Theoretical Framework of Cultural Competence, The
Jirwe, Maria
OBJECTIVES: Several published theoretical frameworks of cultural competence have been developed in North America, Europe and Oceania. The extent to which these frameworks share common characteristics is unknown. This study analyses the core components found in the descriptions of the most frequently cited theoretical frameworks of cultural competence. METHODS: Nine theoretical frameworks from three continents were identified and a documentary analysis was undertaken. RESULTS: Four main themes were identified, namely: an awareness of diversity among human beings, an ability to care for individuals, non-judgmental openness for all individuals, and enhancing cultural competence as a long term continuous process. CONCLUSIONS: The components of each theme are presented and their similarities and differences are considered. The findings can provide a useful framework for nurse educators, researchers and practitioners, when applying the concept of cultural competence to their practice.
KEY WORDS: Cultural Competence, Documentary Analysis, Transcultural Nursing.
ACKNOWLEDGEMENTS: The authors would like to thank AMF Pension, Stockholm county council, the Department of Neurobiology, Care Sciences and Society, the Division of Nursing at Karolinska Institutet and the Stockholms Sjukhem Foundation for their support. Our thanks also go to Julie Hammarwall for the linguistic revision.
Maria Jirwe, PhD candidate, MSc, RN, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholms Sjukhem Foundation, Sweden; Kate Gerrish, PhD, MSc, RN, Professor, Centre for Health and Social Care Research, Sheffield Hallam University, UK; Azita Emami, Senior Lecturer, PhD, RN, Associate Professor, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholms Sjukhem Foundation, Sweden.
The multi-cultural composition of western societies continues to diversify as a result of globalisation, economic migration, and political strife, leading to an increase in asylum seekers and refugees (Brathwaite & Majumdar, 2006; Gebru & Willman, 2003; Pinikahana, Manias, & Happell, 2003; Suh, 2004). In Sweden, approximately 20% of the population was born in another country or one or both parents were (Swedish Statistical Central Bureau, 1999). The multi-cultural composition of today’s societies presents considerable challenges for health care providers (Campinha-Bacote, 2002; Gebru & Willman, 2003).
The term ‘cultural competence’ is used extensively in nursing literature, to refer to the multi-cultural knowledge base that nurses need, together with the ability to apply such knowledge in practice (CampinhaBacote, 2002; Leininger, 1999; Leuning, Swiggum, Wiegert, & McCullough-Zander, 2002). Culturally competent nurses are sensitive to cultural differences, and base their care on this. They also seek to challenge marginalization and discrimination (Gerrish & Papadopoulos, 1999; Meleis, 1999). Transcultural nursing is the field of study in helping nurses to become culturally competent.
The term cultural competence consists of two words, culture and competence. Culture is defined as the learned, shared and transmitted values, beliefs, norms and life practices of a particular group of people (Leininger & McFarland, 2002). Peoples’ culture can be understood through their actions, that is, their behavioural patterns and through understanding why people act in the way they do; their functional patterns (Stier & Olsson, 2004). Culture can also be understood through an interpretation of one’s world, through one’s cognitive processes, or through a person’s understanding of their world, which is linked to their symbolic interactions (Stier & Olsson, 2004). Since cultural background greatly affects several aspects of people’s lives, i.e. their beliefs, language, religion, family structure and body image, this must be considered when caring for people from other cultures (Gerrish & Papadopoulos, 1999; Meleis, 1999). The International Council of Nurses defines competence as a level of performance, which demonstrates effective application of knowledge, skills, attitudes and judgements (ICN 2005). Cultural competence refers to the knowledge, skills, attitudes, and judgements, nurses need in order to care for people from diverse cultural backgrounds (Gerrish, 2000; Meleis, 1999).
Although nurses should have the competence to care for patients from diverse cultural backgrounds, nursing literature has shown that this is not the case (Boi, 2000; Cortis, 2004; Gerrish, 2000; Murphy & Clark, 1993). Studies show that nurses lacked cultural competence in face-to-face interactions and were not able to communicate adequately with patients that spoke a different language. The nurses’ inability to provide culturally competent care to minority-ethnic patients was usually related to their lack of knowledge about communicating with culturally diverse patients (Boi, 2000; Cioffi, 2003; Gerrish, 2001; Murphy & Clark, 1993). McKinley & Blackford, (2001) found that nurses applied the majority cultural groups’ views to individuals from minority groups, by persuading them to assist in the caring process, as they did with patients and families from the majority culture, without knowing that this was not culturally appropriate. These families only accepted because they wanted to be polite and please nursing staff.
