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DOI: 10.1177/10459602013003004

2002 13: 185J Transcult Nurs Joyce Newman Giger and Ruth Davidhizar

The Giger and Davidhizar Transcultural Assessment Model

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JOURNAL OF TRANSCULTURAL NURSING / JULY 2002Giger & Davidhizar / TRANSCULTURAL ASSESSMENT MODEL

The Giger and Davidhizar Transcultural Assessment Model

JOYCE NEWMAN GIGER, EdD, RN, CS, FAAN University of Alabama at Birmingham RUTH DAVIDHIZAR, DNS, RN, CS, FAAN Bethel College

The Giger and Davidhizar Transcultural Assessment Model wasdevelopedin1988inresponsetotheneedfornursingstu- dents in an undergraduate program to assess and provide care for patients that were culturally diverse. The model includes six cultural phenomena: communication, time, space, social organization, environmental control, and bio- logical variations. These provide a framework for patient assessment and from which culturally sensitive care can be designed.

The Giger and Davidhizar Transcultural Assessment Model was developed in 1988 in response to the need for nursing students in an undergraduate program to assess and provide care for patients that were culturally diverse. Today, the fourth edition of Transcultural Nursing: Assessment and Intervention (1999) is in process. In 1998, Mosby Yearbook published a companion book that addresses Canadian ethnic groups (Davidhizar & Giger, 1998). In addition, a pocket guide was also published by Mosby that provides a quick user-friendly format to understand various cultural groups (Geissler,1998).Thesebooksprovidechaptersonsixcultural phenomena and chapters that address cultural groups which havebeenauthoredbynurseswhoareexpertsinthecultureor who are members of the cultural group. TheGigerandDavidhizarTransculturalModelpostulates

that each individual is culturally unique and should be assessed according to six cultural phenomena: (a) communi- cation, (b) space, (c) social organization, (d) time, (e) envi- ronmental control, and (f) biological variations.

Communication. Communication embraces the entire world of human interaction and behavior. Communication is the means by which culture is transmitted and preserved. Both verbal and nonverbal communication are learned in one’sculture.Communicationoftenpresents themostsignif- icant problem in working with clients from diverse cultural backgrounds.

Space. Space refers to the distance between individuals when they interact. All communication occurs in the context of space. According to Hall (1966), there are four distinct zones of interpersonal space: intimate, personal, social and consultative, and public. Rules concerning personal distance varyfromculture toculture.Territorialityrefers tofeelingsor an attitude toward one’s personal area. Each person has their ownterritorialbehavior.Feelingsof territorialityorviolation of theclient’spersonal and intimate spacecancausediscom- fort and may result in a client’s refusing treatment or not returning for further care.

Socialorganization.Socialorganizationreferstotheman- ner inwhichaculturalgrouporganizes itself around the fam- ilygroup.Familystructureandorganization, religiousvalues and beliefs, and role assignments may all relate to ethnicity and culture.

Time. Time is an important aspect of interpersonal com- munication. Cultural groups can be past, present, or future oriented.Preventivehealthcarerequiressomefuturetimeori- entationbecausepreventiveactionsaremotivatedbya future reward.

Environmental control. Environmental control refers to the ability of the person to control nature and to plan and direct factors in the environment that affect them. Many

Journal of Transcultural Nursing, Vol. 13 No. 3, July 2002 185-188 © 2002 Sage Publications

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Americansbelievetheycontrolnaturetomeettheirneedsand thus are more likely to seek health care when needed. If per- sonscomefromaculturalgroupinwhichthereislessbeliefin

internal control and more in external control, there may be a fatalistic view in which seeking health care is viewed as useless.

186 JOURNAL OF TRANSCULTURAL NURSING / JULY 2002

Biological variations

Environmental control

Time Social organization

Culturally Unique Individual Communication

Space

NursingAssessment

FIGURE 1. Giger and Davidhizar’s Transcultural Assessment Model. SOURCE: Giger, J., & Davidhizar, R. (1999). Transcultural Nursing: Assessment and Intervention. St. Louis, MO: Mosby.

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Biological variations. Biological differences, especially genetic variations, exist between individuals in different racialgroups. It isawell-knownfact thatpeoplediffercultur- ally.Lessrecognizedandunderstoodarethebiologicaldiffer- ences that exist among people in various racial groups. Although there isasmuchdiversitywithinculturalandracial groups as there is across and among cultural and racial groups, knowledge of general baseline data relative to the specificculturalgroupisanexcellentstartingpointtoprovide culturally appropriate care. There is some evidence suggesting that different races

metabolize drugs in different ways and at different rates (Echizen, Horari, & Ishizaki, 1989). For example, Chinese people are more sensitive to the cardiovascular effects of Propranolol than are White people. Primaquine is metabo- lized by oxidation and is used in the treatment of malaria. Although Primaquine is given to individuals who lack the enzymes necessary for glucose metabolism or the red blood cells,hemolysisof theredbloodcellsoccurs.Approximately 100millionpeople in theworldareaffectedbythisparticular enzymedeficiencyand thusareunable to ingestPrimaquine. Approximately35%ofAfricanAmericanshave thisparticu- lar enzyme deficiency. Antihypertensives are another cate- gory of drugs that are metabolized differently depending on race. For example, African Americans tend to need higher doses of beta-adrenergic blocking agents such as Inderal. Chinesemen tend toneedonlyabouthalf asmuch Inderal as compared to White American males. One category of differences between racial groups is sus-

