Transcultural Health Care A Culturally Competent Approach, .docx

Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Theories, Models, and Approaches
Larry Purnell, PhD, RN, FAAN
4th Edition
Cultural Theories, Models, and ApproachesLeininger: First
nurse cultural theorist from early 1950s. She states it is for
nursing onlyCampinha-Bacote: basic simple model without
complex constructs but applicable to all healthcare providers.
Also has a Biblical based model.
4th Edition
Cultural Theories, Models, and ApproachesGiger and
Davidhizar: Nursing onlyPurnell: For all health care providers
and is an example of a complexity and holographic conceptual
model with an organizing framework.

4th Edition
Cultural Theories, Models, and ApproachesPapadopoulous,
Tilki, and Taylor Model for Transcultural Nursing and Health
Andrews and Boyle Nursing Assessment Guide Spector’s Health
Traditions Model
4th Edition
Cultural Theories, Models, and ApproachesRamsden's Cultural
Safety Model Jeffrey’s Teaching Cultural Competence in
Nursing and Health Care: Inquiry, Action, and Innovation
4th Edition
Leininger’s Theory of Cultural Care
Diversity and Universality
www.madeleine-leininger.com
Leininger described the phenomena of cultural care based on

her experiences.Began in the 1950s with her doctoral
dissertation conducted in New Guinea www.tcns.org and go to
theories and then to the Sunrise Enabler and her model is
displayed as well as publications.
4th Edition
Transcultural Nursing"Transcultural nursing has been defined as
a formal area of study and practice focused on comparative
human-care (caring) differences and similarities of the beliefs,
values, and patterned lifeways of cultures to provide culturally
congruent, meaningful, and beneficial health care to people.“
Leininger and McFarland text, 3rd ed.,2002, pp5-6.
4th Edition
Leininger: Purpose and GoalTo discover, document, interpret,
explain and predict multiple factors influencing care from a
cultural holistic perspective.The goal of the theory was to
provide culturally congruent care that would contribute to the
health and well being of people, or to help them face disability,
dying, or death using the three modes of action.

4th Edition
Leninger: Theoretical TenetsLeininger’s tenets: Care diversities
(differences) and universalities (commonalties) existed among
cultures in the world which needed to be discovered, and
analyzed for their meaning and uses to establish a body of
transcultural nursing knowledge.
4th Edition
Leininger: AssumptionsCare is essence of nursing and a
distinct, dominant, central, and unifying focus. Some would say
that caring is not unique to nursing. Care is essential for well
being, health, growth, survival, and to face handicaps or
death.Culturally based care is the broadest means to know,
explain, interpret, and predict nursing care phenomena to guide
nursing care decisions and actions.
4th Edition
Leininger AssumptionsNursing is a transcultural humanistic and
scientific care to serve individuals, groups, communities, and
institutions worldwide.Caring is essential to curing and healing
for there can be no curing without caring.Cultural care concepts

meanings and expression patterns of care vary transculturally
with diversity and universality.
4th Edition
Leininger AssumptionsEvery human culture has generic care
knowledge and practices and some professional care knowledge
that vary transculturally.Culture care values, beliefs, and
practices are influenced by the (rays of the sun see the
Model).Beneficial, healthy, and satisfying culturally based care
influences the health and well-being of individuals, families,
groups, and communities within the cultural context.
4th Edition
Leininger AssumptionsCulturally congruent care can only occur
when individuals’, groups’, and communities’ patterns are
known and used in meaningful ways.Culture care differences
and similarities between professionals and clients exist in all
human cultures worldwide.Culture conflicts, imposition
practices, cultural stresses, and pain reflect the lack of
professional care to provide culturally congruent care.

