DECENT WORK EMPLOYMENT AND

TRANSCULTURAL NURSING
NCM 120
WMSU
MA. ESPERANZA E. REAVON, MAN, RN
Week 1: COURSE CONTENT (2 hours)
Essential Transcultural Nursing Care
II.

Concepts, Principles, Examples, and Policy

Statements

Human care as essence in nursing

Culture and Nursing
Cultural Diversity, Universality, Racism, and
Related Concepts
Five Basic Interactional Phenomena (Next
Week)
Week 3: COURSE CONTENT (2 hours)
Topic 2

I. Models of Transcultural Nursing

A. Theory of Universality and Diversity (Madeleine

Leininger)
B. Health Traditions Model (Rachel Spector Leininger)
C. Transcultural Nursing Assessment (Josephine
Campinha-Bacote)
D. Health Assessment Model (Larry Purnell)
E. Cultural Health Assessment Model (Ruth Davidhizar
and Joyce Newman Giger)
F. Ethical Decisions Model (Dula Pacquiao)
G.Cultural Assessment Model (Andrew Boyle)
TOPIC 1
II. FIVE BASIC INTERACTIONAL PHENOMENA
The Five Basic Interactional Phenomena
Nurses working in transcultural contexts need to be clear on five basic concepts, namely,
culture encounter, enculturation, acculturation, socialization, and assimilation. These
concepts come largely from anthropology and are essential in transcultural nursing.

1. Culture encounter or contact refers to a situation in which a person from one

culture meets or briefly interacts with a person from another culture.

For example, nurses giving tours, making brief visits, or having encounters with
people of different cultures seldom become “transcultural experts” of the cultures.
The lack of in-depth knowledge or preparation prior to the encounter is usually
evident.
The Five Basic Interactional Phenomena

2. Enculturation is a very important phenomenon to understand in

transcultural nursing. It refers to the process by which one learns to
take on or live by a particular culture with its specific values, beliefs,
and practices.
Nurses are also enculturated within the nursing profession by learning the norms
(rules of behavior), values, and other expectations of the nursing culture. It is important
that nursing students become enculturated into nursing values, norms, and lifeways to
survive, function, and become professional nurses. Nurses become enculturated into
local hospitals, community agencies, and other health services to accept and maintain
practice expectations.
The Five Basic Interactional Phenomena

3. Acculturation is closely related to enculturation but has some differences.

Acculturation refers to the process by which an individual or group from Culture A
learns how to take on many (but not all) values, behaviors, norms, and lifeways of
Culture B.

Acculturated individuals generally reflect that they have taken on or adopted the lifeways
and values of another culture by their actions and other expressions. It is, however, interesting
that an individual from Culture A may still retain and use some traditional values and practices
from the old culture, but this does not interfere with taking on new culture norms.

With acculturation, one generally becomes attracted to another culture for various reasons
and almost unintentionally learns to take on the lifeways of the new culture in dress, talk, and
daily living. This person or family becomes acculturated to the new culture.
The Five Basic Interactional Phenomena

4. Socialization differs slightly from the above concepts. It refers to the

social process whereby an individual or group from a particular culture
learns how to function within the larger society (or country), that is to know
how to interact appropriately with others and how to survive, work, and live
in relative harmony within a society.

They often refer to this as “taking on the new ways” or “living in x society.” Socialization is
different from acculturation because the goal of socialization is to learn how to adapt to and
function in a large society with its dominant values, ethos, or national lifeways. It is not
necessarily becoming acculturated to a particular local culture or another culture. It requires
becoming an acceptable member of the dominant and larger society.
The Five Basic Interactional Phenomena
5. Assimilation refers to the way an individual or group from one
culture very selectively and usually intentionally selects certain
features of another culture without necessarily taking on many or all
attributes of lifeways that would declare one to be acculturated.

