This document discusses cultural competence models for health care encounters. It summarizes six prominent models from transcultural nursing: 1. Leininger's Sunrise Model stresses culturally congruent care through collaboration, respecting both the provider and patient's cultures. 2. Purnell's Model evaluates 12 cultural domains to acquire patient-specific knowledge. 3. Campinha-Bacote's Model views cultural desire as key, requiring the provider to want, not just have to, understand differences and learn from patients. 4. Jeffreys' Model advises developing moderate self-efficacy to motivate further cultural learning. 5. Andrews and Boyle emphasize strong cross-cultural communication skills.

1. Chapter 7Chapter 7
Cultural Competence in HealthCultural Competence in Health
Care EncountersCare Encounters

2.  To define the health care encounter and its role in the
systems approach to cultural competence
 To review and discuss the practical application of six
widely used cultural competence models from the transcultural
nursing field
 To relate the six cultural phenomena identified in the
GDTAM to the culturally responsive health care encounter:
communication, space, social organization, time, environmental
control, and biological variations
 To describe how to use the LEARN mnemonic to improve
cultural responsiveness in the health care
Chapter ObjectivesChapter Objectives

3. Defined broadly as:
a planned or unplanned interaction
between a provider of health care or related
services and a recipient of care or
information
such as a patient, client, family member, or
community member
Health care encountersHealth care encounters

4.  In a systems approach, health care
encounters include such interactions with
ANY representative of the system,
including volunteers, residents,
receptionists, nurses, physicians,
therapists, support staff, phlebotomists,
nurse educators
 There is a power differential between care
providers and care recipients
Health care encounters in a systemsHealth care encounters in a systems
approachapproach

5.  Requires the provider to take action to
moderate the power differential to form a
more balanced therapeutic alliance
 Onus is on the PROVIDER regardless of
the patient’s level of responsiveness
 There are ethical and legal limits however
 Involve negotiation
Culturally responsive health careCulturally responsive health care
encounterencounter

6. Required transformation in the health care encounter
involves:
Shift from a problem/disease focus to a
human/contextual perspective
Recognition of the provider’s own biases, prejudices and
stereotypes
Consideration of how patients’ concerns might influence
communication and clinical assessment
Development of the communication skills needed to
negotiate effectively and collaboratively, which optimizes
patient outcomes
Nunez and Robertson (2006)Nunez and Robertson (2006)

7. “Substantive area of study and practice focused on
comparative cultural care (caring) values, beliefs,
and practices of individuals or groups of similar or
different cultures. Transcultural nursing’s goal is to
provide culture specific and universal nursing care
practices for the health and well-being of people or
to help them face unfavorable human conditions,
illness or death in culturally meaningful ways.”
(Leininger & McFarland, 2002, page 46)
Definition of Transcultural NursingDefinition of Transcultural Nursing

8. Madeline M Leininger – founder
Historical evolution:
1955 – 1975 – Establishment of field
1975 – 1983 – Expansion of transcultural
nursing programs and research
1983 – present – Worldwide establishment
of transcultural nursing field
Transcultural NursingTranscultural Nursing

9. Model Essential Lesson for the Culturally Responsive Health Care
Encounter
Leininger’s Sunrise Model To be culturally congruent, providers must collaborate with the patient
by sharing power and respecting the patient’s culture as well as their
own.
Purnell Model for Cultural Competence To be consciously competent, a provider must acquire relevant culture-
specific information about the patient.
Campinha-Bacote’s Process of Cultural
Competence in the Delivery of Health Care
Services
To be culturally responsive, the provider must begin with cultural
desire, that is, have the attitude that reflects “I want to” not “I have to”
do so.
Jeffreys’ Cultural Competence and
Confidence (CCC) Model
To continue to develop cultural responsiveness, providers should
exhibit moderate levels of self-efficacy, defined as a balance between
confidence and concern about their skill set, which is most likely to
motivate further learning.
Andrews and Boyle’s Transcultural Concepts
in Nursing Practice
Culturally responsive care is dependent on the strength of the provider’s
verbal and nonverbal crosscultural communication skills.
Giger-Davidhizar Transcultural Assessment
Model (GDTAM)
Culturally responsive care requires that the provider evaluate how the
following six cultural phenomena may affect cultural responsiveness in
the health care encounter: communication, space, social organization,
time, environmental control, and biological variations.
Six Prominent Models fromSix Prominent Models from
Transcultural NursingTranscultural Nursing

10.  Discover factors related to cultural
stresses, pain, racial biases, and even
destructive acts as nontherapeutic to
clients
Leininger’s Sunrise ModelLeininger’s Sunrise Model

