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http://tcn.sagepub.com Journal of Transcultural Nursing

DOI: 10.1177/1043659603262488 2004; 15; 93 J Transcult Nurs

Eunyoung Eunice Suh The Model of Cultural Competence Through an Evolutionary Concept Analysis

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10.1177/1043659603262488JOURNAL OF TRANSCULTURAL NURSING / April 2004Suh / CULTURAL COMPETENCE

THEORY DEPARTMENT

The Model of Cultural Competence Through an Evolutionary Concept Analysis

EUNYOUNG EUNICE SUH, MSN, RN University of Pennsylvania

Becoming a culturally competent health professional is a demanding prerequisite in this multicultural society. Cultural competence is explored and abstracted as a conceptual framework through a concept analysis using the evolutionary method. Its model is constructed from a systemic, comprehen- sive literature review and analysis. Taking into account how cultural competence is viewed by other disciplines (medicine, psychology, education, and social work), a comprehensive definition, antecedents, and consequences of cultural compe- tence in nursing are described and diagrammed. Addition- ally, two model cases and future implications are discussed. The broader American society is composed of a mosaic of discrete cultural groups existing within the context of their values and identities. Those distinct cultures affect each pa- tient’s ways of thinking and his or her perceptions on health care and health behaviors. The proposed model of cultural competence provides a theoretical guide for developing strategies to achieve culturally competent care in nursing practice and research.

Keywords: cultural competence; cultural awareness; cul- tural knowledge; cultural sensitivity; cultural skill; cultural encounter

In this multicultural society, becoming a culturally compe- tent health care professional is a necessary and demanding prerequisite. According to the U.S. Census (2000), more than 30% of the total population is composed of various ethnic

minorities other than non-Hispanic Whites. Thus, approx- imately one out of every three persons in the United States distinguishes him or herself as a “minority.” It is estimated that this minority population will grow consistently to com- prise almost 50% of the whole population by 2050 (U.S. Department of Commerce, 2000). Regarding the nurse workforce, however, nearly 90% of U.S. registered nurses are non-Hispanic White (Trossman, 1998). This disparity between the growing minority populations and the dominant ethnic composition of registered nurses has created a need for culturally competent nursing professionals.

The concept of cultural competence has been a focus of nursing over the past 20 years. This trend has produced a growing body of research concerned with patients’ cultural characteristics. In addition, nursing theories have been de- veloped to explain and address the phenomena of cultural diversity and commonality (Campinha-Bacote, 1994, 1995; Leininger, 1988, 1991; Purnell & Paulanka, 1998). Health care institutions are inevitably affected by this growing trend. Some of them have established guidelines and strategies to inform and instruct nurses on how to more effectively care for diverse populations (Randall-Davie, 1994).

Although cultural competence is becoming one of the es- sential components of nursing practice, the concept of cul- tural competence has not been clearly defined or analyzed (St. Clair & McKenry, 1999). The concept of culture implies many different meanings depending on its definition of scope, for example, culture of an ethnic group or culture of an individual. It is, therefore, not surprising that the concept of cultural competence has been defined in many ways. Cul- tural competence in nursing care has been addressed both explicitly and implicitly in many published articles. Authors sometimes use it interchangeably with various terms such as transcultural nursing, culturally congruent nursing care, or culturally sensitive nursing care.

Author’s Note: The author wishes to express sincere thanks to Dr. Sarah H. Kagan and Dr. Deborah McGuire at the University of Pennsylvania School of Nursing for their insightful advice and comments.

Because conceptual meanings change over time, it is nec- essary to define and analyze the current perspective on cul- tural competence in nursing. Thus, the purpose of this article is to develop a theoretical model of cultural competence through a concept analysis using the evolutionary method (Rodgers, 2000). Clear definitions, attributes, antecedents, and consequences related to cultural competence will be de- rived from a systemic literature review and critical analysis. The model of cultural competence will help to guide nursing practice and research to address the disparity between care needs of diverse populations and nurses’ preparedness.