4th Edition
Leininger’s Sunrise Enabler to
Discover Culture Care
To view the model go to:
http://leiningertheory.blogspot.com/
4th Edition
Leininger Orientational Theory DefinitionsCultural Care
Preservation or Maintenance: all is well with the patient so
encourage to continue what has been doneCultural Care
Accommodation or Negotiation: Needs some change. What is
acceptable weight from the patient’s perspective Cultural Care
Repatterning or Restructuring: Practices are deleterious to
overall health and need restructured: sexually promiscuous and
has not been practicing safe sex
4th Edition
Cultural Competence in the Delivery of Healthcare Services: A

culturally Competent Model of CareDr. Josepha Campinha-
Bacote but cannot display her model. Go to
http://www.transculturalcare.net
4th Edition
Process of Cultural CompetenceCultural Competence is a
process not an event.The process consist of five inter-related
constructs: Cultural desire, cultural awareness, cultural
knowledge, cultural skills, and cultural encounter.The key and
pivotal construct is cultural desire.There is more variation
within a cultural group than across cultural groups.
4th Edition
Process of Cultural CompetenceThere is a direct relationship
between healthcare professionals level of cultural competence
and their ability to provide culturally responsive health
care.Cultural competence is an essential component in
delivering effective and culturally responsive care to culturally
diverse clients.

4th Edition
Cultural Desire. . . Cultural desire is defined as the motivation
of the healthcare professional to “want to” engage in the
process of becoming culturally competent; not the “have to”.
4th Edition
Concepts Cultural awareness is the self-examination and in-
depth exploration of one’s own cultural background.Cultural
knowledge is the process of seeking and obtaining a sound
educational base about culturally diverse groups.Cultural Skills
is the ability to collect relevant cultural data regarding the
client’s presenting problem as well as accurately perform a
culturally based physical assessment.Cultural encounter is the
process which encourages the healthcare professional to directly
engage in face-to-face interactions with clients from culturally
diverse backgrounds.
4th Edition
The Giger and Davidhizar Transcultural Assessment Model
Dr. Joyce Giger
Dr. Ruth Davidhizar (deceased)

4th Edition
Giger and Davidhizar AssumptionsThe Giger and Davidhizar
Transcultural Model postulates that each individual is culturally
unique and should be assessed according to the six cultural
phenomena.
4th Edition
Giger and Davidhizar CommunicationCommunication embraces
the entire world of human interaction and behavior.
Communication is the means by which culture is transmitted
and preserved. Both verbal and non-verbal communication are
learned in one’s culture.
4th Edition
Giger and Davidhizar
SpaceSpace refers to the distance between individuals when
they interact. All communication occurs in the context of

space.Zones of personal space: intimate, personal, social, and
consultative and public. Rules concerning personal distance
vary from culture to culture.
4th Edition
Social OrganizationSocial organization refers to the manner in
which a cultural group organizes itself around the family group.
Family structure and organization, religious values and beliefs,
and role assignments may all relate to ethnicity and culture.
4th Edition
TimeTime is an important aspect of interpersonal
communication. Cultural groups can be past, present, or future
oriented. Preventive health requires some future time
orientation because preventative actions are motivated by a
future reward.

4th Edition
Giger and Davidhizar Environmental ControlEnvironmental
control refers to the ability of the person to control nature and
to plan and direct factors in the environment that affect them.
4th Edition
Biological VariationsBiological differences, especially genetic
variations, exist between individuals in different racial groups.
4th Edition
Boyle and Andrews Culturological AssessmentBiocultural
variations and cultural aspects of the incidence of
diseaseCommunicationCultural affiliations Cultural sanctions
and restrictionsDevelopmental
considerationsEconomicsEducational background