ceptibility to disease. The increased or decreased incidence may be genetically, environmentally, or gene-environmen- tally induced. American Indians have a tuberculosis inci- dencethatis7to15timesthatofnon-Indians.AfricanAmeri- cans have a tuberculosis incidence three times that of White Americans. Urban American Jews have been the most resis- tant to tuberculosis. Ethnic minorities now account for more than two thirdsof all the reportedcasesof tuberculosis in the United States, partly as a result of the increased incidence of tuberculosis among ethnic minorities affected with HIV (Centers for Disease Control, 1998). Diabetes is quite rare among American Eskimos. Diabetes has a high incidence within certain American Indian tribes, including the Semi- nole, Pima, and Papago. NIDDM, or Type 2 diabetes, is a majorhealthproblemforNativeAmericanIndians,occurring as early as the teens or early twenties. Age-specific death rates for diabetes appear to be 2.6 higher for Native Ameri- cans between 25 and 54 years of age, compared with the rest of the general population. The incidence of hypertension is higher inAfricanAmericansthanWhites.Theonsetbyageis earlier in African Americans, and the hypertension is more severe and associated with the higher mortality in African Americans. It is important to remember that susceptibility to disease may also be environmental or a combination of both genetic and environmental factors.

METAPARADIGM FOR THE GIGER AND DAVIDHIZAR MODEL

The metaparadigm for the Giger and Davidhizar model includes:

1. Transcultural nursing: A culturally competent practice field that is client centered and research focused.

2. Culturallycompetentcare:Adynamic, fluid,continuouspro- cess whereby an individual, system, or health care agency findsmeaningful anduseful caredelivery strategiesbasedon knowledge of the cultural heritage, beliefs, attitudes, and be- haviors of those to whom they render care (Davidhizar & Giger, 1998). Cultural competence connotes a higher, more sophisticated level of refinement of cognitive skills and psychomotor skills, attitudes, and personal beliefs. To de- velop cultural competency, it is essential for the health care professional to use knowledge gained from conceptual and theoreticalmodelsof culturally appropriate care.Attainment of cultural competence can assist the astute nurse in devising meaningful interventions to promote optimal health among individuals regardless of race, ethnicity, gender identity, sex- ual identity, or cultural heritage.

3. Culturally unique individuals: An individual is culturally unique and as such is a product of past experiences, cultural beliefs, and cultural norms.

4. Culturally sensitive environments: Culturally diverse health care can and should be rendered in a variety of clinical set- tings. Regardless of the level of care, primary, secondary, or tertiaryknowledgeof culturally relevant informationwill as- sist in planning and implementing a culturally competent treatment regime.

5. Health andhealth status:Health andhealth status isbasedon culturallyspecific illnessandwellnessbehaviors.Anindivid- ual’sculturalbeliefs,values,andattitudesallcontributetothe overarching meaning of health for each individual.

Internal Structure, Linkages, and Concepts

The Giger and Davidhizar Transcultural Assessment Model is based on a number of premises. Culture is a pat- ternedbehavioral response thatdevelopsover timeasa result of imprintingthemindthroughsocialandreligiousstructures andintellectualandartisticmanifestations.Cultureisalsothe result of acquired mechanisms that may have innate influ- encesbutareprimarilyaffectedbyinternalandexternalstim- uli.Culture is shapedbyvalues,beliefs,norms,andpractices that are shared by members of the same cultural group. Cul- ture guides our thinking, doing, and being and becomes pat- terned expressions of who we are. These patterned expres- sions are passed down from one generation to the next. Culture implies a dynamic, ever-changing, active, or passive process. Cultural values guide actions and decision-making and facilitate self-worth and self-esteem.

Knowledge Antecedents

The Giger and Davidhizar Transcultural Assessment Model builds on the seminal work of the founder of trans-

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culturalnursing,Dr.MadeleineLeininger(1985); theworkof Dr.RachelSpector (1996); theclassicworkofOrque,Bloch, andMonrroy(1983); and theclassicworkofHall (1966)and others in space phenomena, communication, and anthropology.