Assimilation is different from becoming fully acculturated or enculturated to

another culture. With assimilation, the individual generally may be attracted to
certain features, values, material goods or lifeways of a culture, but does not adopt
the total lifeways of another culture.
TOPIC 2
MODELS OF TRANSCULTURAL NURSING
 THE THEORY OF UNIVERSALITY AND DIVERSITY (M.
LEININGER)
Madeleine Leininger (July 13,
1925 – August 10, 2012) was an
internationally known educator,
author, theorist, administrator,
researcher, consultant, public
speaker, and the developer of
the concept of transcultural
nursing that has a great impact
on how to deal with patients
of different culture and cultural
background.

She is a Certified Transcultural

Nurse, a Fellow of the Royal
College of Nursing in Australia,
and a Fellow of the American
Academy of Nursing. Her theory
is now a nursing discipline that
is an integral part of how nurses
practice in the healthcare field
today.
Leininger's Cultural Care Diversity and Universality
Theory/Model
Madeleine Leininger's theory and the Sunrise Model that depicts her
theory are perhaps the most well known in nursing literature on culture and
health (Leininger & McFarland, 2006). The theory draws from
anthropological observations and studies of culture, cultural values,
beliefs and practices. The theory of transcultural nursing promotes better
understanding of both the universally held and common understandings of
care among humans as well as the culture-specific caring beliefs and
behaviors that define any particular caring context or interaction. Leininger
states that the theory of cultural care diversity and universality is holistic.
Culture is the specific pattern of behavior that distinguishes any society
from others and gives meaning to human expressions of care. The
following are assumptions about care/caring as they relate to cultural
competency:
• Care (caring) is essential to curing and healing, for there
can be no curing without caring.
• Every human culture has lay (generic, folk, or indigenous)
care knowledge and practices and usually some
professional care knowledge and practices, which 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
ethnohistorical, and environmental contexts of cultures.
• A client who experiences nursing care that fails to be reasonably
congruent with his/her beliefs, values, and caring lifeways will show
signs of cultural conflict, noncompliance, stress and ethical or moral
concern.

• Within a culture care diversity and universality framework, nurses

may take any or all of these culturally congruent action modes
including: cultural preservation, maintenance of patients’ and families’
existing patterns of care and health behaviors, cultural
accommodation/negotiation to modify patterns of care, and cultural
restructuring/repatterning to change or repattern cultural care
behaviors.
 LEININGER’S NURSING THEORY
• Began when Leininger observed that children of different cultures
required different needs
• Purpose: Explicate TCN
• Goal: Providing care that is Culturally Congruent
• Described her theory as “creative and systematic way of discovering
new knowledge:
• Increasingly relevant due to migration and diversity grows
• Broad Theory: Impact of culture on all aspects of human life
• Respecting the culture of the patient and recognizing the importance
of its relationship to care-transcultural nursing.
• Focused on: Preservation, accommodation, or re-patterning
FOUR METAPARADIGMS
1. NUSING= CARING
2. PERSON= FAMILIES, GROUPS
3. HEALTH = NOT UNIQUE IN NURSING
4. ENVIRONMENT= CONTEXT

CULTURE= group’s values, beliefs, norms and life practices that are learned, shared and
handed down
CARING= assisting, supporting and enabling behaviors that ease or improve a patient’s
condition
HEALTH= universal concept across all cultures but is defined differently by each to reflect its
specific values and beliefs
NURSING= learned humanistic art and science tht focuses on personalized behaviors,
functions, processes to promote and maintain health or recovery from illness.
THREE MODES OF ACTION TO DELIVER CARE
1. CULTURE CARE PRESERVATION OR MAINTENANCE
2. CULTURE CARE ACCOMODATION OR NEGOTIATION
3. CULTURE CARE RECONSTRUCTURING OR
REPATTERNING
LEININGER’S NURSING THEORY
SUNRISE MODEL
• Facilitates the application of the theory of Culture Care Diversity and
Universality

LEVEL 1: World Wide Views

LEVEL 2: Person’s different views
LEVEL 3: Health
• Folk: Client’s traditional beliefs and practices on health
• Nursing and professional: biological, physiological, and cultural
health needs learned in an educational level. The Nurse is the
Bride.