11.  What do I believe about health, illness, and
death? How do my identity group memberships,
such as gender, ethnicity, socioeconomic status,
profession, and so on, influence my beliefs?
 How open am I to seeing value and truth in
worldviews and beliefs that differ from my own?
 What do I know about the similarities and
differences between my worldview and beliefs
and those of the patient I am interacting with?
Sunrise Model –Self EvaluationSunrise Model –Self Evaluation
Questions - 1Questions - 1

12.  What knowledge do I need to acquire about the culture,
worldview, health beliefs, and practices of my patient
before the health care encounter?
 How can I interact in the health care encounter to
acquire knowledge during the encounter and test my
assumptions about the patient’s culture, worldview,
health beliefs, and practices?
 How successful am I in negotiating with my patient in
the health care encounter? How will I know if the
patient perceived the encounter as successful?
Sunrise Model –Self EvaluationSunrise Model –Self Evaluation
Questions - 2Questions - 2

13.  Culturally congruent care = knowledge
and respect for your own and your
patient’s worldview, culture and preferred
care expressions, patterns, and practices
 Health care encounter is a negotiation
where provider and patient learn about
each other and agree on common ground
Leininger’s Sunrise ModelLeininger’s Sunrise Model

14.  Published in 1989
 First developed as a clinical assessment
tool for nurses
 Twelve domains
 Provider continuum that ranges from
unconsciously incompetent to
unconsciously competent
Purnell Model for Cultural CompetencePurnell Model for Cultural Competence

15. Purnell’s Twelve DomainsPurnell’s Twelve Domains
• Overview and heritage
• Communication
• Family roles and
organization
• Workforce issues
• Biocultural ecology
• High-risk behavior
• Nutrition
• Pregnancy and
childbearing practices
• Death rituals
• Spirituality
• Health care practice
• Health care practioner

16.  Which of the twelve domains define knowledge I already
have about my patient’s culture?
 Which of the twelve domains define knowledge I need to
acquire about my patient’s culture?
 How can I acquire vital knowledge about my patient’s
culture?
 How will I know where I reside along the continuum of
unconscious incompetence to unconscious competence?
Does where I reside on the continuum differ by cultural
group?
Purnell Model – Self EvaluationPurnell Model – Self Evaluation
QuestionsQuestions

17.  Key concept = cultural desire – the
motivation of the nurse to ‘want to’ engage
in the process of becoming culturally
competent; not to ‘have to’
 Cultural desire is envisioned as the base of
a volcano of cultural competence in the
delivery of health care services
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
CompetenceCompetence

18.  Includes a genuine passion and
commitment to be open and flexible with
others
 Respect and understanding of differences,
yet a commitment to build upon
similarities
 Willingness to learn from patients and
others as cultural informants and a sense
of humility
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
CompetenceCompetence

19.  Cultural awareness – a deliberate cognitive process
seeking awareness, appreciation and sensitivity to patient
culture
 Cultural knowledge – process of seeking and obtaining
information about patient culture
 Cultural skill – applying awareness and knowledge to
perform culturally based physical assessments and
considering physical, biological, and physiological variations
of ethnicity
 Cultural encounters – engaging in direct crosscultural
interactions to build awareness, knowledge and skill –
countering stereotyping
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
Competence - ConstructsCompetence - Constructs

20.  How strong is my cultural desire? What actions
can I take to make it stronger?
 Am I aware of the impact of culture on the health
care encounter? What evidence supports my self-
assessment? How can I build greater awareness?
 What are my cultural skills in the health care
encounter? What are my areas for development?
What evidence supports my self-assessment?
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
Competence – Self Evaluation QuestionsCompetence – Self Evaluation Questions

21.  What are the sources of my cultural knowledge?
Are these sources valid? Do I use my cultural
knowledge appropriately? How can I obtain
more valid cultural knowledge that is relevant to
the health care encounter?
 Do I approach or avoid cultural encounters with
people I perceive to be different from myself?
How can I create opportunities in my life for
more frequent professional and personal
crosscultural encounters?
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
Competence – Self Evaluation QuestionsCompetence – Self Evaluation Questions

22.  Inventory for Assessing the Process of
Cultural Competence Among Health
Professionals Revised (IAPCC-R) – self-
assessment instrument
Campinha-Bacote’s Process of CulturalCampinha-Bacote’s Process of Cultural
Competence – Self Assessment ToolCompetence – Self Assessment Tool

23.  Paired with a self-assessment instrument
 Transcultural self-efficacy –
confidence in one’s own ability to develop
and apply cognitive, practical, and
affective transcultural nursing skills
 Requires self-appraisal and balance
between confidence and concern for skill
set to motivate further learning
Jeffreys’ Cultural Competence andJeffreys’ Cultural Competence and
Confidence (CCC) ModelConfidence (CCC) Model

