Albougami et al.

Int Arch Nurs Health Care 2016, 2:053

Volume 2 | Issue 4

International Archives of ISSN: 2469-5823

Nursing and Health Care

Discussion Paper: Open Access

Comparison of Four Cultural Competence Models in Transcultural

Nursing: A Discussion Paper
Abdulrhman Saad Albougami1*, Karen G Pounds2 and Jazi Shaydeid Alotaibi1
1
Department of Nursing, Majmaah University, Riyadh, Saudi Arabia
2
School of Nursing, Northeastern University, Boston, USA

*Corresponding author: Abdulrhman Saad Albougami, PhD in Nursing, Department of Nursing, Majmaah University,
Riyadh, Saudi Arabia, Tel: +966 4 544 2536, E-mail: [email protected]
patient assessments. For optimal care, the completion of a thorough
Abstract assessment is particularly important when a patient comes from
a different culture [4]. The provision of high-quality care builds
Globalization has brought about tremendous changes to societies
around the world. Increased immigration has led to increasing patients’ comfort and confidence in the healthcare system while
diversity among patients, making culturally congruent healthcare an promoting patient satisfaction [5]. Therefore, the assessment
absolute necessity. Like all healthcare fields, nursing is expected to process should be designed to be accurate, comprehensive, and
adopt a global practice of culturally congruent care. Thus, nurses systematic; in essence, it should assist nurses in reaching concrete
must acquire an in-depth understanding of cultural beliefs, practices, conclusions regarding suitable patient interventions [6,7].
and differences, thus developing a practice of avoiding premature To this end, researchers have developed models to help nurses
generalizations. Cultural competence models have and will continue overcome challenges when caring for culturally diverse patients.
to play a crucial role in making nursing practice more efficient and
These models were designed to encourage culturally appropriate
effective. The aim of this paper is to describe and discuss four well-
known cultural competence models in the nursing literature. These and culturally competent care, and the developers of the models
models have enhanced nursing care delivery to diverse populations emphasize how nurses can use this skill to work effectively with any
by providing a means to overcome difficulties and challenges when population [8]. Following an introduction to transcultural nursing,
dealing with culturally diverse patients. Ultimately, cultural care this paper includes the comparison of four prominent models of
models encourage culturally competent care for patients belonging cultural competence: Leininger, Giger and Davidhizar, Purnell
to different cultures by helping nurses become more understanding and Campinha-Bacote [9-12]. It also discusses the application of
and adaptive to various circumstances, and better able to apply these models with respect to the present literature and outlines the
culturally-focused interventions. This paper reflects on the impact
recommended standards for achieving best practices.
of cultural competence nursing education on patient care.

Keywords Concepts and Definitions

Diversity, Culturally competent care, Cultural competence, Models Transcultural nursing refers to various culture-related aspects
of healthcare delivery that can affect disease management and
the status of individuals’ health and well-being [13]. The main
objective of transcultural nursing is to promote the delivery of
Introduction culturally congruent, meaningful, high-quality, and safe healthcare
to patients belonging to similar or diverse cultures [13]. Accordingly,
Transcultural nursing has been integrated into modern nursing
when different cultures are studied, healthcare professional scan
education due to the increased heterogeneity of patient populations.
understand their similarities and differences. Culture affects an
As more people from a variety of cultures and with a variety of
individual’s concepts and approaches to health and illness. Because
ethnicities now utilize healthcare facilities, nurses need to be aware
nurses need to care for patients belonging to different cultures,
of their varying perceptions and levels of tolerance for healthcare. cultural competence is essential for nursing [14].
This situation can lead to departures from the practice norms that
would otherwise direct patient care, thus opening up a wide array Culture care emphasizes consideration of a patient’s beliefs and
of options regarding treatments and follow-ups. Decision making heritage when developing a healthcare plan. Moreover, it requires
in patient care involves many important considerations, including nurses to acknowledge that individuals belong to different cultures
patients’ attitudes and how they will react to treatment advice [1-3]. and races and, therefore, necessitating treatment that respects the
For these reasons, the adaptability of nursing professionals is crucial, uniqueness of each individual [15]. Transcultural nursing employs
particularly when it comes to cultural diversity, because this issue can the concepts of ethnicity, race, and culture in order to understand
affect the quality of service provided to patients. individuals’ perceptions and behaviors. Nurses must consider these
concepts in order to deliver culturally congruent healthcare. The
Nurses should have sufficient information about different nursing literature has developed a variety of applicable concepts,
cultural backgrounds and customs to be able to conduct holistic including acculturation, cultural awareness, and cultural competence.