LEVEL 4: Decisions
BENEFITS
• Brings awareness of ways patient’s culture effects
their experience of illness, suffering and even death.
• Helps strengthen relationship between nurse and
patient.
• Keep nurse open-minded to treatments
• Understand how the nurse’s own culture affects her
care.
Limitations
• Not enough time to fully comprehend culture
• Miscommunication
• Own Prejudices
• Trying to understand but too different to treat
• Cultural understanding of illnesses or treatments may
be wrong or harmful.
Application to Nursing Care

1. Culture Care Theory of Diversity and Universality can be

applied:
-Encouraging patients to discuss their background and
experience with health care system
-Demonstrate open mindedness
Application to Nursing Care

2. The applications are numerous but are based on

what is known and how much a nurse is willing to
learn about the patients culture. However, It is an
important theory aimed at improving health care.
Spector’s Health Traditions Model (Spector, 2004)
Rachel Spector’s model incorporates three main theories: Estes
and Zitzow’s Heritage Consistency Theory, the HEALTH Traditions Model,
and Giger and Davidhizar’s cultural phenomena affecting health. Heritage
consistency originally described the extent 9 to which a person’s lifestyle
reflected his or her tribal culture, but has been expanded to study a
person’s traditional culture, such as European, Asian, African, or
Hispanic.
The values indicating heritage consistency exist on a continuum.
The HEALTH Traditions Model uses the concept of holistic health and
explores what people do to maintain, protect, or restore health. The
model shows the interrelated phenomena of physical, mental, and
spiritual health with personal methods of maintaining, protecting, and
restoring health.
Spector’s Health Traditions Model (Spector, 2004)
To maintain physical health, an individual may use traditional foods
and clothing that were proven effective within the culture. 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, believing they will assist in restoring health.
Spector also provides a Heritage Assessment Tool to determine
the degree to which a particular person or family adheres to their
traditions. A traditional person observes his or her cultural traditions more
closely. A more acculturated individual practice is less observant of
traditional practices.
https://www.pdffiller.com/&lp=true#59eae795102f43488b80ccb26fe004d8
Campinha-Bacote Model of Cultural Competence
According to Campinha-Bacote (2008), individuals as well as organizations and institutions begin the journey to
cultural competence by first demonstrating an intrinsic motivation to engage in a cultural competence process. The
central concepts in this model are described below:
• Cultural Awareness. The nurse becomes sensitive to the values, beliefs, lifestyle, and practices of the
patient/client, and explores her/his own values, biases and prejudices. Unless the nurse goes through
this process in a conscious, deliberate, and reflective manner there is always the risk of the nurse
imposing her/his own cultural values
during the encounter.
• Cultural Knowledge. Cultural knowledge is the process in which the nurse finds out more about other
cultures and the different worldviews held by people from other cultures. Understanding of the values,
beliefs, practices, and problem-solving strategies of culturally/ethnically diverse groups enables the
nurse to gain confidence
in her/his encounters with them.
• Cultural Skill. Cultural skill as a process is concerned with carrying out a cultural assessment. Based on
the cultural knowledge gained, the nurse is able to conduct a cultural assessment in partnership with the
client/patient.
Campinha-Bacote Model of Cultural Competence
• 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.
• Cultural Desire. Cultural desire is an additional element to the model of cultural
competence. It is seen as a self-motivational aspect of individuals and organizations to
want to engage in the process of cultural competence.

Campinha-Bacote emphasizes that a cultural assessment is needed on every client, for

every client has values, beliefs and practices that must be considered when rendering health
care services. Therefore, cultural assessments should not be limited to specific ethnic
groups, but rather conducted with each patient.
Campinha-Bacote Model of Cultural Competence
Health Assessment Model (Larry Purnell and Paulanka)
The Purnell Model for Cultural Competence is a broadly
utilized model for teaching and studying intercultural
competence, especially within the nursing profession. Employing a
method of systems theory, the model incorporates ideas about
cultures, persons, healthcare and health professionals into a distinct
and extensive evaluation instrument used to establish and
evaluate cultural competence.
healthcare
Health Assessment Model (Larry Purnell and Paulanka)
• 12 Cultural Domains
• It is not intended for domains to stand alone, rather, they affect one
another.