Some nurses still lack cultural competence and therefore, do not practice culturally competent care (Boi, 2000; Cioffi, 2003; Gerrish, 2001; McKinley & Blackford, 2001; Murphy & Clark, 1993). This results in care that is not meaningful (Leininger, 1999). Since it is important for nurses to become culturally competent, it is crucial to educate them in the field of transcultural nursing (Alpers & Zoucha, 1996; Fahrenwald, Boysen, Fischer, & Maurer, 2001; Koskinen & Tossavainen, 2003; Lea, 1994). However, it is important to have guidelines to follow when planning education (Leininger, 1999; Lister, 1999; Marcinkiw, 2003; Purnell, 2002). There is no clear consensus about the components of cultural competence and therefore, nurse educators do not have an easy task when planning curricula. Since the definitions and core characteristics of cultural competence vary, and it is important to identify and clarify this issue.
There is a wealth of international literature on the notion of cultural competence, mostly from North America, Europe, Australia and New Zealand. However, very little literature is available from Sweden. Several theoretical frameworks of cultural competence have been developed but the authors have not presented an analysis of the different components of cultural competence. This study attempts to fill this void.
METHODS
This study analyses the core components found in the descriptions of cultural competence in the most frequently cited theoretical frameworks. The analysis also formed the first part of a larger empirical study examining cultural competence in a Swedish context.
In this study, the method of documentary analysis was used, which draws upon qualitative content analysis. Documentary analysis is a method of analysing documents of varying types, such as health improvement programmes (Elston & Fulop, 2002), clinical practical guidelines (Appleton & Cowley, 1997), health policy implementation (Abbott, Shaw, & Elston, 2004) e-mail conversation (Murray & Sixsmith, 2002) and nursing curricula (Gerrish, McManus & Ashworth, 1997).
When conducting the literature search for this study, we sought to identify the most influential and frequently cited texts in transcultural nursing worldwide. At first, a comprehensive search was conducted in several databases (Pub Med, Medline and Cinahl) for empirical studies in transcultural nursing. The key words used were: cultural competence, cultural safety, cultural awareness, cultural knowledge, cultural skill, and cultural sensitivity, which were also combined with nursing and transcultural nursing. The search rendered over 3000 articles. In order to reduce these, only articles which made reference in the title to cultural competence in the field of nursing practice or education and were written in English, Swedish, Norwegian or Danish were included. This left approximately 1500 articles. To further reduce the number of articles, all the abstracts were scanned to see if they made reference to a theoretical framework of cultural competence. This process identified 82 papers which were read in their entirety and ten theoretical frameworks of cultural competence were identified. These had originally been published in books and used in the 82 articles. The most frequently cited texts were from North America but as we aimed for dispersion worldwide, the literature search was expanded in order to access texts from all continents.
The second search method focused on expanding the search to continents where only a limited number of published scientific papers were found. First, a web search was conducted of nursing departments, in order to identify the texts on transcultural nursing that featured in the curricula. However, no new theoretical frameworks were found, showing that North American texts were dominant. To avoid missing recently published literature, in the third search book reviews published in the Journal of Transcultural Nursing were scrutinised. However, no new theoretical frameworks were identified.
The fourth and final search method focused on analysing the reference lists (Bhandari Devereaux, Montori, Cina, Tandan & Guyatt, 2004) in the 82 papers identified above. One further theoretical framework of cultural competence was identified. With these four search methods, we found literature that used or described theoretical frameworks of cultural competence in all seven continents. However, the 11 theoretical frameworks originated from three continents, North America, Europe and Oceania (see Table 1).
The inclusion criteria for extracting data from the texts of the theoretical frameworks were as follows:
* If the author had published more than one version of the theoretical framework of cultural competence, only the final version was included in the study.
* The description or definition of cultural competence should be written by the author and not be a citation from another author.