Citation: Albougami AS, Pounds KG, Alotaibi JS (2016) Comparison of Four Cultural Competence
Models in Transcultural Nursing: A Discussion Paper. Int Arch Nurs Health Care 2:053
ClinMed Received: May 26, 2016: Accepted: June 27, 2016: Published: July 01, 2016
Copyright: © 2016 Albougami AS, et al. This is an open-access article distributed under the
International Library terms of the Creative Commons Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and source are credited.
 In addition, certain culture-related concepts are particularly required for gaining knowledge about different cultures during
relevant to healthcare and nursing [15]. These include culture, race, healthcare delivery. The models are under continual development
ethnicity, and cultural competence. Culture refers to a set of beliefs, and they guide nursing practice all over the world. Hence, this paper
assumptions, values, and norms that a group of individuals largely focuses on the four particularly significant models.
observe and transfer across generations [16]. Ingram defined culture
as a learned worldview demonstrated by a group of individuals that Leininger Sunrise Model
is transferred socially [17]. Culture affects the beliefs, values, norms, The Leininger Sunrise Model represents the structure of culture
and behaviors of individuals, and it is reflected in language, food, care theory by describing the relationship between anthropological
dress, and social institutions. Culture can significantly affect various and nursing beliefs and principles [9]. Nurses use this model when
aspects of human life, including health and preferences for managing making cultural evaluations of patients. The model connects the
health conditions. Multicultural trends are emerging in numerous concepts of the theory with actual clinical practices, while offering
countries due to globalization and mass immigration [17]. a systemic approach to identifying values, beliefs, behaviors, and
Each culture has distinct characteristics and therefore, community customs. The model encompasses numerous aspects
individuals belonging to different cultures can differ considerably. of culture: religious, financial, social, technological, educational,
These differences must be respected and each individual treated as a legal, political, and philosophical dimensions. These factors, along
unique human being. Indeed, even people belonging to the same race with language and social environment, significantly affect the
may differ culturally. Race is a social classification based on physical services delivered by systems, whether traditional or professional.
characteristics like skin color [16]. It can also serve as an identifying Traditional healthcare systems are based on conventional beliefs
trait of a culture. Similarly, ethnicity indicates cultural membership related to health, whereas professional systems rely on learned
based on people having similar cultural characteristics that have led to knowledge, evidence-based practice, and research [13]. The nursing
a common history. Ethnicity tends to remain with people throughout profession considers patients’ physical, spiritual, and cultural needs.
their lives [16]. A thorough understanding of these needs facilitates the achievement
of desired clinical outcomes. Moreover, Leininger’s model helps
Cultural competence refers to a set of culturally congruent healthcare professionals to avoid the stereotyping of patients [13]. To
practices, behaviors, and policies that allow nursing professionals to accomplish such goals, the model utilizes three concepts: culture care
deliver high-quality services in a variety of cross-cultural scenarios maintenance/preservation, culture care negotiation/accommodation,
[16]. Cultural competence is an essential requirement in nursing. and culture care restructuring/repatterning. Cultural preservation
Culturally congruent healthcare does not aim to facilitate patient refers to nurses’ provision of support for cultural practices, such as
care for ethnic or racial minority groups only; rather, the objective employing acupressure or acupuncture for anxiety and pain relief
is to improve healthcare delivery by considering differences in age, prior to medical interventions. Similarly, cultural negotiation refers
gender, religion, and socioeconomic status [18]. to the support provided to the patients and their family members in
Healthcare professionals, especially nurses, should make an effort carrying out cultural activities that do not pose threats to the health
