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1 Introduction

In addition, to culture being incorporated into formal nursing programs, continuing education of nurses in culturally competent and congruent care is increasingly becoming a requirement for accreditation of healthcare organizations by agencies such as the Joint Commission (The Joint Commission 2010; The Joint Commission International 2011). Education for culturally competent care encompasses knowledge of the cultural values, beliefs, lifeways, and worldview of population groups as well as individuals (Papadopoulos 2006). Although Great Britain has encouraged culturally competent education in nursing and other healthcare professions, no official mandate has materialized (George et al. 2015). Whereas Australia and New Zealand has initiatives on cultural competence in education, a mandate for including cultural competence in nursing education could not be found. The same is true for other countries around the world.

2 Individualistic and Collectivistic Attributes as a Framework

A good starting point for staff at all levels is to gain an understanding of general principles of broad cultural groups and an understanding of individualistic and collectivistic cultures. All cultures that vary along a continuum of individualism and collectivism, subsets of broad worldviews, are somewhat context dependent.

Individualism versus collectivism scale

Individualism

        

Collectivism

1

2

3

4

5

6

7

8

9

10

A degree of individualism and collectivism exists in every culture. Moreover, individualism and collectivism fall along a continuum, and some people from an individualistic culture will, to some degree, align themselves toward the collectivistic end of the scale. Some people from a collectivist culture will, to some degree, hold values along the individualistic end of the scale (see Table 6.1). The degree of acculturation and assimilation and the variant characteristics of culture (see Chap. 2) determine the degree of adherence to traditional individualistic and collectivist cultural values, beliefs, and practices (Hofstede and Hofstede 2005; Purnell 2013). They include orientation to self or group; decision-making; knowledge transmission; individual choice and personal responsibility; the concept of progress, competitiveness, shame, and guilt; help-seeking; expression of identity; and interaction/communication styles (Hofstede 2001; Hofstede and Hofstede 2005; Rothstein-Fisch et al. 2001). One should not confuse individualism from individuality. Individuality is the sense that each person has a separate and equal place in the community and where individuals who are considered “eccentrics or local characters” are tolerated (Purnell 2010; Singelis 1998; Triandis 2001).

Table 6.1 General collectivistic versus individualistic values
Full size table

2.1 Individualism

Individualism is a moral, political, or social outlook that stresses independence (Bui and Turnbull 2003; Greenfield et al. 2003; Markus and Kitayama 1991; Hofstede and Hofstede 2005; Purnell 2013; Triandis 2001). Consistent with individualism, individualistic cultures encourage self-expression. Adherents freely express personal opinions, share many personal issues, and ask personal questions of others to a degree that may be seen as offensive to those who come from a collectivistic culture. Direct, straightforward questioning with the expectation that answers will be direct is usually appreciated with individualism. Small talk before getting down to business is not always appreciated. However, the healthcare provider should take cues from the patient before this immediate, direct, and intrusive approach is initiated. Individualistic cultures usually tend to be more informal and frequently use first names. Ask the patient by what name she/he prefers to be called. Questions that require a “yes” or “no” answer are usually answered truthfully from the patient’s perspective. In individualistic cultures with values on autonomy and productivity, one is expected to be a productive member of society (Purnell 2011, 2013; Singelis 1998). Some highly individualistic countries include Australia, Belgium, the United States, Great Britain, England, Canada, Finland, Germany, Ireland, Israel, Great Britain, Finland, Luxembourg, Norway, the Netherlands, postcommunist Poland, Slovakia, South Africa, Sweden, and Switzerland, to name a few (Darwish and Huber 2003).

Individualistic cultures expect all to follow the rules and hierarchical protocols, and each person is expected to do his/her own work and to work until the job is completed (Eshun and Hodge 2014). In addition, children are often expected to become responsible at a young age and have more independence and self-expression. However, in situations where the group makes decisions, each member has an equal right to express their opinions, and opinions can differ greatly, enhancing the chance the decision is better than what one person’s decision would be. The expectation is that all will follow the decisions made (Eshun and Hodge 2014).

Individualistic cultures socialize (enculturate) their members to view themselves as independent, separate, distinct individuals, where the most important person in society is self. A person feels free to change alliances and is not bound by any particular group (shared identity). Although they are part of a group, they are still free to act independently within the group and less likely to engage in “groupthink.”

