgmental attitudes such as “different is not as good”

7. Being open to cultural encounters

8. Being comfortable with cultural encounters

9. Adapting care to be congruent with the client’s culture

10. Engaging in cultural competence as a conscious process and not necessarily a linear one

11. Accepting responsibility for one’s own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices

Description of the Purnell Model

The Purnell model for cultural competence and its organizing framework can be used in all kinds of practice settings and by all kinds of healthcare providers. The model is depicted graphically as a series of circles, where the outlying rim represents global society, the second rim represents community, the third rim represents family, and the inner rim represents the person (see  Figure 23-1 ). The interior of the circle is divided into 12 pie-shaped wedges depicting cultural domains (constructs) and their associated concepts. The dark center of the circle represents unknown phenomena. Along the bottom of the model is a jagged line representing the nonlinear concept of cultural consciousness.

Figure 23-1 The Purnell model for cultural competence.

Purnell model for cultural competence reprinted with permission of Larry D. Purnell, PhD, RN, FAAN.

The 12 cultural domains and their concepts provide the organizing framework. Each domain includes concepts that need to be addressed when assessing patients in various settings. Moreover, APNs can use these same concepts to better understand their own cultural beliefs, attitudes, values, practices, and behaviors. An especially important concept is the notion that no single domain stands alone; rather, all of the domains are inextricably interconnected. The 12 domains are (1) overview/heritage, (2) communications, (3) family roles and organization, (4) workforce issues, (5) biocultural ecology, (6) high-risk health behaviors, (7) nutrition, (8) pregnancy and the childbearing family, (9) death rituals, (10) spirituality, (11) healthcare practices, and (12) healthcare practitioners (see  Figure 23-1 ).

The Purnell model has clarity, generality, empirical precision, and derivable consequences. The model in its entirety is complex. The practitioner would rarely complete a full assessment using all of the concepts in the 12 domains, especially in any one setting. This cultural model is one of the most thoroughly developed to date ( Catalano, 2011 ).

Macro Aspects of the Purnell Model

The macro aspects of this interactional model include the metaparadigm concepts of global society, community, family, person, and conscious competence. The theory and model are conceptualized from foundations in biology, anthropology, sociology, economics, geography, history, ecology, physiology, psychology, political science, pharmacology, and nutrition, as well as theories from communication, family development, and social support. The model can be used in clinical practice, education, research, and the administration and management of healthcare services; it also can be used to analyze organizational culture.

Phenomena related to a global society include world communication and politics; conflicts and warfare; natural disasters and famines; international exchanges in education, business, commerce, and information technology; advances in health science; space exploration; and the expanded opportunities for people to travel around the world and interact with diverse societies. Information about global events that is widely disseminated by television, radio, satellite transmission, newsprint, and information technology affects all societies, either directly or indirectly. Such events create chaos while consciously and unconsciously forcing people to alter their life ways and worldviews.

In its broadest definition, community is a group of people having a common interest or identity; it goes beyond the physical environment. Community includes the physical, social, and symbolic characteristics that cause people to connect. Bodies of water, mountains, rural versus urban living, and even railroad tracks help people define their physical concept of community. Of course, technology and the Internet now allow people to readily expand their community beyond the physical boundaries that defined communities in the past. Economics, religion, politics, age, generation, and marital status delineate the social concepts of community. Moreover, sharing a specific language or dialect, lifestyle, history, dress, art, or musical interest are symbolic characteristics of a community. People actively and passively interact with the community, necessitating adaptation and assimilation for equilibrium and homeostasis in their worldview. Individuals may willingly change their physical, social, and symbolic community when it no longer meets their needs.

A family is two or more people who are emotionally connected. They may—but do not necessarily—live in close proximity to one another. Family may include physically and emotionally close and distant consanguineous relatives, as well as physically and emotionally connected and distant non-blood-related significant others. Family structure and roles change according to age, generation, marital status, relocation or immigration, and socioeconomic status, requiring each person to rethink his or her individual beliefs and life ways.

A person is a bio-psycho-sociocultural being who is constantly adapting to his or her community. Human beings adapt biologically and physiologically with the aging process; psychologically in the context of social relationships, stress, and relaxation; socially as they interact with the changing community; and ethno-culturally within the broad global society. In Western cultures, a person is considered a separate physical and unique psychological being and a singular member of society; that is, the self remains separate from others. In contrast, in Asian and some other primarily collectivistic cultures, the individual is defined in relation to the family or other group, rather than as a basic unit of nature.

Health is a state of wellness as defined by the individual within his or her ethnocultural group. Health generally includes physical, mental, and spiritual states because group members interact with the family, community, and global society. The concept of health, which permeates all metaparadigm concepts of culture, is defined globally, nationally, regionally, locally, and individually. Thus, people can speak about their personal health status or the health status of the nation or community. Health also can be subjective or objective in nature ( Purnell, 2013 ).

Domains of the Purnell Model and the Organizing Framework

The 12 domains in the Purnell model are listed in this section, along with the major concepts, key questions, and observations to make for each domain.

Overview and Heritage

The overview and heritage domain includes concepts related to the country of origin and current residence, such as the effects of the topography of the country of origin and the current residence on health, economics, politics, reasons for migration, educational status, and occupations.  Box 23-1  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-1 Overview, Inhabited Localities, and Topography

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Where do you currently live? Sample rationale: Someone living in the inner city may be at increased risk for illnesses such as emphysema and asthma because of increased air pollution. American Indians living on reservations have increased tuberculosis rates owing to living conditions and lifestyle.

2. What is your ancestry? Sample rationale: Members of the Amish community have high rates of glutaric acidemia, dwarfism, cartilage-hair hypoplasia, and hemophilia B. Turks have high rates of helminthiasis owing to lifestyle and environment.

3. Where were you born? Sample rationale: Some studies of the Chernobyl (Russia) nuclear incident show an increase in genetic mutations and hereditary defects related to radioactive contamination.

4. How many years have you lived in the United States (or other country, as appropriate)? Sample rationale: May show degree of assimilation and acculturation.

