22.2 Cultural Models

Leininger’s Culture Care Theory

Madeleine Leininger’s theory of culture care diversity and universality, also known as the culture care theory (CCT), is a nursing theory that focuses on the importance of understanding and respecting cultural differences in health care. According to Leininger, nurses should not only be aware of different cultural practices but also incorporate them into their care plans in a way that is congruent with the client’s cultural beliefs, values, and lifeways.

The central idea of this theory is that nurses must understand clients’ values, beliefs, and norms to provide quality care (Figure 22.2). The theory states that culture shapes how people think and behave, as well as their attitudes toward health care providers. If nurses are unaware of these differences, they may make assumptions about their clients’ needs or preferences based on their cultural backgrounds. The theory is based on the following five principles (McFarland & Wehbe-Alamah, 2019):

• Culture is a broad concept that encompasses multiple aspects of human life, including beliefs, values, and practices. Cultural care is a necessary and valuable part of nursing care.
• Care is the essence of nursing. It is an essential and vital part of nursing practice that involves cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are mostly tailor-made to fit with an individual, group, or institution’s cultural values, beliefs, and lifeways.
• Culturally congruent care is the goal of nursing. It aims to provide care consistent with the client’s cultural beliefs, values, and practices.
• Culturally competent care is a process. It involves nursing care that is respectful of and responsive to the cultural beliefs, values, and practices of the client and their community.
• Cultural care preservation, accommodation, and/or repatterning are modes of nursing actions and decisions. These modes of care are used to provide culturally congruent care based on the cultural needs and expectations of the client and their community.

Figure 22.2 The sunrise model visually represents Leininger’s culture care theory, emphasizing the importance of understanding and incorporating cultural factors in health care delivery. By using this model, nurses and other health care professionals can work toward delivering culturally appropriate and sensitive care that respects the unique needs and values of each individual and community. (See McFarland & Wehbe-Alamah, 2019; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The Leininger culture care theory and resulting sunrise model illustrate how culture is essential to nursing care and how providing culturally congruent care leads to better client outcomes. The sunrise model encompasses various dimensions essential to understanding culture care, including worldview, cultural and environmental context, and social structure factors. These dimensions help identify the values, beliefs, and practices that shape a particular culture’s health care needs and preferences (McFarland & Wehbe-Alamah, 2019). Leininger believed that by recognizing and respecting these cultural factors, health care professionals can deliver culturally congruent care that meets the unique needs of individuals, families, and communities. The dimensions of the sunrise model include the following:

• Worldview is the cultural lens through which individuals perceive the world and their health. It includes spirituality, religion, and ethics, which significantly impact health care decisions and practices. Understanding a client’s worldview allows nurses to provide care that aligns with their cultural and spiritual beliefs.
• Cultural and environmental context considers a cultural group’s physical, social, economic, and political aspects, acknowledging the influence of the wider cultural and environmental factors on health and health care practices. By recognizing these contextual influences, nurses can adapt their care to better address the cultural nuances and challenges that clients face.
• Social structure factors reflect a culture’s family roles, gender roles, and social hierarchies. These factors shape health care decision-making processes and expectations. Understanding the social structure factors allows nurses to provide care that considers the dynamics and hierarchies within a culture.

Culture care theory may be used in practice. For example, Nguyen et al. (2019) described how a culturally sensitive intervention was developed and implemented to improve the health outcomes of Vietnamese American women with type 2 diabetes. The intervention was developed based on the principles of Leininger’s Culture Care Theory and included cultural care accommodation and negotiation. Cultural care accommodation was used to adapt the intervention to the cultural beliefs and practices of Vietnamese American women. For example, the intervention included a nutrition education component incorporating traditional Vietnamese foods and recipes. The intervention also included group exercise sessions held in a community center, a familiar and comfortable environment for the women. Cultural care negotiation addressed cultural conflicts and facilitated communication between the health care providers and the Vietnamese American women. For example, the health care providers worked with the women to develop a shared understanding of the importance of blood sugar control and the benefits of taking medication. The providers also discussed the potential side effects of medication and worked with the women to find a medication regimen that was acceptable to them.