4th Edition
Boyle and Andrews Culturological AssessmentHealth related
beliefs and practicesKinship and social networksNutrition
Religion and spiritualityValues orientation
4th Edition
Ramsden Cultural Safety"the effective nursing practice of a
person or a family from another culture, as determined by that
person or family", while unsafe cultural practice is "any action
which diminishes, demeans or disempowers the cultural identity
and wellbeing of an individual" (Nursing Council of New
Zealand (NCNZ).
4th Edition
Ramsden Cultural Safety
http://culturalsafety.massey.ac.nz/RAMSDEN%20THESIS.pdfA
ssumes that nurses and the culture of nursing is exotic to people
Gives the power of definition to the person served Concerned
with human diversity Focus internal on nurse or midwife,
exchanges power, negotiated A key part of Cultural Safety is

that it emphasises life chances rather than life styles
4th Edition
Papadopoulos, Tilki, and Taylor
Cultural Awareness
Self awareness
Cultural identity
Heritage adherence
Ethnocentricity
Stereotyping
Ethnohistory
4th Edition
Cultural Knowledge
Health beliefs and behaviours
Anthropological, Sociological,
Psychological and Biological understanding
Similarities and differences
Health Inequalities

4th Edition
Cultural Sensitivity
Empathy
Interpersonal/communication skills
Trust
Acceptance
Appropriateness
Respect
4th Edition
Cultural Competence
Assessment skills
Diagnostic skills
Clinical Skills
Challenging and addressing prejudice, discrimination, and
inequalities

TRANSCULTURAL
HEALTH CARE
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TRANSCULTURAL
HEALTH CARE
A Culturally Competent Approach
4th Edition
Larry D. Purnell
Phd, RN, FAAN
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F. A. Davis Company
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This book is protected by copyright. No part of it may be
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Library of Congress Cataloging-in-Publication Data
Transcultural health care : a culturally competent approach /
[edited by] Larry D. Purnell. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-3705-4
I. Purnell, Larry D.
[DNLM: 1. Cultural Competency—United States. 2. Delivery

of Health Care—United States. 3. Cultural Diversity—United
States.
4. Ethnic Groups—United States. W 84 AA1]
362.1089—dc23
2012016099
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2780_FM_i-xx 16/07/12 12:22 PM Page iv
v
Foreword
Knowing is not enough, we must apply.
Willing is not enough, we must do.
Goethe
Goethe’s quote is considered a call to action by organ-

izations as prestigious as the Institute of Medicine,
and it remains one of my favorite quotes today. It has
such incredible implications for health care, particu-
larly as we struggle with the extended time it takes to
translate research into practice. In fact, oftentimes, de-
spite strong evidence, we are slow in enacting the
changes we need to improve the health care and nurs-
ing we deliver. In some cases we are waiting for the
“indisputable” evidence, and in other cases we are sim-
ply being resistant to change. But occasionally the
need for change is thrust upon us, momentum builds,
and the realization emerges that there isn’t a need to
prove the obvious before acting but a need to act as
the obvious is all around us. This has become the case
with cultural competence in health care.
My knowing about the importance of cultural com-
petence developed as I grew up in my bilingual, bicul-
tural Puerto Rican family, where perspectives about
health and health care were incredibly varied, and at
times at odds with Western medicine. My knowing
grew, as I trained to be a health-care professional in
underserved and diverse settings such as Newark,
New Jersey, and New York City, where we saw pa-
tients from all cultures, classes, and racial/ethnic back-
grounds. What became crystal clear to me was that
while we were learning the best medications to treat
hypertension or the most advanced algorithms for di-
agnosing and treating disease, if we couldn’t commu-
nicate effectively with our patients or get them to buy
into, agree with, and cooperate with what we were try-
ing to accomplish, then all that medical knowledge
was worth nothing. Whether a doctor, a nurse, or
other health professional, caring for patients required
an understanding of the sociocultural factors that
might impact their health beliefs and behaviors, rang-