5. Were your parents born in the United States (or other country, as appropriate)? Sample rationale: May show degree of assimilation and acculturation.

6. What brought you (your parents/ancestors) to the United States (or other country, as appropriate)? Sample rationale: Refugees may have post-traumatic stress disorders related to their stay in refugee camps.

7. Describe the land or countryside where you live. Is it mountainous? Swampy (and so on)? Sample rationale: People living in or around wooded areas and who have vague symptoms of fever, fatigue, and headache with or without skin rash may have Lyme disease. People emigrating from Panama may have a high risk for dengue fever.

8. Have you lived other places in the United States/world? Sample rationale: People immigrating from, or who have recently visited parts of, Central America or Africa and who present with fever, chills, headache, and fatigue may need to be assessed for malaria or dengue fever.

9. What was the land or countryside like when you lived there? Sample rationale: People who have lived near a contaminated (Superfund) site may be at risk for increased incidence of cancer.

10. What is your income level? Sample rationale: May provide information about the ability to afford prescription medication and other treatment aids such as dressings and prescriptive devices.

11. Does your income allow you to afford the essentials of life? Sample rationale: May have implications for the ability to purchase “fresh fruits and vegetables,” affecting overall health.

12. Are you able to afford health insurance on your salary? Sample rationale: An individual may have the financial wherewithal to afford insurance, but some persons who have a present orientation may not see the value in obtaining health insurance.

13. Do you have health insurance? Sample rationale: If the patient does not have health insurance, he or she may be referred to social services for financial support.

14. What is your educational level (formal/informal/self-taught)? Sample rationale: May have implications for health literacy and teaching.

15. What is your current occupation? If the individual is retired, ask about previous occupations. Sample rationale: A person may currently work in the construction industry but previously have worked in coal mines, which increases the risk for radiation poisoning and black lung. Asbestosis may still be a concern for people working in the construction industry.

16. Have you worked in other occupations? What were they? Sample rationale: An individual may currently work in carpentry but previously have worked in welding and therefore have an increased risk for cataracts.

17. Are there (were there) any particular health hazards associated with your job(s)? Sample rationale: People who work in the ornamental nursery industry and farming are at high risk for health problems related to the use of pesticides.

Questions and observations related to the primary and secondary characteristics of culture not covered in the previous questions include the following:

1. Have you been in the military? If so, in which foreign countries were you stationed? Sample rationale: People who have served in Afghanistan are at high risk for water- and foodborne diseases. Veterans and their families who lived in Camp Lejeune, North Carolina, are at high risk for waterborne illnesses due exposure to benzene and other contaminants in drinking water.

2. Are you married? Sample rationale: Part of a standard assessment and may provide information about support.

3. How many children do you have? Sample rationale: Part of a standard assessment and may provide information about support.

Communication

The communication domain includes concepts related to the dominant language, sign language, dialects, health literacy, and the contextual use of the language; paralanguage variations such as voice volume, tone, intonations, inflections, and willingness to share thoughts and feelings; nonverbal communications such as eye contact, gesturing, facial expressions, use of touch, body language, spatial distancing practices, and acceptable greetings; temporality in terms of past, present, and future orientation of worldview; clock versus social time; and the amount of formality in use of names.  Box 23-2  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-2 Communication

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. What is your full name? Sample rationale: Part of a standard assessment. Complex naming can create difficulties for medical record keeping.

2. What is your legal name? Sample rationale: Hispanic/Latino individuals have an extended name format that includes a first name, middle name, father’s last name, and mother’s last name, with an additional last name of the husband if a woman is married. In these cases, a person selects any combination of last names for his or her legal name.

3. By which name do you wish to be called? Sample rationale: Helps establish trust and increases comfort level of the patient.

4. What is your primary language? Sample rationale: The primary language is usually best for patient education, but the APN should ask about the preferred language. Signing may be a concern because of the differences among Arabic sign languages, American Sign Language, and British Sign Language.

5. Do you speak a specific dialect? Sample rationale: A dialect-specific interpreter is preferred. For example, people from northern China speak a different dialect than people from southern China.

6. Which other languages do you speak? Sample rationale: May be helpful for interpretation if the preferred language interpreter is not available. For example, many Vietnamese persons speak French as a secondary language.

7. Do you find it difficult to share your thoughts, feelings, and ideas with family? Friends? Healthcare providers? Sample rationale: For people who find it difficult to share their feelings, additional time may be needed to establish trust and get full disclosure, especially with sensitive topics such as sexuality and substance use/misuse.

8. Do you mind being touched by friends? Strangers? Healthcare workers? Sample rationale: Reinforces the necessity to ask permission before touching. Always ask permission and explain the rationale for touching.

9. How do you wish to be greeted? Handshake? Nod of the head? Something else? Sample rationale: Preferred greetings help establish trust.

10. Are you usually on time for appointments? Sample rationale: A clear rationale can be given for intolerance of lateness; for example, some healthcare organizations will not see the patient if he or she is more than 15 minutes late and some still may charge for the visit.

11. Are you usually on time for social engagements? Sample rationale: Ask only if the question is pertinent.

12. Observe the client’s speech pattern. Does the speech pattern demonstrate a high or low context? Sample rationale: Clients from highly contexted cultures place greater value on silence and may take more time to give a response.

13. Observe the client when physical contact is made. Does he or she withdraw from the touch or become tense? Sample rationale: Helps establish trust and reinforces the necessity of explaining the reason for touch.

14. How close does the client stand when talking with family members? With healthcare providers? Sample rationale: The APN should not take offense if a patient stands closer to or farther away than the distance to which the APN is accustomed. Spatial distancing is culture bound.

15. Does the client maintain eye contact when talking with the APN? Sample rationale: Some cultures avoid eye contact with people in hierarchal positions (the APN is in a hierarchal position in the healthcare setting) as a sign of respect.