to understand and learn about different cultures. Understanding a of the patients or any other individual in the healthcare setting.
patient’s religious and cultural background can be highly beneficial Finally, cultural restructuring refers to nurses’ efforts to deliver
in delivering healthcare. This understanding may cause healthcare patient-centered care by helping patients modify or change their
professionals to evaluate their own cultural and religious beliefs, cultural activities. Cultural restructuring is suggested only when
which may in turn influence their practices [19]. Such cultural certain cultural practices may cause harm to the patient or those in
awareness denotes an individual’s self-awareness of his or her own the surrounding environment. These concepts can inform nurses in
cultural background, differences, and biases. Acculturation, on the achieving their ultimate goals [16].
other hand, signifies the process of learning about a new culture.
Giger and Davidhizar Transcultural Assessment Model
Nurses should adapt to different cultures by making modifications to
their nursing practices [20]. This model emphasizes the importance of considering every
person as unique in his or her culture [10]. According to Giger and
Evolution of Transcultural Nursing Davidhizar, there are six dimensions common to every culture:
Leininger uncovered a core concept of care during her early communication, space, social organization, time, environmental
education; this concept later became her motivation to specialize in control, and biological variation [10]. The first dimension is
transcultural nursing specifically [9]. She explained this concept as a communication, which is the holistic process of human interaction
fundamental nursing component based on her experience and positive and conduct. The use and preservation of communication takes
feedback from patients. During her work at a child-guidance home, several forms - verbal, nonverbal, and written - and differs in terms
she experienced a cultural shock, leading her to realize that a lack of expression, language and dialect, voice tone and volume, context,
of understanding regarding cultural diversity could explain recurrent emotional implication, facial expression, gestures, and body language.
behavioral patterns in some children. She recognized a major deficit Language can become a barrier to quality healthcare due to simple
in understanding differential patient demands in the context of care misunderstandings and failure to communicate as intended. The
and wellness. She maintained that the quality of nursing education second dimension is space, which is the distance maintained between
suffered due to the absence of training in cultural diversity, the result interacting individuals; this “personal space” differs according to
being a disconnect between patient and nurse. individuals’ cultural backgrounds. The concept of space involves three
other behavioral patterns: attachment with objects in the environment,
The theorist’s identification of this problem shaped a new body posture, and movement in the setting [10]. It is important to
paradigm in nursing care, leading to the advent of transcultural observe tact and to avoid overstepping boundaries with respect to
nursing [9]. Leininger defined transcultural nursing as an area of these aspects of interaction, because doing so can cause patients
study that focuses on comparative cultural care based on the beliefs, unnecessary anxiety. The third dimension is social organization,
practices, and values of care-seeking patients. Its main purpose is which is how certain cultures group themselves in accordance with
to provide both universal and culture-based nursing practices that family, beliefs, and duties. This dimension requires nurses to remain
promote well-being and health. Additionally, it aims to help patients aware that patient conduct can be influenced by factors like sexual
overcome illness in a culturally intelligent and responsive manner orientation, acknowledgement and utilization of titles, and decision-
[16]. making regulations. An awareness of this dimension can help nurses
avoid being perceived as being derogatory or disrespectful. The fourth
Models of Transcultural Nursing dimension is time, which is similar to social organization in terms of
Transcultural nursing models provide nurses with the foundation influence. Time is subdivided into whether the group is clock-oriented,