METHODOLOGY

Rodgers’s (1989) evolutionary concept analysis was used to outline this article. Along with the notion of paradigm shift (Kuhn, 1970), Rodgers’s (1989) evolutionary view of con- cept analysis was developed in opposition to the classical essentialist position. In Rodgers’s evolutionary method, a concept in nursing phenomena is viewed as dynamic, fuzzy, context dependent, and to possess some pragmatic utility or purpose (Rodgers, 2000).

The concept of cultural competence could be defined in many ways depending on different contextual and historical backgrounds of specific populations. Furthermore, the mean- ing of cultural competence is changing continuously over time. Therefore, considering the variation of the concept of cultural competence, Rodgers’s (1998) evolutionary method is an appropriate approach to analyze the concept of cultural competence in nursing phenomena.

LITERATURE SEARCH STRATEGIES

For this concept analysis, in addition to nursing literature, literature connected with medicine, psychology, education, and sociology was used as reference sources. Sample articles were derived from five different online databases: CINAHL, MEDLINE, PsycINFO, ERIC, and Sociological Abstracts from 1982 to the present. Most references were published in the 1990s, demonstrating the recently increased awareness of the concept of cultural competence in health care. The CINAHL database yielded over 300 articles under the key phrase cultural competence. Including the other four data- bases, a total of over 900 references were acquired after initial sampling. Based on the evolutionary method (Rodgers, 2000), 20% of the total articles were randomly selected from CINAHL, PsycINFO, and ERIC. Also, at least 30 articles were randomly selected from MEDLINE and Sociological Abstracts.

Additionally, the author included articles from the major journals focused on culture such as Journal of Cultural Di- versity, Journal of Transcultural Nursing, and Journal of Multicultural Nursing & Health. Lastly, “landmark” works by nurse researchers such as Leininger (1978, 1985, 1988, 1991, 1995, 1996, & 1997), Purnell (1998), and Campinha-

Bacote (1994, 1995, & 1999) were also included. After delet- ing cross-referenced articles, the author analyzed a total of 124 articles and 21 books.

CULTURAL COMPETENCE AS VIEWED BY OTHER DISCIPLINES

Understanding the definitions and applications of the concept of cultural competence in other disciplines closely related to nursing is critical to analyzing cultural compe- tence in the nursing domain. With cultural diversity trends in society and in health care, cultural competence is fre- quently used in medicine, psychology, education, and social work to determine proper interpersonal relationships. More specifically, cultural competence has been highlighted as a required characteristic in interactions with ethnically dif- ferent populations, such as relationships between physician and patient, psychologist and patient, teacher and student, and social worker and care recipient.

Medicine

Medical anthropologists have studied health and illness in different cultures. Medical anthropology as a field of study, however, focuses mainly on beliefs and practices related to health and illness in different cultures (Helman, 2000a). Thus, the concept of cultural competence, which physicians or organizations need to master for appropriate relationships with ethnically diverse patients, has not been clearly defined by medical anthropologists. In practice disci- plines, historically, there has not been much attention given to patients’ cultural aspects due to positivistic biomedical per- spectives. Barzansky, Jonas, and Etzel (2000) reported that only one medical school had a separate required course con- cerning cultural diversity among 125 Liaison Committee on Medical Education (2000) accredited U.S. medical schools in 1999-2000.

In contrast, awareness has recently increased about the need for physicians to possess knowledge and skills related to cultural competence (Barzansky et al., 2000; Dedier, Penson, Williams, & Lynch, 1999; Saha, Komaromy, Koepsell, & Bindman, 1999). Moreover, the influence of patients’ cultural factors on their psychiatric symptoms, patient/physician re- lationships, and adherence to treatment have been recently reported (Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1995; Helman, 2000b, 2000c; Pumariega, Johnson, Sheridan, & Cuffe, 1996; Saha et al., 1999).

Lastly, there is more recognition of the need for cultural diversity training and institutional requirements for such training for preclinical medical students (American Academy of Pediatrics, 1999; Association of American Medical Col- leges, 1998; Barzansky et al., 2000; Bissonette & Route, 1994; Culhane-Pera, Reif, Egli, Baker, & Kassekert, 1997; Godkin & Savageau, 2001; Loudon, Anderson, Gill, & Greenfield, 1999). The notion of cultural competence in med-

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ical practice is an emerging concept in response to changes in societal demographics and thus parallels the discourse in nursing. Cultural competence is considered a process that requires individuals and health care systems to develop and expand their ability to effectively know about, be sensitive to, and have respect for cultural diversity (Association of American Medical Colleges, 1998; Flores, 1997).