Family Roles and Organization

The family roles and organization domain includes concepts related to the head of the household, gender/sex roles (a product of biology and culture), family goals and priorities, developmental tasks of children and adolescents, roles of the aged and extended family, individual and family social status in the community, and acceptance of alternative lifestyles such as single parenting, sexual orientations, childless marriages, and divorce.  Box 23-3  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-3 Family Roles and Organization

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Who makes most of the decisions in your family? Sample rationale: If the decision maker is not accessed, no decision will be made and time will be wasted. In addition, the spokesperson for the family might not be the decision maker, as occurs among many Hispanic/Latino populations.

2. Which types of decisions do(es) the female(s) in your family make? Sample rationale: In many traditional families, the female makes decisions about the household and child care, but not always.

3. Which types of decisions do(es) the male(s) in your family make? Sample rationale: In many traditional families, the male is the primary decision maker regarding affairs outside the household, but not always.

4. What are the duties of the women in the family? Sample rationale: Understanding division of labor can become important when illness occurs.

5. What are the duties of the men in the family? Sample rationale: Understanding division of labor can become important when illness occurs.

6. What should children do to make a good impression for themselves and for the family? Sample rationale: Important to note in school health and family counseling. A child’s behavior can bring shame upon or honor to the family.

7. What would children do that would not make a good impression for themselves and for the family? Sample rationale: Among traditional Chinese, children are to do well in school or shame may come to the family.

8. What are children forbidden to do? Sample rationale: Among traditional Germans and many other cultures, taboo behaviors include talking back to elders and touching another person’s possessions.

9. What should young adults do to make a good impression for themselves and for the family? Sample rationale: Among most Koreans, one of the most important things young adults can do to bring pride to themselves and their families is to do well in school. Otherwise, shame can occur to the extent that many students have committed suicide.

10. What would young adults do that would not make a good impression for themselves and for the family? Sample rationale: Among traditional Mexican families, young adults should not dress in a provocative manner. Otherwise, shame can come to them or their family.

11. What are adolescents forbidden to do? Sample rationale: Taboo behaviors for young adults in Iran include using illicit drugs or engaging in sexual activity before marriage. This behavior can bring shame upon the family.

12. What are the priorities for your family? Sample rationale: For a lower-socioeconomic family, the priority may be having adequate food and shelter with stress on the present but still not forgetting the future. Health care and education may not be priorities if the basic needs are not met.

13. What are the roles of older adults in your family? Are they sought for their advice? Sample rationale: Among traditional Koreans, no decision is made until the advice of older adults has been sought, although the advice might not be followed.

14. Are there extended family members in your household? Who else lives in your household? Sample rationale: Being aware of the household membership is important for health teaching and adequacy of care for sick family members. Most members of traditional Asian cultures live in extended family arrangements. Some families might have children totally unrelated to the host family.

15. What are the roles of extended family members in this household? Sample rationale: In many Filipino families, extended family members provide significant financial and social support and are important resources for child care.

16. What gives you and your family status? Sample rationale: Among the Navajo, status is obtained by sharing what you have with others.

17. Is it acceptable to you for people to have children out of wedlock? Sample rationale: Among traditional Arab families, shame may occur if a pregnancy occurs outside of marriage.

18. Is it acceptable to you for people to live together and not be married? Sample rationale: Among many Asian cultures, if a man and a woman live together without being married, that relationship may cause them to be rejected by their families.

19. Are you accepting of gay, lesbian, or transgendered people? Sample rationale: Not all cultures and individuals are accepting of gay, lesbian, or transgendered populations. Do not disclose these relationships to family members.

20. What is your sexual preference/orientation? (Ask only if appropriate, and then later in the assessment after a modicum of trust has been established). Sample rationale: Important for health counseling if sexually active.

Workforce Issues

The workforce issues domain includes concepts related to autonomy, acculturation, assimilation, gender roles, ethnic communication styles, and healthcare practices of the country of origin.  Box 23-4  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-4 Workforce Issues

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Do you usually report to work on time? Sample rationale: For present-oriented people who are accustomed to a lack of timeliness in the workforce, the supervisor needs to be very clear about the importance of timeliness and any repercussions if timeliness becomes a concern, especially in individualistic cultures.

2. Do you usually report to meetings on time? Sample rationale: In some cultures, such as among Panamanians, a meeting starts when most people have arrived.

3. What concerns do you have about working with someone of the opposite gender? Sample rationale: Strict Muslim separation of the sexes means that there may be family disharmony if men and women are expected to work in close proximity.

4. Do you consider yourself a “loyal” employee? Sample rationale: In Japanese culture, an employer may expect absolute loyalty, and employees often remain with the same company for their entire lives.

5. How long do you expect to remain in your position? Sample rationale: May have implications for health insurance and seeking health care in the United States.

6. What do you do when you do not know how to do something related to your job? Sample rationale: Among many traditional Koreans, when an employee does not know how to do something, rather than going to a supervisor, a coworker of the same nationality (if available) is sought out.

7. Do you consider yourself to be assertive in your job? Sample rationale: Traditional Filipinos are frequently not considered as assertive as some U.S. employers would like.

8. What difficulty does English (or another language) give you in the workforce? Sample rationale: May have implications for accuracy in fulfilling job requirements, both verbally and in writing.

Biocultural Ecology

The biocultural ecology domain includes physical, biological, and physiological variations among ethnic and racial groups such as skin color (the most evident) and physical differences in body habitus; genetic, hereditary, endemic, and topographical diseases; psychological makeup of individuals; and the physiological differences that affect the way drugs are metabolized by the body. In general, most diseases and illnesses may be classified into one of three categories on the basis of their causes: environment, lifestyles, and genetics.

1. Lifestyle causes include cultural practices and behaviors that can generally be controlled—for example, smoking, diet, and stress.

2. Environmental causes refer to the external environment (e.g., air and water pollution) and situations over which the individual has little or no control (e.g., presence of malarial mosquitoes, exposure to chemicals and pesticides, access to care, and associated diseases).

3. Genetic conditions are caused by genes.

Box 23-5  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-5 Biocultural Ecology

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Are you allergic to any medications? Sample rationale: Standard for any assessment.

2. What problems did you have when you took over-the-counter medications? Sample rationale: Looking for possible allergies and side effects is standard for any assessment. The APN should ask about medicines purchased in countries outside the United States. In Mexico and other countries, a wide variety of medicines can be purchased over the counter that would require a prescription in the United States.