• Overview/heritage
Concepts related to country of origin, current residence, the effects of
the topography of the country of origin and current residence,
economics, politics, reasons for emigration, educational status, and
occupations.
Health Assessment Model (Larry Purnell and Paulanka)
• Communication
Concepts related to the dominant language and dialects; contextual use
of the language; paralanguage variations such as voice volume, tone,
and intonations; and the willingness to share thoughts and feelings.
Nonverbal communications such as the use of eye contact, facial
expressions, touch, body language, spatial distancing practices, and
acceptable greetings; temporality in terms of past, present, or future
worldview orientation; clock versus social time; and the use of names
are important concepts.
Health Assessment Model (Larry Purnell and Paulanka)
• Family roles and organization
Concepts related to the head of the household and gender roles; family
roles, priorities, and developmental tasks of children and adolescents;
child-rearing practices; and roles of the ages and extended family
members. Social status and views toward alternative lifestyles such as
single parenting, sexual orientation, child-less marriages, and divorce
are also included in the domain.
Health Assessment Model (Larry Purnell and Paulanka)
• Family roles and organization
Concepts related to the head of the household and gender roles; family
roles, priorities, and developmental tasks of children and adolescents;
child-rearing practices; and roles of the ages and extended family
members. Social status and views toward alternative lifestyles such as
single parenting, sexual orientation, child-less marriages, and divorce
are also included in the domain.
Health Assessment Model (Larry Purnell and Paulanka)
• Workforce issues
Concepts related to autonomy, acculturation, assimilation, gender roles,
ethnic communication styles, individualism, and health care practices
from the country of origin.
• Bicultural ecology
Includes variations in ethnic and racial origins such as skin coloration
and physical differences in body stature; genetic, heredity, endemic, and
topographical diseases; and differences in how the body metabolizes
drugs.
• High-risk behaviors
Includes the use of tobacco, alcohol and recreational drugs; lack of
physical activity; nonuse of safety measures such as seatbelts and
helmets; and high-risk sexual practices.
Health Assessment Model (Larry Purnell and Paulanka)
• Nutrition
Includes having adequate food; the meaning of food; food choices,
rituals, and taboos; and how food and food substances are used during
illness and for health promotion and wellness.
• Pregnancy and childbearing
Includes fertility practices; methods for birth control; views towards
pregnancy; and prescriptive, restrictive, and taboo practices related to
pregnancy, birthing, and postpartum treatment.
• Death rituals
Includes how the individual and the culture view death, rituals and
behaviors to prepare for death, and burial practices. Bereavement
behaviors are also included in this domain.
Health Assessment Model (Larry Purnell and Paulanka)
• Spirituality
Includes religious practices and the use of prayer, behaviors that give
meaning to life, and individual sources of strength.
• Spirituality
Includes religious practices and the use of prayer, behaviors that give
meaning to life, and individual sources of strength.
• Health care practices
Includes the focus of health care such as acute or preventive;
traditional, magicoreligious, and biomedical beliefs; individual
responsibility for health; self-medication practices; and views towards
mental illness, chronicity, and organ donation and transplantation.
Barriers to health care and one’s response to pain and the sick role are
included in this domain.
Health Assessment Model (Larry Purnell and Paulanka)
• Health care practitioner
Concepts include the status, use, and perceptions of traditional, magic
religious, and allopathic biomedical health care providers. In addition,
the gender of the health care provider may have significance.