2.2 Collectivism

Collectivism is a moral, political, or social outlook that stresses human interdependence—it is important to be part of a collective. The individual is defined in terms of a reference group—family, church, work, school, or some other group. Collectivism can stifle individuality and diversity leading to a common social identity (Bui and Turnbull 2003; Greenfield et al. 2003; Hofstede and Hofstede 2005; Markus and Kitayama 1991; Triandis 2001). Some collectivistic cultures include American Indian/Alaskan Native and most indigenous populations, Asian Indian, Chinese, Korean, Pakistani, Filipino, Japanese, Mexican, Spanish, and Taiwanese (Darwish and Huber 2003).

Most collectivist cultures are high context where implicit communication may be valued over explicit communication: the meaning is usually embedded in the information, and the listener must “read between the lines” (Keeskes 2016). Shame and guilt are strong, and the individual must not do anything to cause shame to self, the family, or the organization. Most believe in the hierarchal structure, and one should not stand out in the crowd (Greenfield et al. 2003; Hofstede and Hofstede 2005; Markus and Kitayama 1991; Purnell 2011). To interrupt another in a conversation is considered extremely rude. Sensitive issues that may cause a stigma to family or others are not revealed.

Time is more relaxed; punctuality is valued only in business and situations where it is essential such as in making transportation connections. Most value formality; therefore, always greet the patient and family members formally until told to do otherwise. In most traditional cultures, but not all, men have decision-making authority or are the spokesperson for the family, even if they are not the primary decision-maker. Gender roles are usually less fluid than in individualistic cultures; however, expectations upon immigration may cause significant family discord (Purnell and Pontious 2014).

3 Knowledge of Specific Cultures Cared for in the Practice Setting

Whereas the individualistic and collectivistic framework is a good starting point for understanding culture and a broad assessment guide, providers need to obtain an understanding of the specific cultural and subcultural groups seen in their practice. Specific content of the groups should include the overview and heritage of the group, communication practices, family roles and organization, workforce issues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and the childbearing family, death rituals, spirituality and religion, healthcare practices, and healthcare practitioners. A brief description of these concepts follows (Purnell 2013; Purnell and Fenkl 2018).

  1. 1.

    Overview and Heritage: Includes concepts related to the country of origin and current residence and 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.

  2. 2.

    Communication: Includes concepts related to the dominant language, dialects, 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. Differences between the language spoken by the healthcare provider and the patient, educational level, and health literacy can add to communication difficulties. Effective communication is the first and probably the most important aspect of obtaining an accurate health assessment (see this chapter).

  3. 3.

    Family Roles and Organization: Includes concepts related to the head of the household, gender 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, same-sex partnerships and marriage, childless marriages, and divorce.

  4. 4.

    Workforce Issues: Includes concepts related to autonomy, acculturation, assimilation, gender roles, ethnic communication styles, and healthcare practices of the country of origin.

  5. 5.

    Biocultural Ecology: 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 can be divided into three categories: lifestyle, environment, and genetics. Lifestyle causes include cultural practices and behaviors that can generally be controlled, for example, smoking, diet, and stress. Environment 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., the presence of malarial mosquitos, exposure to chemicals and pesticides, access to care, and associated diseases and illnesses). Genetic conditions are caused by genes.

  6. 6.

    High-Risk Health Behaviors: 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 safety measures to prevent contracting HIV and sexually transmitted infections.

  7. 7.

    Nutrition: Includes the meaning of food, common foods and rituals, nutritional deficiencies and food limitations, and the use of food for health promotion and wellness and illness and disease prevention. Multiple diseases and illnesses are a consequence of this major cultural component.

  8. 8.

    Pregnancy and Childbearing Practices: Includes culturally sanctioned and unsanctioned fertility practices, views on pregnancy, and prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and the postpartum period.

  9. 9.

    Death Rituals: Includes how the individual and the society view death and euthanasia, rituals to prepare for death, burial practices, and bereavement behaviors. Death rituals are slow to change.

  10. 10.

    Spirituality: Includes formal religious beliefs related to faith and affiliation and the use of prayer, behavioral practices that give meaning to life, and individual sources of strength.

  11. 11.

    Healthcare Practices: Includes the focus of healthcare (acute versus preventive); traditional, magico-religious, 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.

  12. 12.

    Healthcare Practitioners: Includes the status, use, and perceptions of traditional, magico-religious, and biomedical healthcare providers and the gender of the healthcare provider.