3. What problems did you have when you took prescription medications? Sample rationale: Looking for possible allergies and side effects is standard for any assessment.

4. What are the major illnesses and diseases in your family? Sample rationale: Looking for opportunities for health promotion and teaching is standard for any assessment. In addition, many Asians and Pacific Islanders have high incidences of glucose-6-phosphate dehydrogenase deficiency and alpha-thalassemia.

5. Are you aware of any genetic diseases in your family? Sample rationale: Members of Amish, Jewish, and other populations have many hereditary and genetic illnesses, and heritage can be important for counseling.

6. What are the major health problems in the country from which you come (if appropriate)? Sample rationale: Vietnamese immigrants and people who have spent time in refugee camps have a high incidence of hepatitis A, tuberculosis, and other infectious diseases.

7. With which race do you identify? Sample rationale: May be important for organizational demographics for grants.

8. Observe skin coloration and physical characteristics. Sample rationale: To assess for rashes on people with dark skin, the APN may need to palpate the area rather than relying on visual cues.

9. Observe for physical handicaps and disabilities. Sample rationale: Part of standard assessment. Many people do not disclose handicaps or disabilities, especially learning disabilities, upon initial encounter unless specifically asked.

10. For clients who have undergone transgendered surgery, ask if they have all their organs. Sample rationale: Women who transgender to male usually still have ovaries and a uterus. Men who transgender to female usually still have a prostrate.

High-Risk Health Behaviors

The high-risk health behaviors domain includes substance use and misuse of tobacco, alcohol, and recreational drugs; lack of physical activity; increased calorie consumption; nonuse of safety measures such as seat belts, helmets, and safe driving practices; and not taking measures to prevent contracting HIV and sexually transmitted infections.  Box 23-6  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-6 High-Risk Health Behaviors

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. How many cigarettes per day do you smoke? Sample rationale: Standard for any assessment. Because smoking carries a stigma in some cultures, the APN should assess smoking with a nonjudgmental attitude.

2. Do you smoke a pipe (or cigars)? Sample rationale: Standard for any assessment. Because smoking carries a stigma in some cultures, the APN should assess smoking with a nonjudgmental attitude.

3. Do you chew tobacco? Sample rationale: In parts of rural Appalachia and other areas of the world, chewing tobacco is common; this increases the risk for oropharyngeal cancer.

4. For how many years have you smoked/chewed tobacco? Sample rationale: Part of a standard assessment if there is a history of tobacco use.

5. How much do you drink each day? Ask about wine, beer, spirits, coffee, sweet tea and other drinks high in sugar, and energy drinks. Sample rationale: Part of a standard assessment; important for follow-up with laboratory tests.

6. Which recreational drugs do you use? Sample rationale: Part of a standard assessment. The APN should ask this question in a nonjudgmental manner to encourage the patient to disclose this sensitive information.

7. How often do you use recreational drugs? Sample rationale: Part of a standard assessment for determining the degree of risk.

8. Do you exercise each day? What type of exercise? For how long? Sample rationale: Part of a standard assessment for health promotion and wellness.

9. Do you use seat belts/helmets? Sample rationale: Part of a standard assessment for injury prevention.

10. What precautions do you take to prevent getting a sexually transmitted infection/HIV? Sample rationale: Part of a standard assessment for health promotion and wellness, and illness and disease prevention.

Nutrition

The nutrition domain includes the meaning of food, common foods and rituals, nutritional deficiencies and food limitations, and the use of food for health promotion, restoration, illness, and disease prevention.  Box 23-7  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-7 Nutrition

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Are you satisfied with your weight? Sample rationale: In many cultures, being overweight is seen as positive; members of these cultures do not adhere to the U.S. weight recommendations.

2. Which foods do you eat to maintain your health? Sample rationale: Food choices are seen as a means for promoting health. In the dominant U.S. culture, fresh fruits and vegetables are encouraged for health promotion.

3. Do you avoid certain foods to maintain your health? Sample rationale: Most Mexicans, as well as members of other cultures, try to avoid foods with high fat content.

4. Why do you avoid these foods? Sample rationale: People may avoid specific foods because they were not part of their diet when growing up, because they do not like the taste of the food, or because they do not like the appearance of the food. Recommending foods that the patient does not find pleasing diminishes the chance that the recommendations will be followed.

5. Which foods do you eat when you are ill? Sample rationale: In many cultures, common foods eaten when ill include toast and tea or ginger ale.

6. Which foods do you avoid when you are ill? Sample rationale: Recommending a food that the person culturally or personally avoids diminishes the chance that the recommendations will be followed.

7. Why do you avoid these foods (if appropriate)? Sample rationale: Foods may be avoided for a number of reasons.

8. For which illnesses do you eat certain foods? Sample rationale: In many cultures, people drink a “hot toddy” for a cold or minor illness. The ingredients for a hot toddy vary but generally include tea, lemon or lime, sugar or honey, and some type of liquor such as whiskey or rum.

9. Which foods do you eat to balance your diet? Sample rationale: Not all cultures adhere to the U.S. government’s food pyramids because the food choices are not part of their cultural diet. Many Asians, Hispanics, and African Americans have lactose intolerance and, therefore, cannot follow the recommendations in these food pyramids.

10. Which foods do you eat every day? Sample rationale: Most people have specific foods that they eat on almost a daily basis. Incorporating these foods into dietary prescriptions will increase compliance with dietary instructions.

11. Which foods do you eat every week? Sample rationale: Most people have specific foods that they eat on almost a weekly basis. Incorporating these foods into dietary prescriptions will increase compliance with dietary instructions.

12. Which foods do you eat that are part of your cultural heritage? Sample rationale: Including culturally preferred foods into nutritional recommendations increases compliance.

13. Which foods are high-status foods in your family/culture? Sample rationale: High-status foods vary according to cost and availability. Among Panamanians, canned sausages are high-status foods; the same items are low-status foods in the United States. Lobster is low status in the Philippines because of its ready availability but is high status in the United States because of its cost.