After comparing the 11 theoretical frameworks identified with the inclusion criteria, two were excluded as they related to anthropology and did not define cultural competence. The nine remaining theoretical frameworks originated from three continents, seven from North America (USA), one from Europe (United Kingdom) and one from Oceania (New Zealand) were included in the study (see Table 2).
The nine texts were read in their entirety and the sections describing cultural competence were copied verbatim on to separate data extraction sheets (Abbott, Shaw & Elston, 2004). These were then analysed using qualitative content analysis.
ANALYSIS
Qualitative content analysis is a technique suitable for analysing text documents, which are not originally meant for research. The assumption is that a text is more than what the reader can see at first sight and the method is used for finding the interpretation of the text, the underlying meaning, and the latent content (Graneheim & Lundman, 2004; Woods & Catanzaro, 1988).
The analysis process is illustrated in Table 3. Each data extraction sheet was analysed individually by reading the texts and then by marking the meaning units that correlated to the aim of the study. The meaning units were condensed and where possible, an interpretation was made of the condensed meaning unit. The texts from the text documents were not as rich as an interview text and therefore, it was difficult to condense these further. In this case, Graneheim and Lundman (2004) suggest that the condensed meaning units are seen as a whole, and instead of abstracting them into codes and categories they are abstracted into sub-themes. A sub-theme can be seen as a thread that runs through the condensed text with the same underlying meaning. The meaning units, condensed meaning units, and interpretation of the condensed meaning unit, were not separated during this procedure. Instead, they were kept side by side, in order to see the full meaning and the context of the sub-theme, as this would ensure that the core meaning of the text was not lost. The next step was to link the sub-themes together to form broader themes (Graneheim & Lundman, 2004).
RESULTS
Four themes relating to cultural competence were identified:
* An awareness of diversity among human beings
* An ability to care for individuals
* Non-judgmental openness for all individuals
* Enhancing cultural competence as a longterm continuous process
The themes are discussed below and illustrated with quotes from the texts in Table 4. The relation between the themes and the sub-themes are clarified in Figure 1.
Theme 1: An Awareness of Diversity Among Human Beings
All the theoretical frameworks suggested that nurses must become aware of the diversity of patients, in order to deliver culturally competent care. Two dimensions of awareness were identified, awareness of oneself and an awareness of the other.
A.: Awareness of Oneself
Awareness of oneself is the first step in developing cultural competence. In order to care for patients from different cultural backgrounds, nurses must first become aware that everyone has a cultural background. Nurses must begin by understanding that they have their own cultural values, attitudes and belief systems, which include prejudices and stereotypical attitudes. It is also important to understand that the nursing profession has a culture of its own.
B.: Awareness of the Other
Awareness of the other is the second step in raising a person’s awareness of the diversity among human beings. When nurses become aware of their own cultural background, this helps them to acknowledge other people’s cultural differences. Awareness of the other is usually described as a parallel process to awareness of oneself in regard to cultural values and beliefs.
Theme 11: An Ability to Care for Individuals
The analysis showed that it was important to have an ability to care for individuals. In this theme, three underlying sub-themes were identified: (A) to be skilled in performing cultural assessments, (B) to be knowledgeable about other cultures, and (C) to be able to meet specific cultural needs. All three sub-themes are central to the concept of cultural competence.
A. To be skilled in performing cultural assessments
Nurses need to have skills in performing cultural assessments of both patients and themselves. A cultural assessment includes the culturally relevant data nurses collect about their patients, as well as the assessment process itself. The nurse’s approach to the patient when conducting cultural assessments was important and it was also crucial that the nurse considered the patient’s verbal and non-verbal communication. The data collection usually consists of information from the following categories: nutrition, pregnancy, childbirth, death rituals, spirituality, social class, folk traditions, religion, and extended family, and other important topics.
B. To be knowledgeable about other cultures
The second aspect linked to the ability to care for individuals, was related to having knowledge about other cultures. This consisted of four different areas:
* educational cultural knowledge,
* using documented cultural knowledge,
* having knowledge about worldviews and
* having knowledge about cultural encounters between people from different cultures.