• Concepts of Cultural Consciousness

• Variant cultural characteristics: age, generation, nationality, race, color,
gender, religion, educational status, socioeconomic status, occupation,
military status, political beliefs, urban versus rural residence, enclave
identity, marital status, parental status, physical characteristics, sexual
orientation, gender issues, and reason for migration (sojourner,
immigrant, undocumented status)
Concepts of Cultural Consciousness
• Unconsciously incompetent
Not being aware that one is lacking knowledge about another
culture
• Consciously incompetent
Being aware that one is lacking knowledge about another culture
• Consciously competent
Learning about the client’s culture, verifying generalizations about
the client’s culture, and providing culturally specific interventions
• Unconsciously competent
Automatically providing culturally congruent care to clients of
diverse cultures
The purposes of the Purnell Model are to
• Provide a framework for all healthcare providers to learn concepts and
characteristics of culture;
• Define circumstances that affect a person's cultural worldview in the context
of historical perspectives;
• Provide a model that links the most central relationships of culture;
• Interrelate characteristics of culture to promote congruence and to facilitate
the delivery of consciously sensitive and competent health care;
• Provide a framework that reflects human characteristics such as motivation,
intentional ity, and meaning;
• Provide a structure for analyzing cultural data; and
• View the individual, family, or group within their unique ethnocultural
environment.
Cultural Health Assessment Model (Ruth Davidhizar and Joyce
Newman Giger)
The Transcultural Assessment Model: Six Dimensions

The Transcultural Assessment Model was developed in response to

student nurses’ need to assess and design care for culturally diverse
patients (Giger & Davidhizar, 2002). This model provides a framework that
can be incorporated into nursing education curricula. The model assesses
differences between individuals in cultural groups by inquiring about six
cultural dimensions: communication, time, space, social organization,
environmental control, and biological variations. This assessment
framework can be utilized by student nurses to facilitate the design and
delivery of sensitive care (Giger & Davidhizar, 2002).
Cultural Health Assessment Model (Ruth Davidhizar and Joyce
Newman Giger)

Culture is a patterned behavioral response that develops

overtime as a result of imprinting the mind through social,
and religious structures and intellectual and artistic
manifestations.