14. Which foods are eaten only by men? Women? Children? Teenagers? Older people? Sample rationale: Among some Guatemalan highland indigenous populations, primarily men eat eggs for the added protein value. The belief is that because men do heavy labor, they need more protein. However, they are supposed to share the protein foods on their plates with children.

15. How many meals do you eat each day? Sample rationale: Not all cultures eat the standard U.S. three meals per day. Among many Turks, people eat four to six times per day, but they consume smaller amounts at these meals than do most European Americans.

16. What time do you eat each meal? Sample rationale: May have implications for medication administration.

17. Do you snack between meals? Sample rationale: Studies have demonstrated that young adults in Appalachia snack frequently without eating a regular meal.

18. Which foods do you eat when you snack? Sample rationale: Many snacks are not considered healthy food choices. The APN can recommend healthy snacks to replace less healthy food choices.

19. Which holidays do you celebrate? Sample rationale: Holidays are a time for special meals and a time when many people consume excessive amounts of calories. Among other celebrations, many Hispanic/Latino cultures celebrate all of the Catholic religious holidays, as well as the patron saint of their state or their province, their village, and their school.

20. Which foods do you eat on particular holidays? Sample rationale: Foods are an important part of maintaining one’s culture, and diet is one measure of acculturation.

21. Who usually buys the food in your household? Sample rationale: Many times it is just as important for the APN to talk with the person who purchases the food as with the person who prepares the meals. In migrant worker camps, the person who purchases the foods is not the person who cooks for the group. If one member of the group needs a special diet (e.g., a diabetic individual), the purchaser of the food needs to be included in nutritional education.

22. Who does the cooking in your household? Sample rationale: The person who does the cooking should be included in dietary counseling and education for special diets.

23. Do you have a refrigerator? Sample rationale: For homeless persons and many living on remote reservations, proper food storage must be taken into consideration.

24. How do you cook your food? Sample rationale: Preparation practices can add significant calories to meals.

25. How do you prepare meat? Sample rationale: Preparation practices can add significant calories to meals.

26. How do you prepare vegetables? Sample rationale: Preparation practices can add significant calories to meals.

27. What do you drink with your meals? Sample rationale: Beverages can add significant calories to meals.

28. Do you drink special teas? Sample rationale: Teas are used by many people for health promotion and wellness and in times of illness.

29. Do you have any food allergies/intolerances? Sample rationale: Many African Americans and Asians have lactose intolerance. Encouraging milk and milk products in the diet would not be beneficial for these persons.

30. Are there certain foods that cause problems when you eat them? Sample rationale: Looking for allergies or food to avoid in dietary counseling.

31. How does your diet change with each season? Sample rationale: Most people’s diet changes with the seasons. For those individuals who live in colder climates, fresh fruits and vegetables may be too expensive in the winter; these individuals must rely on frozen or canned vegetables that are high in sodium content.

32. Are your food habits different on days you work from when you are not working? Sample rationale: A common occurrence is for some people to eat less healthy foods during the busy workweek, especially those who are single.

Pregnancy and Childbearing Practices

The pregnancy and childbearing practices domain includes culturally sanctioned and unsanctioned fertility practices, views on pregnancy, and prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and the postpartum period.  Box 23-8  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-8 Pregnancy and Childbearing Practices

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. How many children do you have? Sample rationale: Part of a standard assessment.

2. Have you ever had an abortion? Stillborn? Miscarriage? Sample rationale: Part of a standard obstetrical/gynecological assessment.

3. What do you use for birth control? Sample rationale: Each cultural and religious group has acceptable and unacceptable methods of birth control. Islamic jurists have ruled that the use of “reversible” forms of birth control is “undesirable but not forbidden.”

4. What does it mean to you and your family when you are pregnant? Sample rationale: In some cultures, a woman is not a true woman and has not reached her potential until she becomes pregnant.

5. Which special foods do you eat when you are pregnant? Sample rationale: Although there are no specifically prescribed foods for a pregnant Polish woman, she is expected to eat for two.

6. Which foods do you avoid when you are pregnant? Sample rationale: Korean women who are pregnant avoid coffee, spicy foods, chicken, and crab. Among Haitians, women are restricted from eating spices that may irritate the fetus.

7. Which activities do you avoid when you are pregnant? Sample rationale: A belief among traditional Mexicans is that a pregnant woman should not walk in the moonlight for fear that the baby will be born with a cleft lip or palate.

8. Do you do anything special when you are pregnant? Sample rationale: A belief in many cultures is that a pregnant woman should not reach over her head for fear the cord will wrap around the baby’s neck.

9. Do you eat nonfood substances when you are pregnant? Sample rationale: Eating nonfood substances is common among many cultural groups. Many African Americans eat clay in the belief that it has important minerals that the fetus needs.

10. Who do you want with you when you deliver your baby? Sample rationale: Most Filipino women prefer their mothers or another female family member, rather than husbands, to be present during the delivery.

11. In which position do you want to be when you deliver your baby? Sample rationale: Traditional Indian women in Guatemala prefer to deliver in a squatting position rather than in the supine position.

12. Which special foods do you eat after delivery? Sample rationale: Haitian women are encouraged to eat rice, porridge, plantains, and red beans after delivery to build up the blood.

13. Which foods do you avoid after delivery? Sample rationale: Chinese women avoid cold fruits and vegetables after delivery; instead, they eat cooked fruits and vegetables.

14. Which activities do you avoid after you deliver? Sample rationale: Russian women do no strenuous activity after delivery to prevent any complications.

15. Do you do anything special after delivery? Sample rationale: Traditional Haitian women have a series of three special baths that are given to them by family members.

16. Who will help you with the baby after delivery? Sample rationale: Looking for home support for the mother and rest of the family.

17. What bathing restrictions do you have after you deliver? Sample rationale: Many Arab women may be reluctant to bathe in a tub of water postpartum because they believe air may get into the mother and cause illness.

18. Do you want to keep the placenta? Sample rationale: Traditional Guatemalan women burn the placenta to keep away evil spirits. Other cultures may bury the placenta.