ing from how they presented their symptoms, to how
they viewed disease and illness, to what informed their
health care, diagnostic, and treatment choices. Cases
where we couldn’t bring our knowledge to bear to ease
suffering or cure disease because of “cultural differ-
ences” with patients were the ones that kept us up at
night and were the most frustrating and disappointing
of all. Along the way I also learned to appreciate that
we all have culture and that the tools and skills I
needed to learn to communicate clearly with patients
wouldn’t just be helpful in the care of those who were
culturally different from me, but to any patient with
whom I interacted. For at the end of the day, there
were always three cultures in the room—my culture;
the patient’s culture; and the cultures of medicine,
nursing, and other health professions—making every
encounter cross-cultural in one way or another.
Despite these almost daily epiphanies during my
training, there were few resources available that might
provide me with guidance on how to become an effec-
tive communicator and caregiver in this new world I
was entering. Fortunately, this has changed. New
models have been developed, leaders have emerged,
and health-care professionals no longer need to go
blindly into cross-cultural encounters without guid-
ance, as there are real and practical approaches that
facilitate improved understanding, communication,
and care. Knowing is not enough, we must apply.
Transcultural Health Care: A Culturally Compe-
tent Approach builds on a framework for cultural
competence—which is essential in the care of the
individual—by bringing together health-care providers
of various backgrounds and disciplines to share their

knowledge, expertise, and experiences in the field
with particulars about different populations. This
information is presented to provide details about the
social and cultural fabric of different cultural groups,
with the important caveat that it is not to be used to
stereotype patients within these groups, as each pa-
tient is an individual and diversity can be as extensive
within groups as it is among groups. It is from this
principle—that learning background information
about cultural groups can help health-care providers
both develop a “radar” for potential pitfalls when
caring for them and serve as a springboard for in-
quiry with the individual patient—that Transcultural
Health Care emerges.
Why is this book, and this edition, so timely? In the
past, arguments about the importance of cultural
competence were based primarily on making the case
that our nation was becoming increasingly diverse and
that as health-care professionals we need to be pre-
pared to care for patients of different sociocultural
backgrounds. This is an important argument, no
2780_FM_i-xx 16/07/12 12:22 PM Page v
doubt. Shortly thereafter, research began to emerge
demonstrating that being inattentive to cultural issues
in the clinical setting leads to lower quality of care
for specific populations, such as racial and ethnic
minorities—a term that became known as disparities
in health care. Yet what has evolved more recently is a
burgeoning literature documenting the impact of cul-
tural factors on health-care quality, cost, and safety.
New research demonstrates that when we are not

skilled or prepared to care for patients from diverse
backgrounds, they may, when compared to their Cau-
casian counterparts, suffer more medical errors with
greater clinical consequences; have longer hospital
stays for the same common clinical conditions; and
may have more unnecessary tests ordered—all due to
language or cultural barriers between health-care
providers and patients. With health-care reform and
payment reform on the horizon, we literally can no
longer afford to be ill prepared to meet the needs of
an increasingly diverse nation.
As we look toward the future, we see signs of a
breakthrough occurring. More and more is being writ-
ten about the topic of cultural competence. Students
who years ago had to be convinced of the importance
of this issue are now arriving more sensitized about
cultural competence than ever before and are demand-
ing to build their skills in the field. More research is
being conducted on cultural competence and its im-
pact on quality, safety, and cost. Additional areas are
being cross-linked to cultural competence, such as
patient-centeredness and health literacy. New quality
measures and accreditation standards are being devel-
oped, and in some states cultural competence training
has become a condition of health professional licen-
sure. There is little doubt that the field of cultural
competence is moving from the margin to the main-
stream and from a luxury to a necessity. As individual
providers, we must all do our part to ensure that we
are delivering high-quality care to any patient we see,
regardless of her or his race, ethnicity, culture, socio -
economic class, or language proficiency. Transcultural
Health Care: A Culturally Competent Approach helps
us build the radar to identify and understand key