24. Areas of skill development:
Affective – builds self-awareness about provider’s own
culture and personal biases and effect on health care
encounter
Cognitive – builds general and specific knowledge about
patient culture and effect on health care encounter
Practical – builds provider’s capacity to exhibit cultural
competence through patient communication and
interaction to develop and implement valid patient-specific
cultural needs assessment
CCC Transcultural Nursing SkillsCCC Transcultural Nursing Skills

25.  How do I rate my own transcultural self-
efficacy? How does my rating affect my
motivation to develop my affective, cognitive,
and practical transcultural skills?
 Am I self-aware about my own culturally based
values, beliefs, and behaviors, especially as they
pertain to the health care encounter? Am I
committed to continually developing my self-
awareness? What am I doing to build my
affective transcultural skills?
Jeffreys’ CCC Model –Jeffreys’ CCC Model –
Self Evaluation Questions 1Self Evaluation Questions 1

26.  What knowledge do I have about the culture,
worldview, health beliefs, and practices of my
patients? What additional knowledge do I need?
What am I doing to build my cognitive
transcultural skills?
 Does my style of communication with the patient
in the health care encounter enable me to deliver
patient-centered care that is culturally
responsive? What am I doing to build my
practical transcultural skills?
Jeffreys’ CCC Model –Jeffreys’ CCC Model –
Self Evaluation Questions 2Self Evaluation Questions 2

27.  Crosscultural communication as bridge
between provider and patient
 Communication has verbal and nonverbal
dimensions, occurs in environmental
context, reflects similarities and beliefs in
provider and patient cultural values,
beliefs, and behaviors in health care
Andrews and Boyle’s TransculturalAndrews and Boyle’s Transcultural
Concepts in Nursing PracticeConcepts in Nursing Practice

28. Andrews and Boyle’s ModelAndrews and Boyle’s Model
Aspects of verbal
communication:
•Language
•Appropriate use of
titles and greetings
Aspects of nonverbal
communication:
•Time
•Space
•Distance
•Modesty
•Touch

29.  What aspects of verbal and nonverbal
communication do I use effectively in health care
encounters with diverse patients? What aspects
do I need to develop?
 What do I know about similarities and
differences in verbal and nonverbal
communication norms among cultural groups?
What else do I need to learn?
Andrews and Boyle’s –Andrews and Boyle’s –
Self Evaluation Questions 1Self Evaluation Questions 1

30.  Do I focus on memorizing health beliefs and
practices of different groups or on developing my
crosscultural communication skills? Which
approach do I believe is more important to
cultural competence in the health care encounter
and why?
Andrews and Boyle’s –Andrews and Boyle’s –
Self Evaluation Questions 2Self Evaluation Questions 2

31.  Communication
 Space
 Social organization
 Time
 Environmental control
 Biological variations
Giger-Davidhizar TransculturalGiger-Davidhizar Transcultural
Assessment Model (GDTAM)Assessment Model (GDTAM)

32.  Consensual validation – process of
ascertaining whether the receiver grasped
and comprehended the intended message
of the sender
 Projection – attributing one’s own
thoughts, desires, expectations, and
behavior to another
CommunicationCommunication

33.  Proxemics – focuses on the cultural
meaning of interpersonal distance in
communication
 Touch and the healing process
Space - GDTAMSpace - GDTAM

34.  Social organization – pattern of
relationships among people in a group –
generally associated with ethnicity
 Religion - can be an important component
Social Organization - GDTAMSocial Organization - GDTAM

35.  Culturally determined
 Task-focused cultures – “on time”
 Relationship-focused cultures – “in time”
Time - GDTAMTime - GDTAM

37.  Locus of control – the extent to which
people believe they have mastery over
their own experiences and outcomes
 Internal vs. external
 Learned through enculturation in the
family and community
 Environmental exposure to hazardous
waste and environment pollution varies by
SES and is associated with race and
ethnicity
Environmental Control - GDTAMEnvironmental Control - GDTAM

38.  Ethnopharmacology – field of study that
examines responses to drugs in
relationship to genetic variations among
ethnic groups
 Role of genetics in predisposition to
diseases and drug metabolism
Biological variations - GDTAMBiological variations - GDTAM

39.  Listen to the patient’s perspective
 Explain and share one’s own perspective
 Acknowledge differences & similarities
between two perspectives
 Recommend treatment
 Negotiate a mutually agreed-on plan
LEARNLEARN
Berlin and Fowkes (1983)Berlin and Fowkes (1983)

40. Key TermsKey Terms
• Consensual validation
• Cultural desire
• Decenter
• Enculturation
• Ethnopharmacology
• Health care encounter
• Locus of control
• Power
• Proxemics
• Self-monitor
• Social organization
• Transcultural nursing
• Transcultural self-efficacy