19. What do you do to care for the baby’s umbilical cord? Sample rationale: A common practice among Central American Indians is to place a coin or metal object, held on with an abdominal binder, to prevent the umbilicus from protruding.

Death Rituals

The death rituals domain includes how an individual and society view death and euthanasia, rituals to prepare for death, burial practices, and bereavement behaviors. In most cultures, death rituals are slow to change.  Box 23-9  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-9 Death Rituals

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. What special activities need to be performed to prepare for death? Sample rationale: When death is impending, Muslims want the bed to face toward Mecca.

2. Would you want to know about your impending death? Sample rationale: A belief among traditional Hindus is that people might give up hope if impending death is made known to them.

3. What is your preferred burial practice? Burial? Cremation? Sample rationale: The patient’s wishes should be granted and the family should be encouraged to honor them.

4. How soon after death does burial occur? Sample rationale: For traditional Jews, burial should occur before sundown the next day, although there are exceptions.

5. How do men grieve in your culture? Sample rationale: A wide range of grieving practices exists, and all practices should be unconditionally accepted.

6. How do women grieve in your culture? Sample rationale: A wide range of grieving practices exists and all practices should be unconditionally accepted.

7. What does death mean to you? Sample rationale: According to Muslim beliefs, death is foreordained and worldly life is but a preparation for eternal life.

8. Do you believe in an afterlife? Sample rationale: Most Germans and German Americans believe that there is a better life after death.

9. Are children included in death rituals? Sample rationale: Members of Amish groups include children in all aspects of dying and burial.

Spirituality

The spirituality domain includes formal religious beliefs related to faith and affiliation and the use of prayer, behavior practices that give meaning to life, and individual sources of strength. A person may be spiritual but not religious.  Box 23-10  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-10 Spirituality

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. What is your religion? Sample rationale: Traditional Judaism is more than a religion and prescribes male and female relationships as well as nutritional practices.

2. Do you consider yourself deeply religious? Sample rationale: Some people are religious but do not attend church on a regular basis.

3. How many times per day do you pray? Sample rationale: Islam requires prayer five times per day.

4. What items do you need to pray? Sample rationale: If possible, Muslims need a prayer rug.

5. Do you meditate? Sample rationale: Meditation may or may not be part of religious practice.

6. What gives strength and meaning to your life? Sample rationale: For some persons, religion is the most important thing in life; for others, the priority might be family or even work.

7. In which spiritual practices do you engage for your physical and emotional health? Sample rationale: For some people the key practice is prayer, for others meditation, and for others just having quiet time.

Healthcare Practices

The healthcare practices domain includes the focus of health care (acute versus preventive); traditional, magicoreligious, and biomedical beliefs and practices; individual responsibility for health; self-medicating practices; views on mental illness, chronicity, and rehabilitation; acceptance of blood and blood products; and organ donation and transplantation.  Box 23-11  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-11 Healthcare Practices

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. In what prevention activities do you engage to maintain your health? Sample rationale: A strong value in the dominant European American culture is to have regularly scheduled health checkups, including breast self-examinations and mammograms.

2. Who in your family takes responsibility for your health? Sample rationale: In many Hispanic/Latino cultures, the female in the family assumes the primary responsibility for the health of the family.

3. What over-the-counter medicines do you use? Sample rationale: Most cultural groups and individuals use over-the-counter medication, but some use them to the exclusion of prescription medicines. For many persons who have relatives in other countries, a large variety of prescription medications may be purchased and sent to family members in the United States.

4. Which herbal teas and folk medicines do you use? Sample rationale: Guatemalans, like members of many Hispanic/Latino populations, use a wide variety of herbal teas for many health conditions.

5. For which conditions do you use herbal medicines? Sample rationale: Many Panamanian men use “cat’s claw” tea for prostate problems and delay going to a Western health professional.

6. What do you usually do when you are in pain? Sample rationale: Traditional Chinese individuals cope with pain by using externally applied treatments such as oils and massage.

7. How do you express your pain? Sample rationale: Many Filipinos view pain as part of living an honorable life and, therefore, may appear stoic and tolerate a high degree of pain.

8. How are people in your culture viewed or treated when they have a mental illness? Sample rationale: In many rural areas of Appalachia, rather than admitting that a person has a mental health illness, they are likely to say the person is “odd” or “quite turned.”

9. How are people with physical disabilities treated in your culture? Sample rationale: In Haitian culture, people with a disability are seen as being as important as anyone else and are incorporated into all family and social activities.

10. What do you do when you are sick? Stay in bed, continue your normal activities, or something else? Sample rationale: Many people from an Eastern European heritage believe in the idea that “If you are not dead, take something for relief and continue with your daily routines.”

11. What are your beliefs about rehabilitation? Sample rationale: Studies demonstrate that Germans are more accepting of rehabilitation than are other groups who have been studied. If rehabilitation is needed to function at maximum capacity, then all rehabilitation exercises are done.

12. How are people with chronic illnesses viewed or treated in your culture? Sample rationale: In cases of chronic illness among African Americans, close family and spiritual ties ensure that one’s responsibilities are taken care of (by the family and even church members).

13. Are you averse to blood transfusions? Sample rationale: There is a religious prohibition against a Jehovah Witness receiving blood. In addition, many people do not want a blood transfusion for fear of contracting HIV/AIDS.

14. Is organ donation acceptable to you? Sample rationale: Jewish law views organ transplants from four perspectives: the recipient, the living donor, the cadaver donor, and the dying donor. Because life is sacred, if the recipient’s life can be prolonged without considerable risk, then the transplant is favorably viewed.

15. Are you an organ donor? Sample rationale: Part of a standard health assessment. Many misconceptions exist about organ donations, and the APN can play a significant role in clarifying these misconceptions.

16. Would you consider having an organ transplant if needed? Sample rationale: Organ donation and transplantation among Koreans are rare, reflecting traditional attitudes toward integrity and purity. The APN can have a significant influence on Koreans’ decisions about organ donation and transplantation by providing factual information.

17. Are healthcare services readily available to you? Sample rationale: APNs need to be aware of access problems for health care.