Albougami et al. Int Arch Nurs Health Care 2016, 2:053 ISSN: 2469-5823 • Page 2 of 5 •
like most Westerners, or socially oriented. The clock-oriented group of the sick. The twelfth and final domain, healthcare professionals,
is fixated on time itself, and individuals with this orientation seek to involves the perceptions and roles of traditional and folk healthcare
keep appointments so as not to be seen as ill-mannered or offensive. practices [24].
The behavior of socially oriented groups emphasizes the here and
now. Such individuals understand time as a flexible spectrum defined Campinha-Bacote Model of Cultural Competence in
by the duration of activities; an activity does not begin until the Healthcare Delivery
preceding event has ended. The fifth dimension is environmental
Campinha-Bacote first developed her model, known as “cultural
control, which implicates how the person perceives society and its
competency in the delivery of healthcare services,” in 1998, revising
internal and external factors, such as beliefs and understandings
it in 2002 [12]. The model considers cultural competence not as
regarding how illness occurs, how it should be treated, and how
a  consequence brought about by certain factors, but as a process.
health is uplifted and maintained. The sixth and last dimension is
The concept of cultural competence can be defined as a process in
biological orientation. Races vary biologically due to differences in
which the nurse attempts to achieve greater efficiency and the ability
DNA, and some races are more prone to certain diseases than others.
to work in a culturally diverse environment while caring for the
Other notable elements of this model are a deeper understanding of
patient, whether an individual, a family, or a group [12]. To achieve
pain tolerance and deficiencies and predilections in nutrition [21,22].
cultural competence, a nurse must undertake a process of developing
Purnell Model for Cultural Competence the capacity to deliver efficient and high-quality care, a process that
encompasses five components. The first involves cultural awareness,
The Purnell model focuses on providing a foundation for a process in which healthcare professionals consciously acknowledge
understanding the various attributes of a different culture, allowing their own cultural backgrounds, which helps them avoid biases
nurses to adequately view patient attributes, such as incitement, toward other cultures. The second component is cultural skill, defined
experiences, and notions about healthcare and illness [11]. This as the ability to obtain the necessary information from patients via
model is presented in a diagram with parallel circles that represent culturally-appropriate conduct and physical assessment. The third
aspects of global society as well as the community, family, and person. component is cultural knowledge, a process in which healthcare
The Purnell model includes twelve domains: overview or heritage, professionals open their minds to understand variations in cultural
communication, family roles and organization, workforce issues, and ethnic traits as they relate to patient attitudes toward illness and
bio-cultural ecology, high-risk behaviors, nutrition, pregnancy, death health. The fourth component is cultural encounter during which
rituals, spirituality, healthcare practices, and healthcare professionals stereotyping is avoided through the interaction between healthcare
[11]. Purnell considered these domains to be important in evaluating professionals and members of different cultures. During this process,
the traits and characteristics of various ethnic groups. The model can overreliance on conventional views is discouraged. The fifth and last
be depicted with a frame representing global society and an outer component is cultural desire, which is the driving force for becoming
circle signifying community. The second circle signifies family, and educated, skilled, competent, and aware of culture; it also presumes a
the innermost circle depicts the individual [23]. willingness to have transcultural interactions [25].
The first domain is culture and heritage, which includes the
Discussion across Models
country of derivation, the geographical influence of the original
and present home, political affairs, economics, educational status, Transcultural nursing models have played a significant role