4 Cultural Theories and Models for Patient Assessment

A number of cultural theories and models for patient assessment have been developed. Some are very extensive, while others are more general in nature without a specific framework. All of these theories and models should be included in formal education programs. In practice, each organization can select the model or theory that they deem fits their needs.

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 are acronymic approaches: LEARN and BATHE. 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 and 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 (McCullough et al. 1998).

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.

The Campinha-Bacote Model is a practice model focusing on the process of cultural competence in the delivery of healthcare services. This model, which is currently referred to as a volcano model, is used primarily in practice and education; it does not have an accompanying organizational framework. According to Transcultural C.A.R.E. Associates (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 cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire (Transcultural C.A.R.E. Associates 2015).

The Giger and Davidhizar Model focuses on assessment and intervention from a transcultural nursing perspective. The six areas of human diversity and variation include communication, space, social orientation, time, environmental control, and biological variations (Giger and Davidhizar 2012).

The Papadopoulos, Tilki, and Taylor Model focuses on the process of cultural competence in the delivery of healthcare services 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 cultural awareness that includes an ethnohistory, cultural knowledge, cultural competence, and cultural sensitivity. The center of the model includes compassion (Papadopoulos 2006).

Leininger’s Cultural Care: Diversity and Universality Theory and Sunrise Model promote 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. This theory incorporates (a) care (caring); (b) generic, folk, or indigenous care knowledge and practices; (c) professional care knowledge and practices that vary transculturally; (d) worldview, language, philosophy, religion, and spirituality; and (e) kinship, social, political, legal, educational, economic, technological, ethnohistorical, and environmental contexts of cultures. Within a cultural care diversity and universality framework, nurses may take any or all of three culturally congruent action modes: (a) cultural preservation/maintenance, (b) cultural care accommodation/negotiation, and (c) cultural care repatterning/restructuring (McFarland and Wehbe-Alamah 2015).

Spector’s HEALTH Traditions Model incorporates three main theories: Estes and Zitzow’s heritage consistency theory, the HEALTH Traditions Model, and Giger and Davidhizar’s theory about the cultural phenomena affecting health. 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. 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 2009).

The cultural safety model includes actions which recognize and respect the cultural identities of others and safely meet their needs, expectations, and rights. Strategies that enhance the ability to be culturally safe are (a) reflecting on one’s own culture, attitudes, and beliefs about “others”; (b) having clear, value-free, open, and respectful communication; (c) developing trust; (d) recognizing and avoiding stereotypical barriers; (e) being prepared to engage with others in a two-way dialogue where knowledge is shared; (f) and understanding the influence of culture shock (Cultural Connections for Learning: Cultural Safety 2013).

Cultural humility has three processes: (a) lifelong commitment to self-evaluation and self-critique, (b) a desire to fix power imbalances, and (c) aspiring to develop partnerships with people and groups who advocate for others (American Psychological Association 2013).

The Purnell Model for Cultural Competence has been classified as a holographic and complexity theory because it includes a model and organizing framework that can be used by all health disciplines. The purposes of this model are to (a) provide a framework for all healthcare providers to learn concepts and characteristics of culture; (b) define circumstances that affect a person’s cultural worldview in the context of historical perspectives; (c) provide a model that links the most central relationships of culture; (d) interrelate characteristics of culture to promote congruence and to facilitate the delivery of consciously sensitive and competent healthcare; (e) provide a framework that reflects human characteristics such as motivation, intentionality, and meaning and provide a structure for analyzing cultural data; and (f) view the individual, family, or group within their unique ethnocultural environment (Purnell and Fenkl 2018) (see Appendices 1 and 2).

5 Interdisciplinary Practice

Cultural competence is a requisite for all professionals who have direct or indirect contact with patients. Most cultural concepts, knowledge, and practice skills are shared by all health disciplines, making cultural competence a requirement for all. For example, cross-cultural communication principles do not change for direct care professionals, auxiliary staff, or administrative personnel. Workshops and conferences should include multidisciplinary professionals where personal cultural stories can be shared.

6 Recommendations

Recommendations for clinical practice, administration, education, and research follow.