18. Do you have transportation problems in trying to access needed healthcare services? Sample rationale: Many organizations provide vouchers for public transportation if necessary.

19. Can you afford health care? Sample rationale: If the patient does not have adequate resources for health care, a social worker should be contacted for assistance.

20. Do you feel welcome when you see a healthcare professional? Sample rationale: If the answer is no, determine the reason. Just greeting the patient in a preferred manner, such as being formal with older African Americans, can make them feel welcome.

21. Which traditional healthcare practices do you use? Acupuncture, acupressure, cai gao, moxibustion, aromatherapy, coining/cupping, or something else? Sample rationale: If the APN is familiar with traditional practices in the culture, more specific information can be obtained.

22. Which home difficulties do you have that might prevent you from receiving health care? Sample rationale: Lack of support at home for child care may mean that a mother might not obtain regularly scheduled preventive care such as mammograms or Pap smears.

Healthcare Practitioners

The healthcare practitioners domain includes the status, use, and perceptions of traditional, magicoreligious, and biomedical healthcare providers and the gender of the healthcare provider.  Box 23-12  lists specific questions and a sample rationale that the APN should consider for this domain.

Box 23-12 Healthcare Practitioners

The following are suggested questions, each accompanied by a sample rationale, that the APN can ask in a cultural assessment.

1. Which healthcare providers do you see when you are ill? Physicians? Nurses? Folk traditional healers? Sample rationale: Not all patients see Western allopathic practitioners for illnesses, at least not as the first contact. The APN should also determine which treatments have been recommended by complementary alternative practitioners.

2. Do you prefer a same-sex healthcare provider for routine health problems? For intimate care? Sample rationale: Among traditional Islamic patients, a male healthcare provider should not tend to a female patient unless it is an emergency.

3. Which healers do you use in addition to physicians and nurses? Sample rationale: If the APN is familiar with the specific culture, he or she can ask more informed questions. Among many Hispanic/Latino groups, traditional healers include curanderos, yerberos, masajistas, sacerdotes, sobadores, and espiritistas.

4. For which conditions do you use healers? Sample rationale: Many Hispanics/Latinos use a variety of traditional healers. APNs who are caring for these populations should familiarize themselves with the specific groups’ traditional healers and be able to ask the question in a nonjudgmental manner. Being able to integrate traditional healers with allopathic professionals will increase compliance with recommendations.

INDIVIDUAL PROFESSIONAL CULTURAL COMPETENCE

Much debate, especially in the last decade, has focused on the process of objectively measuring individual competence. Most tools for measuring cultural competence are self-reported and subjective in nature. A number of tools have been developed to assess individual and organizational cultural competence ( Purnell, 2016 ). Some of these tools have been validated and are specific to a discipline or area of practice, whereas others are more general in nature. Most of these tools are available online. The Office of Minority Health has published a document on cultural competence standards ( http://minorityhealth.hhs.gov/ ).

Cultural competence is a journey, rather than a skill mastered once and then used in an unchanging manner for the remainder of one’s career. Its success relies on the willingness and ability of an individual to deliver culturally congruent and acceptable health and nursing care to clients. Individual cultural competence can be arbitrarily divided among cultural-general approaches, the clinical encounter, and language.

Cultural-General Competence

APNs need a cultural-general framework for assessment, as well as culturally specific knowledge about the clients to whom care is provided. Some cultural-general concepts follow:

1. Developing an awareness of one’s own existence, sensations, thoughts, and environment without letting these factors have an undue influence on people from other backgrounds

2. Continuing to learn about the cultures of clients to whom one provides care

3. Demonstrating knowledge and understanding of the client’s culture, health-related needs, and meanings of health and illness

4. Accepting and respecting cultural differences in a manner that facilitates the client’s and family’s ability to make decisions to meet their needs and beliefs

5. Recognizing that the APN’s beliefs and values may not be the same as the client’s

6. Resisting judgmental attitudes such as “different is not as good”

7. Being open to new cultural encounters

8. Recognizing that the variant characteristics of culture determine the degree to which clients adhere to the beliefs, values, and practices of their dominant culture

9. Having contact and experience with the communities from which clients come

10. Being willing to work with clients of diverse cultures and subcultures

11. Accepting responsibility for one’s own education in cultural competence by attending conferences, reading the literature, and observing cultural practices

12. Promoting respect for individuals by discouraging racial and ethnic slurs among coworkers

13. Intervening with staff behavior that is insensitive, lacks cultural understanding, or reflects prejudice

The Clinical Encounter

Some principles and guidelines for APNs in the clinical encounter follow:

1. Adapting care to be congruent with the client’s culture

2. Responding respectively to all clients and their families (including addressing clients and family members in the manner that they prefer, either formally or informally)

3. Collecting cultural data on assessments

4. Forming generalizations as a method for formulating questions rather than stereotyping

5. Recognizing culturally based healthcare beliefs and practices

6. Knowing the most common diseases and illnesses affecting the unique population to whom care is provided

7. Individualizing care plans to be consistent with the client’s cultural beliefs

8. Having knowledge of the communication styles of clients to whom you provide care

9. Accepting varied gender roles and childrearing practices from clients to whom you provide care

10. Having a working knowledge of the religious and spiritual practices of clients to whom you provide care

11. Having an understanding of the family dynamics of clients to whom you provide care

12. Using faces and language pain scales in the ethnicity and preferred languages of the clients

13. Recognizing and accepting traditional, complementary, and alternative practices of clients to whom you provide care

14. Incorporating clients’ cultural food choices and dietary practices into care plans

15. Incorporating clients’ health literacy into care plans and health education initiatives

Language

Language ability has been determined to be one of the most important aspects in APNs’ abilities to obtain an adequate assessment for many culturally diverse patients. Some guidelines for language follow:

1. Developing skills and using interpreters (includes sign language) with clients and families who have limited English proficiency

2. Providing clients with educational documents that are translated into their preferred language

3. Providing discharge instructions at a level that the client and family understand and in the language that the client and family prefer

4. Providing medication and treatment instruction in the language that the client prefers

5. Using pain scales in the language of the client

ORGANIZATIONAL CULTURAL COMPETENCE

Individual cultural competence is not sufficient to ensure the delivery of culturally competent care; the organization delivering the care must also demonstrate a commitment to cultural competence. Several things must be in place for an organization to demonstrate cultural competence. A list of attributes of culturally competent organizations, organized arbitrarily by governance and administration, education and orientation, and language, follows ( Purnell et al., 2011 ;  Purnell, 2013 ).