In fact, the authors informed that a culturally appropriate

model must recognize differences in groups while also
avoiding stereotypical approaches to client care.
 Communication
For student nurses to deliver safe, culturally competent care, a
mutual understanding of the patient’s cultural needs must be achieved
through communication. Communication, verbal and non-verbal, account
for a large portion of the cultural disconnect between student nurses and
their patients (Momeni, Jirwe, & Emami, 2008). When communication
barriers were present, patients often expressed concerns and fears of being
misunderstood as well as a strong sense of insecurity during interactions
with nursing staff (Cioffi, 2003). Nursing students may ask themselves these
questions and formulate possible solutions: “Have I ever been
misunderstood, either through spoken words or body language?” and
“Have I ever been treated differently related to mental health or learning
disabilities?”
 Time
To understand individualistic views of culture, student nurses
must assess patient views about passage of time, points in time, and
duration of time. Many countries and cultures are oriented with a focus
on the past. These cultures value tradition and doing things as their
predecessors have done. This can lead to reluctance in accepting new
technology or treatments. Some cultures stress the present and may
seem relatively unconcerned with the future. These individuals may
disregard preventative measures and may show up late or miss
appointments (Giger & Davidhizar, 2004). Student nurses may question
their personal and cultural views related to time: “Is the past, present, or
future most important to me?” and “How does my view of time reflect in my
personal heath choices?”
Space
Humans vary greatly in their comfort level related to
personal space. Some of these spatial concerns are related to
personal preferences, while others are a reflection of cultural
principles. Student nurses must be aware of their patients’
comfort level related to body distance during conversation,
proximity to family members, perception of space, eye contact,
and personal and cultural touch practices (Giger & Davidhizar,
2004). Student nurses may question, “What is my personal comfort
level related to touch, eye contact, and conversational distance?” and
“Can I identify a situation where I was made uncomfortable by
another individual related to my personal space?”
 Social Organization
Humans often learn and adopt cultural beliefs through social
organization. Individuals from culturally diverse backgrounds will all
manifest different degrees of acculturation into the beliefs of their
dominant culture. In some circumstances, cultural values stem from
the opinion of elders or patriarchs, while others place value on
position in family. In this context, student nurses need to factor in
geography, socioeconomic status, religious affiliation, gender and
sexual orientation, as well as age and life cycle status (Giger &
Davidhizar, 2004). Student nurses could self-evaluate by pondering
these questions: “What role do my parents and family member play
in my beliefs?” and “Have my cultural views changed related to my
current stage of life?”
 Environmental Control
Environmental control can be explained in the patient’s ability,
within their cultural system, to plan activities that control their
environment as well as their perception of personal control over factors
in the environment (Giger & Davidhizar, 2004). Examples of assessment
factors which play a role in environmental control are locus of control,
folk medicine, and health beliefs. Student nurses need to understand
that these issues play an extremely vital role in the way patients define
illness and wellness, utilize health care resources and respond to health
associated experiences (Eggenberger, Grassley, & Restrepo, 2006).
Questions that student nurses might ponder are: “Am I superstitious and
do I believe that I am in complete control of my health and wellness?” and
“What non-medical/alternative methods do I believe in and utilize to obtain
health?
 Biological Variation
When assessing a patient’s cultural underpinnings, biological
variations need to be evaluated carefully to avoid stereotypes and
discrimination. These factors include race, body structure, genetic
variations, nutritional preferences and psychological characteristics
(Davidhizar, & Giger, 2008). Nursing examples include diseases related to
specific ethnic groups as well as rural versus urban health. Student nurses
must remember the uniqueness of individuals and that a person’s
association with an ethnic group does not mean that the individual patient
will follow the socially accepted definition of his/her biological foundation
(Vandenberg & Kalischuk, 2014). Questions that a nursing student might
reflect upon with patients are: “What is an accepted stereotype related to your
ethnic group that is not true about you?” and “What health care practice do you
not participate in that most of your ethnic group does?”
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
Ethical Decisions Model (Dula Pacquiao)
CULTURAL ASSESSMENT MODEL: Andrew
Boyle
• The goals of the Andrews/Boyle Transcultural Interprofessional Practice (TIP) model
are to provide a patient- or client-centered systematic, logical, orderly, scientific
process for delivering safe, culturally congruent and competent, affordable,
accessible, evidence-based, and quality care for people from diverse backgrounds
across the life span.
• Key components of the TIP model include the context from which people's health-
related values, attitudes, beliefs, and practices emerge; the interprofessional health
care team; effective verbal and nonverbal communication among all team members;
and a five-step systematic, scientific problem-solving process-assessment, mutual
goal setting, and planning, implementing, and evaluating the effectiveness of
therapeutic interventions and care.
• The model is applicable wherever nurses practice, teach, learn, lead, consult, and
conduct research domestically and globally.
CULTURAL ASSESSMENT MODEL: Andrew
Boyle

1. Assessment Guide for Individuals and Families

2. Assessment Guide for families, Groups, and Communities
3. Assessment Guide for Healthcare Organizations and Facilities
CULTURAL ASSESSMENT MODEL:
1. Assessment Guide for Individuals and Families

• Biocultural Variations and Cultural Aspects of the Incidence of

Disease
• Communication
• Cultural Affiliations
• Cultural Sanctions and Restrictions
• Developmental Consideration
CULTURAL ASSESSMENT MODEL:
1. Assessment Guide for Individuals and Families

• Kinship and Social Networks

• Nutrition
• Values Orientation
• Economics
• Educational Background
• Health-Related Beliefs and Practices
CULTURAL ASSESSMENT MODEL:
2. Assessment Guide for Families, Groups and Communities

• Family and Kinship Systems

• Social Life and Networks
• Political or Government Systems
• Language and Traditions
• Worldviews, Value Orientations, and Culture Norms
• Religious Beliefs and Practices
• Health Care Systems
• Economic Factors
 CULTURAL ASSESSMENT MODEL:
3. Assessment Guide for Health Care Organizations and Facilities

• Physical Environment
• Language, Communication, and Ethnohistory
• Technology
• Religious/ Philosophical Factors
• Social Factors
• Cultural Values
• Political/ Legal Factors
• Economic Factors
• Education