Psychology

The concept of culture in psychology has been prevalent for more than 50 years. Three prominent mental health pro- fessionals, Carl Jung, Erik Erikson, and Alan Roland, ex- panded their view of other cultures (Bennett & Finger, 2000) in the last five decades. Since its introduction and adoption into mainstream psychology, the need for culturally compe- tent psychotherapy, which encompasses proper interpersonal communication and a relationship between psychologists and ethnically different patients, has been acknowledged and studied (D. Sue & Sue, 1999; S. Sue, 1998; S. Sue & Zane, 1987; Valencia & Yaniz, 1999). With this comprehensive un- derstanding, the American Psychological Association’s (APA) Board of Ethnic Minority Affairs (BEMA) established the guidelines for providers of psychological services to eth- nic, linguistic, and culturally diverse populations (American Psychological Association Office of Ethnic Minority Affairs, 1993). The guidelines focus on psychological service pro- viders’ understanding of the role of culture and appropriate approach to interpersonal communication (American Psychological Association Office of Ethnic Minority Affairs, 1993).

Overall, the concept of cultural competence in psychology is defined as “effectiveness in psychotherapy” (Sue, 1998). It has been demonstrated that a culturally competent psychol- ogist possesses awareness of diversity, cultural knowledge, cross-cultural communication skills, and proper attitudes necessary to provide effective care for diverse populations (D’Andrea, Daniels, & Heck, 1991; Fong & Gibbs, 1995; Mio, 1989; Parker, Valley, & Geary, 1986; Pope & Reynolds, 1997; Sue, 1998; Sue & Zane, 1987; Valencia & Yaniz, 1999; Williams & Becker, 1994).

Education

American education has also been affected by societal de- mographic changes. For example, recently developed pro- cess-oriented models for serving diverse learners, such as Helms’ Racial Identity Theory (1984), Bennett’s Develop- ment Model of Intercultural Sensitivity (1993), and Banks’ Typology of Ethnicity (1994), implicitly contain the concept of cross-cultural competence. These models also emphasize the culturally competent teacher’s role interacting with cul- turally diverse students (Craig, Hull, Haggart, & Perez- Selles, 2000; Gibson, 1998; Grant-Thompson & Atkinson, 1997; McAllister & Irvine, 2000; Osher & Mejia, 1999). Dis- tinctively in school education, a teacher’s bilingual ability

was emphasized for effective communication (Madding, 2000; Mangan, 1995; McMeniman & Evans, 1997; Osher & Mejia, 1999; Skutnabb-Kangas & Phillipson, 1983; Vanikar, 1985). Similar to the definitions in psychology, cultural com- petence in school education is composed of awareness and acceptance of cultural differences, awareness of the teacher’s own cultural values, knowledge of the students’ culture, and ability to adapt practical skills to fit the students’ cultural con- text (Grant & Haynes, 1995; McManus, 1988; Sowers-Hoag & Sandau-Beckler, 1996). Additionally, the concept of cul- tural competence is defined as a “dynamic process of growth through ongoing questioning, self-assessment, knowledge and skill-building, starting with the students’ level of current competence and supporting enhancement of their abilities” (Sowers-Hoag & Sandau-Beckler, 1996, p. 37).

Social Work

Literature yielded from the Sociological Abstracts data- base mainly concerned social work practices for diverse pop- ulations. Because the scope of practice in social work over- laps that of mental health, education, and medical care, cultural competence in social work mirrors psychology and education. Originating from Western civilization’s view of the individual and society, the social work discipline has widely advocated for civil rights and social welfare of op- pressed minority populations (Lum, 1982). During the last 20 years in particular, attention to and discourse on welfare in minorities has increased enormously (Manoleas, 1994). All schools of social work accredited by the Council of Social Work Education (CSWE) presently include course content on cultural diversity (Boyle & Springer, 2001).