Educational cultural knowledge is usually acquired through training courses on transcultural nursing, which can help nurses to gain a deeper understanding as to how a person’s beliefs and values have been shaped. Nurses can also improve their cultural knowledge through interactions with patients and colleagues from other cultures. This type of cultural knowledge can help them to understand how their own cultural values, attitudes and beliefs have been influenced by family, ethnic background and society.
The theoretical frameworks showed different viewpoints, depending on the approach that was used. North American frameworks took an anthropological approach where the nurse studies the “exotic” patient, while in New Zealand the nurse is regarded as “exotic” from the patient’s viewpoint. North American frameworks and particularly Leininger and McFarland (2002), claim that by developing cultural knowledge, nurses can obtain the emic perspective of the culture, something that the theoretical framework from New Zealand states is not possible, since the nurse is always an outsider. But presumably, developing cultural knowledge helps nurses to be more responsive and understanding towards their patients.
Although nurses might have cultural knowledge, this does not mean that they always use it. In order to be culturally competent, nurses require the ability to use their personal cultural knowledge and that derived from research.
Understanding different worldviews is also valuable. The material indicates that a worldview is like a lens or a paradigm, a way of viewing the world. When nurses become aware of their patients’ worldviews they have a greater ability to understand their behaviour. All groups in society have their own explanations about illness and health. By means of these explanations, people develop belief systems, which can be viewed as the group’s worldview. Explanations can be: spiritual, religious, natural/holistic or biological. By understanding these different worldviews, the nurses can gain an understanding of the different explanations of health, illness and care and therefore, are better able to provide culturally competent care. In addition, the nursing culture itself has its own explanation for health and illness, which is not necessarily the same as the patient’s.
The fourth area is related to knowledge about cultural encounters and their effect on individuals. The encounter is the process where nurses interact face-toface with patients. The theoretical frameworks show that the encounter has a considerable affect on the patient. However, the frameworks have different approaches regarding the definition of what a cultural encounter is. North American frameworks suggest that a cultural encounter occurs between a nurse and patient from different ethic backgrounds, while the theoretical framework from New Zealand suggests that all encounters are cultural encounters, as they believe that the nursing culture is a culture itself. Whatever approach the frameworks use, they show that the encounter between the nurse and the patient affects the patient. It is also important to keep in mind that the nursing culture is a powerful culture since the patients are dependent on the nurse, something that both the theoretical frameworks from New Zealand and Great Britain point out. Also, the theoretical frameworks from New Zealand and Great Britain are more focused on anti-oppressive and anti-racial attitudes when compared to the theoretical frameworks from North America.
C. To be able to meet specific cultural needs
In order to meet the patients’ specific cultural needs, nurses need the ability to understand the patient’s cultural beliefs during the nursing process. The theoretical frameworks imply that it is important that nurses are skilled in this area otherwise they might not be able to accommodate the patient’s perspective when making Healthcare and lifestyle recommendations.
Theme III: Non-judgmental Openness for all Individuals
The third theme that emerged was non-judgmental openness for all individuals, which included the nurses’ willingness to overcome prejudices and ethnocentrism and a genuine interest in people from other cultures. Equality and sensitivity was also important. The findings show that nurses were not able to deliver culturally competent care when taking the approach that they had to care for these patients, rather than wanted to care for them. If nurses were not genuinely interested, they were not likely to understand that people have diverse values, beliefs and needs.
Theme IV: Enhancing Cultural Competence as a Long-term Continuous Process
The analysis found that cultural competence was linked to all the above-mentioned factors. In addition, cultural competence can be seen as a step-by-step process where the nurse becomes culturally aware and then makes an effort to continuously develop this knowledge. Nurses working with patients from diverse cultures should always strive to improve their knowledge in this area, as by doing so; they will increase their cultural competence.
DISCUSSION
The analysis presented in this paper identified four themes featured in the most commonly cited theoretical frameworks of cultural competence. These themes will be discussed and considered within the context of the wider literature which has cited the frameworks. Whereas other authors have undertaken a concept analysis of cultural competence, they have not made a detailed analysis of the common characteristics of cultural competence in several theoretical frameworks. For example, Smith (1998) draws on the work of Campinha-Bacote and Suh (2004) defines cultural competence by quoting Campinha-Bacote and Gerrish and Papadopoulos. Moreover Smith and Suh did not undertake a detailed analysis of the original theoretical frameworks; rather they have drawn upon a breadth of literature relating the application of the frameworks to education and research. The depth of the analysis of cultural competence in this paper, therefore, compliments the broader based concept analyses.