The study found that the culturally sensitive intervention led to improvements in the participants’ health outcomes, including better blood sugar control and improved quality of life. The authors suggest that using Leininger’s culture care theory can help nurses and other health care providers develop culturally sensitive interventions that improve the health outcomes of diverse client populations (Nguyen et al., 2019).

Giger and Davidhizar Transcultural Assessment Model

In 1988 Giger and Davidhizar developed the transcultural assessment model, introduced in Cultural Influences on Health Beliefs and Practices, to address the need for nursing students to provide care for clients from diverse cultural backgrounds. This model is designed to help health care providers identify and understand cultural differences in clients and to provide culturally competent care. According to this model, every culture shares six dimensions: communication, space, social organization, time, environmental control, and biological variation (Figure 22.3) (Giger & Davidhizar, 2002).

Communication: This dimension acknowledges that communication patterns and language differ among cultures and that health care professionals should be aware of these differences to provide culturally competent care.

Space: This dimension refers to the physical and personal space individuals require in different cultures. For instance, some cultures prefer to have more physical space between themselves and others, while others prefer to be in closer proximity to others. Understanding a client’s space expectations can help health care providers create a comfortable care environment, which is crucial for building trust, rapport, and communication with the client. Additionally, space expectations can influence how clients respond to treatments or procedures; for example, some clients may feel more comfortable if a family member is present during a medical examination, while others may feel uncomfortable with the same arrangement.

Social Organization: This dimension is the way a culture structures itself around the family group and/or community, including the way communication, decision making, and role distribution occur within and among groups.

Time: This dimension is “a cultural specific orientation to the past, present, and future.” Inquiries about the perception of time can help health care providers understand how clients view the timing of events, the importance of punctuality, and the value of time concerning health and illness.

Environmental Control: This dimension is defined as the perception of an individual’s ability to control nature and the environment, including the use of natural resources, cultural sanctions, and technology.

Biological Variation: This dimension is defined as the factors such as race, body structure, genetic variations, nutritional preferences, and psychological characteristics that need to be considered when assessing a client’s cultural foundation to avoid stereotypes and discrimination.

Figure 22.3 In the Giger and Davidhazar transcultural assessment model, six cultural dimensions provide a framework for client assessment and from which culturally sensitive care can be designed. (See Giger & Davidhizar, 2002; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

One strength of the Giger and Davidhizar transcultural assessment model is its holistic approach to cultural assessment (Albougami et al., 2016). The model looks at multiple dimensions of culture and how they interact with health and illness in order to provide nurses with a comprehensive understanding of clients’ experiences. However, the model has its limitations. Some critics argue that the model does not consider the diversity within cultures and assumes that all individuals from a particular culture will have the same beliefs or practices. For instance, if a nurse assumes that all people who identify as Hispanic have the same culture, they may make incorrect assumptions about an individual client, which may lead to cultural misunderstandings that affect the client’s care.

Additionally, the model may not be as useful for clients from cultures not well-represented in the model’s dimensions (Albougami et al., 2016). Let’s say that a nurse is caring for a client from a small, remote tribe in Africa. The tribe has unique cultural beliefs and practices that are not well-represented in the Giger and Davidhizar Transcultural Assessment Model’s dimensions. The nurse may struggle to understand the client’s cultural needs and be unable to provide culturally sensitive care using the model alone. The tribe may have specific beliefs around illness and healing that are not captured in the transcultural assessment model’s dimensions. The nurse may not be aware of these beliefs and may not be able to provide care that aligns with the client’s cultural practices. This can lead to a breakdown in trust between the client and the nurse and may result in the client receiving suboptimal care. Nurses should be aware of the limitations when using the model to provide culturally sensitive care. Table 22.1 provides a case example using the Giger and Davidhizar transcultural assessment model.