Among numerous conceptual definitions of cultural com- petence in social work, Green (1982) first defined it as “the ability to conduct professional work in a way that is con- sistent with the expectations which members of a distinctive culture regard as appropriate among themselves” (p. 87). Cultural competence is not a goal to be achieved but “a pro- cess of striving to become increasingly self-aware, to value diversity, and to become knowledgeable about cultural strengths and vulnerabilities experienced by families living in this country” (Bonecutter & Gleeson, 1997, p. 111). The con- cept of culture is interwoven implicitly with earlier social work theories, such as Culture-Centered Systems Theory (Bates & Harvey, 1975), Cultural Duality Theory (Chestang, 1976), and Cross-Cultural Relations Theory (Bochner, 1982). Typically in Cross-Cultural Relations Theory (Bochner, 1982), the outcome of cross-cultural interaction can range from cultural rejection to acceptance in which the person’s cultural competence can play an important role (Lum, 1982). The Cultural Competence Attainment Model recently developed by McPhatter (1997) explicitly addresses cultural competence. The components of the model are an enlightened consciousness, a grounded knowledge base, and

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cumulative skill proficiency. The model is holistic, circular, and interconnected (McPhatter, 1997).

In general, cultural consciousness or awareness, cultural knowledge, proper skill, and attitudes or values are consid- ered as key components of cultural competence in social work practices (Bitonti, Albers, & Reilly, 1996; Boyle & Springer, 2001; Carrillo, Holzhalb, & Thyer, 1993; Chau, 1992; Dana, Behn, & Gonwa, 1992; Freeman, 1994; Grant & Haynes, 1995; Harvey & Rauch, 1997; Haynes, Eweiss, Mageed, & Chung, 1997; Krajewski-Jaime, Brown, Ziefert, & Kaufman, 1996; Leung, Cheung, & Stevenson, 1994; Manoleas, 1994; Rauch, 1999; Ronnau, 1994; Schlesinger & Devore, 1995; Stevenson, Cheung, & Leung, 1992; Williams, 1997).

HISTORICAL CONTEXT

Historically, nursing care for ethnically diverse popula- tions has not been a main concern in nursing education, re- search, and practice (Leininger, 1997). The origin of cultural competence began with Madeleine Leininger (1978) and her Theory of Culture Care Diversity and Universality (1985, 1988, & 1991). Leininger (1985, 1988, & 1991) implicitly described the concept of cultural competence in the dimen- sion of culturally congruent nursing care. Leininger (1991) developed her theory with its philosophical base on the natu- ralistic and qualitative paradigm as opposed to logical posi- tivist perspectives.

Since then, culturally competent nursing care for minority populations has been rapidly a matter of common interest in various societal and health care areas. According to Meleis (1996), the urgency to achieve culturally competent nursing care is due to “increasing diversity, increasing disclosure of identities, care delivery moving to home, and increasing ineq- uity in access to health care” (p. 2).

In the late 1990s, several models were developed to in- clude patient’s cultural factors in nursing practice. These models include Purnell’s (Purnell & Paulanka, 1998) Model for Cultural Competence, Warren’s (1999) Cultural Compe- tence: An Interlocking Paradigm, and Campinha-Bacote’s (1999) Process of Cultural Competence in the Delivery of Healthcare Services.

Literature from the late 1990s to the present demonstrates that demands for culturally competent nursing care are wide- spread in nursing practices from institutional care, such as hospital and long-term care, to case management (Remus & Handler, 2001) and home health care (de Savorgnani & Haring, 1999). Incorporating cultural diversity issues into nursing curricula through formal classes (Reeves, 2001) and multicultural immersion experiences are vital (Frisch, 1990; Heuer, Russell, & Kahlstorf, 1997; Lockhart & Resick, 1997; Ryan, Twibell, Brigham, & Bennett, 2000; Zorn, 1996).