cross-cultural issues among diverse populations and,
when applied with the tools and skills that are essen-
tial for exploring the sociocultural perspectives of the
individual patient, positions us for success. Now it is
time for us to learn the lessons and skills so gracefully
shared with us in this book to make a difference in pa-
tients’ lives. Willing is not enough, we must do.
Joseph R. Betancourt, MD, MPH
Director, The Disparities
Solution
s Center and
Director of Multicultural Education,
Massachusetts General Hospital
Associate Professor of Medicine,
Harvard Medical School
Cofounder, Manhattan Cross-Cultural Group
vi Foreword
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vii
Preface
The Purnell Model for Cultural Competence and its
accompanying organizing framework continue to be
used in education, clinical practice, administration,
and research. The Model and selected chapters have
been translated into Arabic, Flemish, French, Korean,
Portuguese, Spanish, Turkish, and Korean, attesting
to its value on a worldwide basis. In addition, many
health-care organizations have adapted the organizing
framework as a cultural assessment tool, and numer-
ous students in the United States and overseas
have used the Model to guide research for theses and
dissertations. The Model is increasingly being used
as a guide to help ensure organizational cultural
competence.
This fourth edition of Transcultural Health Care:
A Culturally Competent Approach has been revised
based upon responses from students, faculty, and
practicing health-care professionals such as nurses,
physicians, emergency medical technicians, nutrition-

ists, and people in noetic sciences. In addition, this edi-
tion is divided into two units. Unit 1, Foundations for
Cultural Competence: Individual and Organizational,
has the following features:
• An expanded chapter on the overview of transcul-
tural diversity and health care
• A separate chapter on the Purnell Model for
Cultural Competence, with specific questions in the
organizing framework instead of objectives
• A separate chapter on individual competence and
evidence-based practice
• A separate chapter on organizational cultural
competence
• A separate chapter on global health
Unit 2 is entitled Aggregate Data for Cultural-
Specific Groups. As in previous editions, we have made
a concerted effort to use nonstereotypical language
when describing cultural attributes of specific cultures,
recognizing that there are exceptions to every descrip-

tion provided and that the differences within a cultural
group are determined by variant cultural characteris-
tics. One important change on the Model is that the pri-
mary and secondary characteristics of culture are now
called “variant cultural characteristics” at the sugges-
tion of gay, lesbian, and transgendered communities.
The first time a cultural term is used in a chapter, it
is in boldface type and is defined in the glossary.
Because faculty and clinical practitioners have found
the Appendix—Cultural, Ethnic, and Racial Diseases
and Illnesses—valuable, it remains in the book.
Abstracts are included in the main textbook for each
culturally specific full chapter located on Davis Plus.
Space and cost concerns limit the number of chapters
that are included in the book; therefore, additional cul-
tural groups are on Davis Plus. Also on Davis Plus are
student resources such as review questions, Web sites of
interest, case studies, and reflective exercises. Additional
faculty resources on Davis Plus include PowerPoint
slides with clicker check questions for each chapter and
a question bank.

Specific criteria were used for identifying the groups
represented in the book and those included in elec-
tronic format. Groups included in the book were
selected based on any of the following six criteria:
• The group has a large population in North
America, such as people of Appalachian, Mexican,
German, and African American heritage.
• The group is relatively new in its migration status,
such as people of Haitian, Somali, and Arab
heritage.
• The group is widely dispersed throughout
North America, such as people of Iranian,
Korean, Hindu, and Filipino heritage.
• The group is of particular interest to readers, such
as people from Amish heritage.
• The group is of particular interest to students and
staff from other countries, such as European
Americans.
A particular strength of each chapter is that it has

been written by individuals who are intimately famil-
iar with the specific culture. Again, we have strived to
portray each culture comprehensively, positively, and
without stereotyping. We hope you enjoy the book.
Larry D. Purnell
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2780_FM_i-xx 16/07/12 12:22 PM Page viii
ix
Contributors
Richard Adair, MD
Adjunct Professor of Medicine
University of Minnesota
Minneapolis, Minnesota
Karen Aroian, PhD, RN, FAAN

Director of Research and Chatlos Endowed Professor
University of Florida College of Nursing
Orlando, Florida
Linda Ciofu Baumann, PhD, RN, FAAN
University of Wisconsin-Madison
Madison, Wisconsin
Joseph R. Betancourt, MD, MPH
Director of Disparities

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