and profession. The second domain comprises important notions in forming the basic foundations of nursing practice. Despite their
relevant to communication, such as primary language and dialects, positive contributions, the transcultural models have been criticized
circumstantial effectiveness and convenience of the language, for their limitations and failure to acknowledge certain issues related
paralinguistic differences, and nonverbal communication. The third to the educational and practical components of transcultural nursing
domain, family roles and organization, involves who heads the [8]. For example, the Leininger model has been critiqued for failing
household in terms of gender and age. The organization of the family to acknowledge political and structural processes. Critics have argued
is affected by goals and priorities, developmental tasks, social status, that it focuses exclusively on cultural diversity, biases, conventional
and alternative lifestyles. The fourth domain is workforce issues, views, and the inequity between nurses and patients. According to
including acculturation, autonomy, and the presence of language these critiques, the model also failsto acknowledge that cultural
barriers. The fifth domain includes factors of bio-cultural ecology, diversity needs to go beyond between group differences and be
which encompass observable differences with respect to ethnic and understood from the perspective of differences among individuals
racial origins, like skin color and other physical variations. The from the same culture, due to varying socioeconomic backgrounds,
sixth domain is high-risk behaviors, such as using tobacco, alcohol, age groups, and types of communities. Conversely, the model has
or recreational drugs. This domain also includes physical activity been praised for its clear and simple way of evaluating professional
and levels of safety or precautions taken. The seventh domain is and societal cultures [3].
nutrition. Depending on their place of origin, individuals or groups
Integrating cultural competence models are a beneficial
are accustomed to certain foods and draw meaning from the foods
addition to nursing curricula and clinical training in undergraduate
they eat. Food consumption associated with certain rituals may affect
and graduate nursing programs [26-28]. Numerous studies have
health. Some ethnic groups suffer from certain nutritional limitations
investigated how these models can be integrated effectively into
and deficiencies. The eighth domain is pregnancy. Pregnancy is
nursing curricula. Kardong-Edgren and Campinha-Bacote assessed
viewed differently, because there are a myriad of beliefs accompanying
the effectiveness of four nursing programs’ curricula in producing
this life phase. The act of birthing and the postpartum period involve
culturally competent graduates [29]. Two of these programs had
certain practices that need to be taken into consideration when
adopted models advocated by transcultural-nursing theorists, such
dealing with a particular ethno-cultural group. The ninth domain is
as Campinha-Bacote and Leininger. One of the other programs
death rituals. Perceptions of death differ from culture to culture in
used an approach that integrated concepts from various models. The
terms of how death is accepted, what rituals are performed, and how
remaining program involves a free-standing course with no specific
one should behave following a death. The tenth domain is spirituality,
model used. According to the study’s results, graduating nursing
which includes religious practice, use of prayer, individual strength,
students scored in the culturally aware range, as measured by the
the meaning of life, and how spirituality relates to health. The
Campinha-Bacote’s Inventory for Assessing the Process of Cultural
eleventh domain reflects healthcare practices. This domain includes
Competency among Healthcare Professionals-Revised (IAPCC-R)
the responsibility for health and the barriers that must be overcome
questionnaire, regardless of which program they attended [29].
to achieve successful health outcomes. Healthcare practices include
traditional practices, magical religious practices, chronic-disease This finding is consistent with Noble and Rom’s study that
treatment and rehabilitation, mental-health practices, and the roles employed the Campinha-Bacote model and an adaptation of the