DEFINITION OF CULTURAL COMPETENCE

Due to its broad usage and applicability, the concept of culture has been defined in many different ways by health care practitioners. Generally, culture is understood as an im- portant societal factor determining values, beliefs, and behav- iors of an individual or group in respect to health care prac- tices (Dvorak, 2000; Gonser, 2000; Helman, 2000a; Herrick & Brown, 1998; Rorie, Paine, & Barger, 1996; Tuck, 1997). The definition of cultural competence is found in many arti- cles reflecting various points of view. In the aforementioned Model for Cultural Competence (Purnell & Paulanka, 1998), cultural competence is defined as (a) developing an aware- ness of one’s own existence, sensations, thoughts, and envi- ronment without letting it have an undue influence on those from other backgrounds; (b) demonstrating knowledge and understanding of the client’s culture; (c) accepting and re- specting cultural differences; and (d) adapting care to be congruent with the client’s culture (p. 2).

The American Academy of Nursing’s (1992) Expert Panel on Culturally Competent Care made 10 recommendations for culturally competent health care and defined culturally com- petent care as care that is “sensitive to issues related to cul- ture, race, gender, and sexual orientation,” achieving self- efficacy in communication skills, cultural assessments, and acquisition of knowledge related to health practices of certain cultures (p. 278).

Campinha-Bacote (1995, 1999) integrated the four com- ponents of her model and defined cultural competence as an ongoing process of seeking cultural awareness, cultural knowledge, cultural skill, and cultural encounters. She de- scribed cultural competence as “the process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client (in- dividual, family or community)” (Campinha-Bacote, 1999, p. 203). This is the most frequently cited definition of the term in nursing literature.

The most comprehensive definition of cultural compe- tence in nursing practice for this analysis can be defined and integrated as “cultural competence is an ongoing process with a goal of achieving ability to work effectively with cul- turally diverse groups and communities with a detailed awareness, specific knowledge, refined skills, and personal and professional respect for cultural attributes, both differ- ences and similarities” (see, e.g., Campinha-Bacote, 1995; Dvorak, 2000; Gerrish & Papadopoulos, 1999; Gonser, 2000; Herrick & Brown, 1998; Hewitt, 1993; Holland & Courtney, 1998; St. Clair & McKenry, 1999; Tuck, 1997; Weaver, 1999).

ATTRIBUTES OF CULTURAL COMPETENCE

Attributes of a concept are the cluster of characteristics that are the most frequently associated with the concept and that allow the analyst the broadest insight into the concept

96 JOURNAL OF TRANSCULTURAL NURSING / April 2004

(Walker & Avant, 1995). Ability, openness, and flexibility are identified as the attributes of cultural competence distin- guished from its components or antecedents (see Figure 1).

The first attribute of cultural competence is ability. It is characterized as the nurses’ ability to effectively care for eth- nically diverse populations. In other words, cultural compe- tence is about nurses’ extensive ability to resolve cultural dis- parity between patients and health care professionals. Most of the existing definitions of cultural competence contain the word “ability” (Campinha-Bacote, 1994, 1995; Campinha- Bacote & Padgett, 1995; Dana et al., 1992; Krajewski-Jaime et al., 1996).

Openness to cultural diversity is another attribute of cul- tural competence (Germain, 1999; Lipson & Meleis, 1989; Lynam & Anderson, 1986; Rorie et al., 1996; Talabere, 1996; Valencia & Yaniz, 1999; Well, 2000; Zoucha, 2000). Open- ness largely includes the care providers’ having an open mind (Fitz, 1997), acceptance and respect (Purnell & Paulanka, 1998; Randall-Davie, 1994), being nonjudgmental (Herrick & Brown, 1998), and having an objective attitude (Wells, 2000) to cultural attributes.

Lastly, flexibility is an implicit attribute of cultural compe- tence, which broadly means an ability to adapt oneself to dif- ferent situations (Boi, 2000; Herrick & Brown, 1998). Specif- ically, flexibility related to cultural competence embraces culturally relativistic perspective (Talabere, 1996), intersubjectivity (Mendyka, 2000), and commitment to and appreciation of other cultures (Valencia & Yaniz, 1999).

ANTECEDENTS

Antecedents are those events or incidents that must pre- cede the occurrence of a concept (Walker & Avant, 1995). Antecedents of cultural competence can be grouped accord- ing to cognitive, affective, behavioral, and environmental domains (see Figure 1).