6.1 Recommendations for Clinical Practice

Staff at all levels should attend continuing education classes, in-services, conferences, and other learning experiences to maintain cross-cultural skills. Upon admission, professional staff need to use a comprehensive cultural assessment tool that can be added to as time and circumstances permit (see this chapter). The assessment should include the patient’s cultural and ethnic background as well as familiar genetic and hereditary health conditions. The assessment needs to include not just current work environment but previous work as well. In addition, the work history needs to be completed for patients who are retired. Environmental living arrangements are included in an assessment.

6.2 Recommendations for Administration

Organizational administration has the prime responsibility to assure that culturally competent care is delivered throughout the organization. The organization’s mission and philosophy must be addressed at the department level as well as each unit within a department. Administrators and managers, whether in direct or indirect care, must role model cultural competence and work with national and community organizations to ensure that patients’ needs are being met. They should also seek positions and be involved on community and national boards.

Staff should be provided with unit-written resources and partner with universities for online resources that all staff can access. In addition, administration can support and host workshops and conferences as effective approaches to culturally congruent nursing practice. Hosting community health fairs with ethnic community organizations that support vulnerable populations adds value to the organization’s mission.

6.3 Recommendations for Education

In the academic setting, all the concepts included in Chap. 2, knowledge of cultures, should be included. The preference is to have a separate course on culture that includes both cultural general as well as cultural specific information in every course and include the use of complementary and alternative practices. What might be complementary and alternative in one culture may be mainstream health care in other cultures.

The curriculum must include content on vulnerable populations, socioeconomics, and cultural general information on the populations in clinical areas that also stress the importance of individual cultural values and beliefs. Culture needs to also be integrated throughout all courses such as pathophysiology, pharmacology, and simulation labs and clinical courses. If a specific cultural course is not feasible, maintain a system that assures cultural content is included in all courses so that cultural content is not lost.

In the service setting, cultural content needs to be addressed in orientation with annual in-service training in cultural competence for all levels of staff including management, other professionals, and auxiliary staff in any department with patient contact. Classes to increase staff’s cultural knowledge about the ethnically diverse patients who receive health services in the facility should be conducted and reinforced in the organization’s intranet with population health beliefs and values.

Educators should mentor staff for whom the dominant language is not the same as the patient’s for sociopragmatic competence specific to the medical setting (Sedgwick and Garner 2017). A variety of modalities to teach cultural competency can include workshops, conferences, online training, films, and immersion experiences whether in diverse communities, in the home environment, or in other countries. Faculty should partner with transcultural experts to provide staff with continuing education courses, consultation, and practice skills for culturally competent care.

6.4 Recommendations for Research

Journal clubs can be established to review current scholarly evidence-based literature on the populations served by the organization and should be instituted and offered at times that clinical staff can attend. Consultants from local university and college faculty can be employed to facilitate implementation of evidence-based cross-cultural practice. Staff wanting to conduct research can partner with local faculty for expertise in the research process and study design.

An interdisciplinary team of researchers and educators can collaborate on quality improvement projects and to apply for funding. Initial research should be on ethnic/cultural groups common to the organization. Although it might not be possible to translate satisfaction surveys in all the patients’ languages served by the organization, at least they should be translated into the most common languages of patients; otherwise, only part of the data is collected. The results of satisfaction served can be used in quality improvement projects or to conduct research.

Conclusion

Cultural competence has become one of the most important initiatives worldwide for a number of reasons. Diversity has increased in many countries due to wars, political strife, world socioeconomic conditions, and migration. In addition, the last few decades have demonstrated that culturally congruent care increases patient satisfaction, improves patient care, and reduces cost. The recognition of the social determinants of health with vulnerable populations (see Chap. 1) has been a focus to help alleviate heath disparities. Therefore, a requisite is to include culturally competent education in formal health-related programs and continue the process where the organization includes cultural competence during orientation and yearly thereafter. Cultural competence education and training are for all healthcare providers, including those who encounter diverse patients and families even though they may not be direct care providers.

Formal education must include content on the various models and approaches to learn culture and provide a stand-alone course on culture if possible and then integrate culture in every theory and clinical course. If a separate stand-alone course is not possible, the education organization needs to keep a tracking system to assure that culture is included in every course. Cultural competence is required for the organization and the individual provider. The American Association of Colleges of Nursing; the Office of Minority Health in the United States, Australia, and New Zealand; Royal College of Nursing; American Medical Association; National Medical Association; International Council of Nursing; and the American Nurses Association have all recognized the importance of culturally competent education.