Governance and Administration

1. The organization has a mission statement and policies that address diversity.

2. The board of governance includes members of the ethnicity of the community that the organization serves.

3. A committee for cultural competence exists and includes staff, managers, administrators, chaplains, and members who are representative of the community.

4. The organization engages in community diversity fairs.

5. The organization seeks resources from federal, state, and private agencies to continually upgrade and integrate cultural competence into its care.

6. The organization partners with diverse community agencies.

7. The organization networks with diverse community leaders.

8. Administrators, managers, and staff are encouraged to be active in developing public policy for the client base to whom they deliver care.

9. Policy statements include efforts to eliminate bias and prejudice on the part of both clients and staff.

10. Programs reflect the needs of the diverse community.

11. The organization’s programs are advertised in community newspapers and on the radio and television in the languages of the community.

12. There is a willingness to support a mentoring program to entice recruitment into the health professions.

13. Data collected include race, ethnicity, culture, and language preferences of the staff and client base.

14. Patient rights documents are available in the major languages of the community.

15. Cultural and linguistic standards are adhered to by all members of the organization.

16. Fiscal resources are available for interpretation and translation.

17. Strategic planning reflects the needs of the community.

18. Input on research priorities is sought from consumers.

19. Researchers are reflective of the staff, clients, and community.

20. Human resources recruitment and hiring activities reflect the diversity of the community.

21. The job analysis procedure includes scoring for ethnocultural and language ability.

22. Position descriptions and evaluation practices reflect cultural competence.

23. Conflict and grievance procedures reflect the language of the staff.

24. The organization actively recruits bilingual staff.

25. Staff members are compensated for bilingual ability and certification.

26. The ethics committee includes members who are reflective of the staff and clients.

27. The hours of operation of clinics are adjusted to meet the needs of the community.

28. Pictures and posters are reflective of the client base.

29. Food choices are reflective of the client and staff preferences.

30. The holiday calendar represents the holidays recognized by the client population base.

31. Intake forms reflect cultural assessment.

32. Pain scales are available in the diverse languages used by the population served.

33. Culturally appropriate toys are available (e.g., Hispanic Santa, African American dolls).

34. If staff members are used as interpreters or if professional interpretation is available, a plan is in effect to address their job duties while interpreting for patients and staff (also a requirement established by The Joint Commission).

35. Education and orientation diversity are addressed as part of new employees’ orientation, in-service, and continuing education programs.

1. Nursing care delivery systems, the U.S. system of insurance reimbursement, and issues related to culture and autonomy are discussed.

2. Mentoring programs exist for diverse student and staff populations.

3. Diversity of the health professions is included in orientation.

4. All employees are offered education on both general cultural topics and the culture-specific needs of populations for whom they provide care.

5. Cultural celebrations are reflective of the staff and clients.

6. Resources are available to staff both the clinical unit and the library.

7. Staff members are trained in language interpretation.

8. Health classes are offered to clients whom the community serves.

9. Certification in culture for staff is offered at various levels.

10. Pharmacists, nurses, and physicians are educated in ethnopharmacology.

11. Lunch-and-learn series support the ongoing development of cultural competence.

Language

1. There are mechanisms in place for translation of written materials in the preferred language of the client.

2. Policies address interpretation (including sign language) and translation services.

3. Resources are available for translation of educational materials and discharge instructions in the languages of the client population.

4. The organization engages in activities that address the health literacy of the population whom it serves.

5. Written documents undergo a cultural sensitivity review.

6. Consent and procedure forms are translated into the languages of the population served.

7. English as a second language classes exist for staff.

8. Language classes are offered to clients and family (in English and the language of the population served).

9. Waiting areas have literature in the language of the population served.

10. Directions to referral facilities are in the languages of the client base.

11. Videos are in the language of the client base and have pictures reflective of the client base.

12. Diverse language includes sign language.

13. The need for an interpreter is determined ahead of time whenever possible.

14. The telephone system prompts are in the languages of the community.

15. Television programs are available in the languages of the community.

16. Satisfaction surveys are available in the languages of the community.

17. Staff surveys are available in the languages of the employees.

18. Audiovisual materials for staff and clients are available in their preferred languages.

19. Wellness and health promotion classes are offered in the languages of the client base.

SUMMARY

APNs—whether they work in clinical practice, education, research, policy, or administration and management—will inevitably work with multicultural patients and with diverse disciplines. When one considers the cultures of the patient, the APN, the profession, and the organization with a diverse workforce, culture competence becomes exceedingly complex. Even though the APN may have exceedingly excellent clinical practice skills, if he or she does not understand and include patients’ culture into the nursing process, recommendations will not be followed.

APNs have a crucial role in helping eliminate health disparities, addressing social justice, collaborating with other health disciplines, advancing policy formulation, and participating in or conducting research. The Graduate Cultural Competencies developed by the AACN clearly outline APN core competencies:

· Prioritize the social and cultural factors that affect health in designing and delivering care across multiple contents.

· Construct socially and empirically derived cultural knowledge of people and populations to guide practice and research.

· Assume leadership in developing, implementing, and evaluating culturally competent nursing and other healthcare services.

· Transform systems to address social justice and health disparities.

· Provide leadership to educators and members of the healthcare or research team in learning, applying, and evaluating continuous cultural competence development.

· Conduct culturally competent scholarship that can be utilized in practice ( AACN, 2011 ).

To this end, culturally competent care is not a luxury for APNs; it is a necessity.

The Purnell model for cultural competence provides a comprehensive guide for developing culturally competent health and nursing care. To date, this model has been used in organizational cultural competence with administration and management as well as research ( Purnell et al., 2011 ).