Cognitive Domain

The cognitive domain includes cultural awareness and cultural knowledge. First, cultural awareness is a cognitive recognition of a need for cultural competence, which stems from the appreciation of cultural diversity. Cultural aware- ness is described as becoming “appreciative and sensitive to the values, beliefs, lifeways, practices, and problem solving strategies of clients’ cultures” (Campinha-Bacote, 1999, p. 204). It embraces examining one’s own cultural prejudice and biases toward other cultures and in-depth exploration of one’s own cultural background (Bernal, 1998; Bucher, Klemm, & Adepoju, 1996; Campbell & Campbell, 1996; Campinha-Bacote, 1999; Cotton, 1999; Holland & Courtney, 1998; Kurasaki & Sue, 1998; Papadopoulos, Tilki, & Taylor, 1998; Stevenson et al., 1992; Wells, 2000; Zoucha, 2000).

Second, cultural knowledge is an educational foundation used to understand other cultures. It includes learning about other cultures’ worldview (Bucher et al., 1996), languages (Bernal, 1998), and the elements of culture, such as his- torical, political, social, and economic factors (Gerrish & Papadopoulos, 1999; Wells, 2000). Cultural knowledge can

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Cognitive Domain Cultural Awareness Cultural Knowledge

Receiver Based Variables Holistic nursing care

Quality of Life Health care satisfaction Adherence to treatment

Provider Based Variables Personal & professional growth

Cognitive development

Health Outcome Variables Quality of nursing performance

Treatment effectiveness Cost effectiveness

Affective Domain Cultural Sensitivity

Behavioral Domain Cultural Skills

Environmental Domain Cultural Encounters

Cultural Competence

Ability

Openness Flexibility

FIGURE 1. The Model of Cultural Competence.

be especially achieved by the experience of participating in cultural immersion (Heuer et al., 1997). Preparedness of health care professionals with proper cultural knowledge has been addressed as an essential prerequisite of cultural compe- tence in many nursing literatures (Bernal, 1998; Bucher et al., 1996; Campbell & Campbell, 1996; Hogan-Quigley, 1998; Kurasaki & Sue, 1998; Sawyer et al., 1995; Thomas, Brandt, & O’Connor, 1999; Wells, 2000).

Affective Domain

Unlike cognition-focused antecedents, cultural sensitivity includes one’s affective recognition related to cultural dif- ferences. Cultural sensitivity is widely used, thus proposing many different meanings (Bernal, 1998). In this analysis, however, cultural sensitivity is viewed as intentional and af- fective perception of cultural diversity, which is an essential component of cultural competence (Cosentino, 1999; Fielo & Degazon, 1997; Sawyer et al., 1995). Cultural sensitivity de- notes respect for cultural differences (Peragallo, 1999; Yoos, Kitzman, Olds, & Overacker, 1995) and having an accepting attitude (Jones, Bond, & Cason, 1998).

Behavioral Domain

Manifesting proficient cultural skill is an antecedent in the behavioral domain. Cultural skill includes relevant cultural data assessment, culturally based physical assessments, as well as intercultural communication skills (Bucher et al., 1996; Campbell & Campbell, 1996; Campinha-Bacote, 1999; Holland & Courtney, 1998; Kurasaki & Sue, 1998; Thomas et al., 1999). Cultural skill enables health care pro- fessionals to learn patients’ cultural beliefs, values, and prac- tices and to determine proper nursing intervention within the context of the people being evaluated (Campbell & Campbell, 1996).

Environmental Domain

Lastly, different from the former antecedents that are pre- required components of cultural competence, the cultural en- counter is an environmental precondition to make cultural competence occur. Cultural encounter implies any situation in which a nurse comes across a patient from a culture other than the nurse’s own. In other words, cultural encounter pro- vides an environment that allows cultural competence to ensue (Baldwin, 1999; Bucher et al., 1996; Campinha- Bacote, 1995, 1999; Frisch, 1990; Holland & Courtney, 1998; Rorie et al., 1996; Schlickau, 1996; St. Clair & McKenry, 1999; Zorn, 1996). To educate nursing students in culturally diverse situations, cultural encounter is designed as a program such as a cultural immersion experience pro- gram (Lockhart & Resick, 1997; Ryan et al., 2000) or an international nursing program (Frisch, 1990; Heuer et al., 1997).