APPLICATION TO THEORY, RESEARCH, AND PRACTICE

Giger and Strickland (1995) received $750,000 to test the usefulness of the model to identify behavioral risk reduction strategies and chronic genetic indicators for premenopausal, AfricanAmericanwomenwithhigh-risk indicesofcoronary heart disease. In 1998, Linda Smith, DSN, completed a pilot studyusing themodel.Theprimarypurposeof thestudywas to describe the relationship among the scores and subscores on scales measuring concepts of cultural competency. Three scales were used: the cultural attitude scale originally devel- oped by Bonaparte (1977, 1979) and modified by Rooda (1990, 1992), the cultural self-efficacy scale developed by Bernal and Froman (1987), and the knowledge-based ques- tions on cultural competencies developed by Rooda (1990). In this study, the model served as the theoretical foundation, and the three scales served as the instruments. In 1998, Dr. SharonMullenandDr.CarlaG.PhillipsatOhioUniversity’s SchoolofNursingalsousedthemodelastheoverarchingthe- oretical framework to explore the cultural beliefs of south- easternOhioAppalachians.Theprimarypurposeof thequal- itative ethnographic study was to identify cultural beliefs of southeasternOhioAppalachiansasameansofprovidingcul- turally competent care. Giger and Davidhizar’s model was usedtoidentifyculturalbeliefs fromthesixculturalphenom- ena previously described by Giger and Davidhizar (1990, 1995, 1998, 1999). Subjects were 14 adults who had resided in the area their entire lives. The Giger and Davidhizar Transcultural Assessment Model, which also included inter- view questions and observational guidelines, was used for structural interviews.Findingsfromthisstudysuggested that theseindividualsweremoresociallyinclined,communicated more openly, had more of an internal locus of control, had fewer personal space needs, were more future oriented, used no significant home remedies, tended to be conscientious about getting to appointments on time, and were more likely to follow medical protocols than Appalachians in general.

AREAS OF FUTURE DEVELOPMENT

Workrelativetobiologicalvariationspecificallyregarding geneticvariationscontinuestoundergorefinementwithaddi- tional research by various researchers, including Giger and Strickland.

REFERENCES Bernal, H., & Froman, R. (1987). The confidence of community health

nurses in caring for ethnically diverse populations. Image: Journal of Nursing Scholarship, 19(4), 201-203.

Bonaparte,B.(1977).Aninvestigationof therelationbetweenegodefensive- ness and open-closed mindedness of female registered public nurses and their attitude toward culturally different patients. Unpublished doctoral dissertation, New York University, New York, NY.

Bonaparte, B. (1979). Ego defensiveness, open-closed mindedness, and nurses’ attitude toward culturally different patients. Nursing Research, 28(3), 166-172.

Centers forDiseaseControl andPrevention. (1998). HIV/AIDS surveillance report, 1997. Atlanta, GA: U.S. Department of Health and Human Services.

Davidhizar,R.,&Giger, J. (1998). Canadian transcultural nursing: Assess- ment and intervention. St. Louis, MO: C. V. Mosby.

Echizen,H.,Horari,Y.,&Ishizaki,T. (1989). Letter to theeditor. New Eng- land Journal of Medicine, 32(4), 258.

Geissler,E.(1998).Pocketguidetoculturalassessment.St.Louis,MO:C.V. Mosby.

Giger, J., & Davidhizar, R. (1990). Transcultural nursing: Assessment and intervention (1st ed.). St. Louis, MO: C. V. Mosby.

Giger, J., & Davidhizar, R. (1995). Transcultural nursing: Assessment and intervention (2nd ed.). St. Louis, MO: C. V. Mosby.

Giger, J., & Davidhizar, R. (1999). Transcultural nursing: Assessment and intervention (3rd ed.). St. Louis, MO: C. V. Mosby.

Giger, J., & Strickland, O. (1995). Behavioral risk reduction strategies for chronic indicators and high-risk factors for premenopausal African American women (25-45) with coronary heart disease. Grant No. N95- 019, Department of Defense, Uniformed Health Services, University of Health Sciences. Bethesda, MD: Tri-Service Nursing Research.

Hall, E. T. (1966). The silent language. Westport, CT: Greenwood. Leininger, M. (1985). Transcultural care, diversity, and universality: A the-

ory of nursing. Nursing and Health Care, 6(4), 209-212. Orque, M. S., Bloch, B., & Monrroy, L.S.A. (Eds.). (1983). Ethnic nursing

care: A multicultural approach (pp. 5-48). St. Louis, MO: C. V. Mosby Rooda, L. (1990). Attitudes of nurses toward culturally diverse patients.

Unpublished doctoral dissertation, Purdue University, West Lafayette, IN.

Rooda, L. (1992). Knowledge and attitudes of nurses toward culturally diverse patients: An examination of the social contact theory. Journal of the National Black Nurses Association, 6(1), 48-56.

Spector, R. (1996). Cultural diversity in health and illness (3rd ed.). Norwalk, CT: Appleton & Lange.

Joyce Newman Giger is a professor in the School of Nursing at University of Alabama at Birmingham. She received her EdD in nursing education from Ball State University. Areas of interest in- clude cultural diversity, psychiatric nursing, genetic research, and nursing administration. She is a fellow in the American Academy of Nursing; has published more than 100 manuscripts, book chapters, andbooksontopicsrelatedtoculturaldiversity;andhasdoneexten- sive research on topics related to cultural phenomena.

Ruth Davidhizar is dean of nursing in the Division of Nursing at Bethel College. She received her DNS in nursing from Indiana Uni- versity. Areas of interest include transcultural nursing, psychiatric nursing, and nursing education. She is the author of more than 700 articles,bookchapters,andbooksonculturalcompetencyandother health-related topics.

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