Purnell Model for Cultural Competence

The Purnell model for cultural competence is based on the belief that culture affects every aspect of human life, including health and illness (Purnell, 2002). The model offers a framework for health care providers to develop cultural competence and improve client outcomes. Figure 22.4 illustrates the model, and Table 22.2 presents a client example incorporating the 12 domains of the model.

Figure 22.4 The Purnell model for cultural competence consists of 12 domains that provide a comprehensive framework for understanding and promotion cultural competence in health care. (See Purnell, 2018; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Community health nurses using the Purnell model would consider factors such as communication styles, family dynamics, health care practices, and dietary preferences within specific cultural groups. For instance, when working with a Hispanic community, a community health nurse using the Purnell model would recognize the importance of language and might utilize interpreters to facilitate effective communication. The nurse would also understand the significance of family involvement in health care decisions and involve family members in the care process. Additionally, the nurse would consider traditional Hispanic food preferences and cultural beliefs around nutrition, incorporating culturally appropriate dietary advice.

Strengths of the Purnell model include its comprehensive nature and emphasis on understanding each client’s unique cultural background. It provides a structured framework for nurses to assess, plan, and implement care tailored to each client’s cultural needs. The model has also been revised and updated to reflect changes in health care practices and incorporate new research findings.

Limitations of the Purnell model are its complexity and that it may be too time-consuming to apply in a busy clinical setting. This is because the model involves a detailed assessment of all 12 domains of an individual’s culture, including beliefs, values, traditions, and practices. The model also requires nurses and other health care providers to be knowledgeable about a wide range of cultures. Additionally, the model focuses primarily on individual clients and may not adequately address the cultural needs of families or communities.

Campinha-Bacote’s Process of Cultural Competence in the Delivery of Healthcare Services

Campinha-Bacote’s model of cultural competence in the delivery of healthcare services is a framework that helps health care providers become more culturally competent in their care delivery. This model is based on five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire (Campinha-Bacote, 2018). Within these constructs, cultural competence and cultural humility are not alternative approaches. Instead, they work together to define a process that not only is a lifelong reflective process but also places importance on cultural encounters and learning to increase cultural competence.

• Cultural awareness is the first construct and refers to nurses’ self-awareness of their own cultural values and beliefs.
• Cultural knowledge refers to nurses’ understanding of different cultures and their values, beliefs, and practices.
• Cultural skill refers to nurses’ ability to adapt their skills to meet the needs of clients from different cultures.
• Cultural encounters are nurses’ direct engagement with clients from different cultures.
• Cultural desire refers to nurses’ motivation to become culturally competent.
• Cultural competemility refers to the synergistic relationship between cultural competence and cultural humility.

One of the strengths of this model is its emphasis on the importance of the nurse’s self-awareness and motivation to become culturally competent. It recognizes that cultural competence is not just about acquiring knowledge or skills but also about a nurse’s commitment to providing culturally sensitive care. Both are critical for providing culturally sensitive care to clients from diverse backgrounds.

There are also some limitations to Campinha-Bacote’s model of cultural competence. Some critics argue that this model does not clearly define cultural competence and does not offer specific strategies for health care providers to become more culturally competent (Albougami et al., 2016). Additionally, this model may not be as useful for clients from cultures not well-represented in the model’s constructs. For example, consider a nurse who is working with a client from a culture that places a high value on community and collective decision making. While the Campinha-Bacote model includes the construct of cultural encounters, which emphasizes the importance of interacting with individuals from diverse cultural backgrounds, it may not fully prepare the nurse to understand and respect the client’s cultural values around decision making. In this case, the nurse may need additional resources or training to address the client’s cultural background and values. This could involve consulting with a cultural expert or community leader or seeking out literature or other resources that provide insights into the client’s culture. Table 22.3 presents a client example incorporating the constructs of this model.