CONSEQUENCES

Cultural competence has been described as a nurse’s re- quired ability, openness, and flexibility to work with patients from cultures other than the nurse’s own with detailed aware- ness, knowledge, sensitivity, and skills. As a result of cul- tural competence, several consequences are addressed in the reviewed literature. Those consequences are categorized into three categories: receiver-based variables, provider-based variables, and health outcome variables.

Receiver-Based Variables

Receiver-based variables include the patient’s subjective experiences when he or she receives culturally competent nursing care. Cultural competence produces holistic care for ethnically diverse patients (Phillips & Lobar, 1995), which is considered to be the most effective care (Boi, 2000). Cultural competence also increases the patient’s quality of life (Aday, 1994; Snowden & Holschuh, 1992; Wells, Golding, Hough, Burnam, & Karno, 1989) and health care satisfaction (Rooda, 1993). A good perception of health care providers (Saha et al., 1999) and better adherence to prescribed medical regi- mens (Ahmann, 1994; St. Clair & McKenry, 1999) are achieved following culturally competent care as well.

Provider-Based Variables

Provider-based variables indicate things health care pro- viders could obtain following cultural competence in the situ- ation of caring for culturally diverse patients. For example, following cultural competence in a group of nursing students who were immersed in a different culture, personal and pro- fessional growth in values, communication, and nursing practice were reported (Heuer et al., 1997; Ryan et al., 2000; Schlickau, 1996). Also, nursing students who participated in an international nursing program demonstrated significantly more growth in their cognitive development than those who did not (Frisch, 1990). The long-term effects of the cultural immersion experience lasted for years, enhancing interna- tional perspective and increasing personal development (Zorn, 1996).

Health Outcome Variables

Several consequences related to health outcomes were identified. Quality of nursing performance (Rooda, 1993) was increased following culturally competent care. Care provider–patient rapport and intersubjectivity were estab- lished (Sue, 1998). Cultural competence also produced treat- ment effectiveness (Sue, 1998) as well as cost effectiveness (Remus & Handler, 2001). Overall, cultural competence re- sulted in decreasing health disparities between ethnic groups (Brookins, 1993; Jones et al., 1998).

98 JOURNAL OF TRANSCULTURAL NURSING / April 2004

MODEL CASES

A model case is a real-life example of the use of the con- cept that embraces all the attributes of the concept (Walker & Avant, 1995). Model cases should be identified rather than constructed by the investigator because the evolutionary method is an inductive technique (Rogers, 2000). A nurse’s narrative chosen from the study by DiCicco-Bloom (2000) showed that a nurse’s lack of cultural competence caused dis- tance between the nurse and a Pakistani woman.

My patient was a young Pakistani woman of the Muslim faith. She was giving birth to a stillborn. The policy on the floor was to encourage mothers to look at and hold their stillborn child to assist them with closure and the grieving process. Her mother and her husband accompanied the woman. When I presented the idea to the family, the mother of the patient and the husband of the patient both said, “No way, we don’t do those things. The baby has gone and we have moved on.” The patient said nothing. She seemed aloof and detached. The other nurses told me that she had a Ph.D. and that she was very intelligent. I didn’t understand why she didn’t speak up. If I had understood the culture better, I might have had a better handle on the situation. After she had delivered and when the family left, I brought the dead baby to her. She stared at it and then held it. She didn’t show any emotion. I saw her leave the next day as if nothing had happened. I don’t know if I did the right thing. (p. 31)

The nurse was not culturally sensitive enough to be aware that the Pakistani woman’s culture affected her process of grief. Also, she did not have cultural knowledge and commu- nication skills. The aforementioned consequences did not oc- cur in this case: The patient did not receive culturally compe- tent care, and the nurse could not expand her perspective to diverse cultures. In contrast, the following clinical situation (Warren, 1999) demonstrates a positive exemplar of cultural competence in nursing practice.