When undertaking the analysis, it became evident that many authors used a broad range of terms when describing the various components of cultural competence. For example, while one North American theoretical framework use the concept “cultural-bound health care needs” (Spector, 2004), another used “cultural-specific care needs” (Leininger & McFarland, 2002). As these terms were not well defined it was not clear whether they meant the same thing.
The theoretical frameworks from North America and New Zealand referred to cultural groups in their broadest sense as they included substantive cultural groups and sub-groups. However, this broader use of the concept of culture was not evident in the literature, considering the implementation of the North American theoretical frameworks. Leininger and McFarland (Leininger & McFarland, 2002) includes, for example, the homeless, the elderly, the mentally ill, and abused women as sub-groups, but the published literature only applied her framework of cultural competence when studying immigrant or ethnic minority groups (c.f. Bonura, Fender, Roesler, & Pacquiao, 2001; Holt, 2001; Ozolins & Hjelm, 2003; Zoucha & Husted, 2000). The theoretical framework from New Zealand, however, has been used with immigrant groups and with sub-cultures such as, children, women, and mental health patients (Wepa, 2005).
It is clear from the analysis that the frameworks have much in common despite being developed in three separate continents. However, some differences were identified. Most notably, the North American frameworks placed less emphasis on racism and other forms of oppression, compared to the frameworks from New Zealand and Britain. Additionally, the North American and British frameworks considered cultural competence primarily within the context of encounters between nurses and patients from different ethnic backgrounds, whereas the New Zealand framework took a much broader view of culture by identifying all encounters between nurses and patients as cross-cultural encounters. These differences were clearly evident in the broader literature, when the theoretical frameworks were applied to practice, education and research.
The differences in the various frameworks are likely to reflect the socio-cultural, historical and political context in which they were developed. Thus, much of the literature relating to the application of the North American theoretical frameworks focuses on cultural competence in relation to the main cultural groups, such as Latin Hispanic and African Americans as well as smaller migrant communities (Bonura, Fender, Roesler & Pacquiao, 2001; Fahrenwald, Boysen, Fischer & Maurer, 2001). In contrast, literature on cultural competence in the UK reflects the history of colonialism and migrant communities from former British colonies such as India, Pakistan and the Caribbean, as well as more recent asylum seekers and refugees (Gerrish, Chau, Sobowale, & Birks, 2004; Papadopoulos, Tilki & Taylor 1998). The New Zealand framework was developed by a Maori nurse and the emphasis on cultural competence in relation to other disadvantaged groups, such as the homeless and the mentally ill may reflect the Maori experience of disadvantage and discrimination under British colonialism.
Åström, Engtröm, Marklund & Statens kulturråd (1993) draws a distinction between cultural anthropology that is prevalent in the USA and social anthropology, which is common in the UK. These differences were evident in the North American frameworks, which emphasised culture, while the British ones emphasised ethnicity alongside culture.
The various components of cultural competence identified in this study clarify the broad range of knowledge, skills and attitudes that nurses need, in order to respond to the needs of patients from diverse cultural backgrounds. Awareness on oneself and awareness of other cultures is an important pre-requisite which leads to cultural competence. Nurse educators must consider these factors when planning nursing curricula. However, analyses of nursing curricula in Sweden (Momeni, 2006), Australia (Pinikahana, Manias & Happell 2003) and the United Kingdom (Gerrish, Husband & Mackenzie 1996) have shown that nursing programmes often fail to address the development of cultural competence in any detail.
CONCLUSIONS
Many commonalities were found regarding the core components of cultural competence in the nine theoretical frameworks analysed in this study. However, some variations were identified regarding the main focus of the frameworks, which reflect the context in which they were developed. The components of cultural competence outlined in this paper can provide a useful framework for nurse educators, researchers and practitioners when applying the concept of cultural competence into their practice.
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Maria Jirwe, PhD candidate, MSc, RN
Kate Gerrish, PhD, MSc, RN
Azita Emami, PhD, RN
Copyright Riley Publications, Inc. Fall 2006
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