Albougami et al. Int Arch Nurs Health Care 2016, 2:053 ISSN: 2469-5823 • Page 3 of 5 •
IAPCC-R questionnaire to evaluate an educational intervention’s remain a significant part of nursing education and practice. Nurses
effectiveness in strengthening the cultural competence of nursing can benefit from the Leininger model by learning a simple method
students in Israel [30]. Nobel and Rom found that cultural knowledge of exploring professional and societal culture [9]. Additionally, Giger
among the students was low because they lacked an understanding of and Davidhizar’s six components can enhance their understanding
how cultural knowledge can be integrated with nursing interventions of the processes of observation and reflection [10]. On the other
and applied in patient care. They also reported that employing a hand, the major assumptions of the Purnell model for cultural
cultural competence program significantly enhances the level of competence and their associated framework involves drawing on a
cultural awareness among students, a realistic goal for undergraduate broader perspective, which makes them applicable to all healthcare
nursing students. Nobel and Rom also note that it may be more environments and practice disciplines [11]. Finally, the Campinha-
appropriate for faculty to expect a high level of cultural competence Bacote model holds more immediate appeal, because it helps in
to occur after graduation [30]. Nobel and Rom also suggested that the addressing cultural competence with respect to healthcare delivery
usefulness of this approach was enhanced by allowing faculty who [12].
had experience with culturally competent care to share their expertise
Establishing Best Practice Standards in Cultural Competence
with faculty who were deficient in this respect [31,32].
Nursing Education. In order to establish quality nursing care,
The nursing program based on the Giger-Davidhizar transcultural optimum standards for both local and global settings need to
assessment model was an appropriate guide for faculty to impart the be developed in the nursing profession [36]. Nursing requires a
skills necessary for culturally responsive and competent care with distinct approach, one that involves reaching successful endpoints
respect to six healthcare phenomena [10]. This simple and modern of traditional education and strategies necessary to achieve such
elaboration of the Leininger model is used to assess and strengthen goals. Salminen et al. point out the significance of acknowledging the
nurses’ acknowledgment of cultural diversity. Giger and Davidhizar demonstration of competency categories [37].
take an approach that is different than Lininger’s Sunrise Model,
They offer recommendations for dealing with the future challenges
arguing that not every individual of the same culture or ethnicity
pertaining to nursing education. For instance, they recommended
behaves in the same manner. First developed in 2004, the model
requiring competency courses for nursing students and practicing
is used to help undergraduate nursing students provide and assess
nurses in their academic curricula and continuing education
health care for individuals from varying cultural backgrounds. The
workshops, respectively. These courses and workshops may include
current version of the model sets a framework that enables nurses
subject-specific content, learning strategies, and assessments for
to assess culture’s role in health and illness. It can also serve as an
acquired learning. In addition, successfully addressing the needs of
academic and clinical framework for developing cultural competence
culturally diverse populations ultimately requires the combination of
[21].
theoretical research and clinical practice [38]. Ensuring the provision
In addition, the Purnell model is a framework that can be of high-quality nursing education is guided by local, national, and
employed to incorporate transcultural competence into nursing international guidelines that lead to universal standards of culturally
practice [11]. Lipson and Desantis noted that the Purnell model often sensitive healthcare practice to disseminate knowledge by means of
is used in undergraduate communication and health assessment cross-cultural activities and encourage the understanding of diverse
programs [22]. This model can be used by all healthcare professionals populations [39].
in both their practice and academic development. As a result, the
model represents an organizing framework that utilizes precise Conclusion
questions and provides a helpful format for assessing culture in This paper discussed the transcultural nursing models of
clinical settings. Flexibility is one of the strongest features of the Leininger, Giger and Davidhizar, Purnell, and Campinha-Bacote.
Purnell model, enhancing its applicability in various healthcare No particular model was deemed superior to the others; all four have
contexts. Moreover, the model’s healthcare framework allows nurses made and can make significant contributions to nursing education and
to learn the different characteristics and concepts of cultural diversity. practice. Leininger developed her model to bring about the practice
The model interlinks historical elements and their influence on a of culturally congruent nursing. Her research gave rise to the concept
person’s international cultural perspective and elaborates on the chief of transcultural competence in nursing. Giger and Davidhizar focuses
relationships of culture, thus allowing culturally competent care [22]. on the individual, not just the cultural group, seeing each individual as
The model’s framework encourages nurses to consider and reflect culturally unique from the perspective of the six dimensions. Purnell
on the unique characteristics of every patient, including their views created a diagrammatic representation containing twelve cultural
of illness, motivation, and healthcare. Finally, the model’s structure domains, which determine variations in values, beliefs, and practices
facilitates the analysis of cultural data, allowing nurses to cater to of an individual’s cultural heritage. Campinha-Bacote defines cultural
families, groups, and individuals in terms of their respective cultural competence as a process instead of merely an endpoint. Overall, the
uniqueness using various communication strategies [24]. Campinha-Bacote model is sufficiently comprehensive to guide
empirical research and the development of educational interventions.
Critical Appraisal of Transcultural Models
The model’s five components can be used to strengthen the cultural
Brathwaite compared several transcultural nursing models competence of nurses practicing in countries all over the world.
using the following criteria: comprehensiveness, logical congruence,
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