One day Mr. and Mrs. Chen, accompanied by Mr. Chen’s father, come to the clinic with their 6-month-old daughter. The clinic nurse who has been following the Chen family’s care, notices that the baby has an acute respiratory infection (ARI) and abrasions and surface burns on her back. The nurse inquires if any treatments have been used on the baby. Mrs. Chen says yes and that Mr. Chen (indicating her father-in- law) has been treating her. The nurse realizing that grand- fathers are highly respected and are the treatment providers in Vietnamese culture, asks Mr. Chen if he could describe the treatment he has been using. He states that moxibustion/ cupping and coining are the treatments he is using for the baby’s cold. The nurse acknowledges that she understands the purpose of these treatments (i.e., to expel the poisons from the body) but also mentions that the baby could develop infec- tions because of the breaks in the skin. She also states that some persons in America might think that the baby is being abused because of the marks on the body. The nurse makes a

suggestion and ask if it is possible for Mr. Chen to use less pressure, cover the coin with a piece of cloth, and slightly cool and cover the moxibustion glass with cloth before he applies it to the skin whenever he uses these treatments. . . . The nurse also consults with the clinic physician regarding the baby’s ARI, abrasions, and burns. The physician pre- scribes an antibiotic for the baby’s ARI and some ointment for the burns. The Chen family returns to the clinic in 1 week. The baby’s ARI is gone, and the bruises and burns are almost completely healed. Mr. Chen states that they have been fol- lowing all the nurse’s suggestions, including giving the West- ern medicines. (p. 203)

This model case demonstrates that the clinic nurse was sensitive enough to be aware of Vietnamese traditional treat- ments. The nurse also showed openness in accepting cultural differences and flexibility in allowing the Chen family to con- tinue their traditional treatment for the baby. The nurse also had an ability to effectively work with the Chen family in terms of having cultural awareness, knowledge, sensitivity, and skills. As the consequences of the nurse’s cultural com- petence, the baby’s ARI and burns were healed (treatment effectiveness), and the Chen family followed the Western medicines (patient adherence). The nurse achieved personal development through expanded cross-cultural experience and positive clinical outcomes.

IMPLICATIONS AND DISCUSSION

Through a comprehensive literature review and analysis using Rodgers’s evolutionary method (1989), the model of cultural competence was developed (see Figure 1). This theo- retical framework presents that achieving cultural compe- tence is a process requiring specific ability, openness to cul- tural attributes, and flexibility to adjust to those attributes, both differences and similarities. Cultural awareness, knowl- edge, sensitivity, skills, and encounters should precede cul- tural competence. Its affirmative consequences are also dem- onstrated from three different standpoints: receiver-based variables, provider-based variables, and health outcome variables.

This model of cultural competence provides a practical guide to develop strategies for culturally competent care in practice especially by offering cognitive, affective, behav- ioral, and environmental aspects of cultural competence. Also, three different domains of consequences are the out- comes of culturally competent care that can be tested in service-based fields such as nursing, medicine, psychology, education, and social work. The model of cultural compe- tence indicates that just knowing about patients’ cultures is not sufficient to become a culturally competent nurse. It de- mands nurses to carefully reflect their own cultural prestige and achieve multifactorial prerequisites of cultural compe- tence. Cultural competence, thus, is a fundamental schema rather than a matter of fact. Also, cultural competence is an

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ongoing process that requires a nurse’s commitment to a new way of thinking, which may change over time and with exposure to new and different groups.

The broader American society is composed of a mosaic picture of discrete cultural groups existing within the context of their own values and identities. Those distinct cultures are embedded in the thinking of each patient, affecting his or her perceptions on health care and health behaviors. To deliver culturally competent nursing care to those diverse patients, nurses need to recognize that cultural competence is not just what nurses achieve but rather what nurses become.

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Eunyoung Eunice Suh, RN, MSN, is a PhD candidate in the School of Nursing at the University of Pennsylvania. She received her MSN in oncology nursing from Seoul National University at Seoul, Korea. Her research interests include cancer care in minority populations.

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