Journal of Nursing Education

Major Article 

From Cultural Competence to Cultural Respect: A Critical Review of Six Models

Maria José Botelho, EdD; Christina A. Lima, MSN, AGPCNP-BC

Abstract

Background:

Despite the development of cultural competence models in response to the increase in cultural diversity in the United States, health disparities based on ethnicity and cross-cultural mismatches in health care practices still exist.

Method:

This article critically reviews six noteworthy conceptual models of cultural competence and enlists multilayered definitions of culture from cultural anthropology, critical multicultural education, and critical literary theory, as well as critical discourse analytical tools to deconstruct these frameworks.

Results:

Although these models assist providers to become more culturally sensitive, they can essentialize and oversimplify patients' cultural experience, as well as mask the dynamism and complexities of their communities and power relations.

Conclusion:

Competence implies that practitioners can master diverse cultural experiences. Building on some of the promising practices of these six models and the practices of cultural humility and relational ethics, processes and practices are proposed for practitioners to reconstruct their ongoing cross-cultural work in nursing. [J Nurs Educ. 2020;59(6):311–318.]

Abstract

Background:

Despite the development of cultural competence models in response to the increase in cultural diversity in the United States, health disparities based on ethnicity and cross-cultural mismatches in health care practices still exist.

Method:

This article critically reviews six noteworthy conceptual models of cultural competence and enlists multilayered definitions of culture from cultural anthropology, critical multicultural education, and critical literary theory, as well as critical discourse analytical tools to deconstruct these frameworks.

Results:

Although these models assist providers to become more culturally sensitive, they can essentialize and oversimplify patients' cultural experience, as well as mask the dynamism and complexities of their communities and power relations.

Conclusion:

Competence implies that practitioners can master diverse cultural experiences. Building on some of the promising practices of these six models and the practices of cultural humility and relational ethics, processes and practices are proposed for practitioners to reconstruct their ongoing cross-cultural work in nursing. [J Nurs Educ. 2020;59(6):311–318.]

This article reviews several noteworthy models of cultural competence in the health care literature, identifies similarities and differences among these frameworks, and critically engages these areas of the literature to reconsider their import for the teaching and practice of cross-cultural nursing. Multiple conceptualizations of culture as theorized in the fields of cultural anthropology, critical multicultural education, critical literary theory, and critical discourse analysis guide this article. Lastly, guidelines are proposed for providers to transform their practice and use the following case vignette, which we will return to at the end of the article, to problematize cultural competence.

Case Vignette

During a clinical rotation as a nursing student, Christina, one of the authors who is of White Portuguese-American descent, was caring for a patient who was hospitalized for community-acquired pneumonia. Before examining the patient, Christina reviewed the patient's health record and learned that she had immigrated from Cuba to the United States many years ago. The patient's primary language was Spanish, but she also spoke English as Christina observed. Before the nurse and Christina transferred the patient from a chair to bed via a Hoyer lift, they first made certain the patient was not experiencing pain. The nurse then asked the patient's son to ask his mother if she was in any discomfort. The nurse had access to the patient's medical record and had observed the initial interactions between the patient and her son. Soon after, the son asked, “Ma, are you in pain?” and the patient replied, “No!”

The commitment to culturally responsive care is an ongoing priority for health care and federal agencies (Mullins et al., 2005). According to the U.S. Census Bureau (2011), the diversity of the U.S. population has increased greatly. From 2000 to 2010, U.S. Latino communities grew from 12.5% to 16.3%, African American communities increased from 12.3% to 12.6%, “some other races” grew from 5.5% to 6.2%, and Asian communities increased from 3.6% to 4.8%. By the year 2044, the United States is projected to be a “plurality nation.” Although the White population will still be the largest, no racial or ethnic group is estimated to comprise more than 50% of the nation's population total (Colby & Ortman, 2015).

Betancourt et al. (2005) maintain that cultural competence in health care policy, practice, and education holds great promise for providing high-quality health care to all patients, regardless of their race, ethnicity, class, or language. Many health care educators work closely with students and novice and experienced providers to better serve culturally and linguistically diverse communities. Two systematic literature reviews demonstrate that culturally-based care can improve providers' knowledge and practices, and patient satisfaction (Beach et al., 2005; Renzaho et al., 2013).

Although cultural competence frameworks were created in health care to assist nursing educators, nursing students, and other providers to become more culturally responsive, this critical literature review demonstrates that these models can essentialize and perpetuate assumptions about cultural experience, as evident in the above vignette, distorting and masking the dynamism and complexities of culture.

Conceptual Framing

Anthropologist Edward Tylor (1871/1958) was the first to theorize the construct of culture. Tylor defined culture as “that complex whole…any other capabilities and habits acquired by [a person] as a member of society” (as cited in Schim et al., 2007, p. 104). This definition of culture has grounded the anthropological, educational, and health care literature, rendering culture as a timeless, bounded, and static experience, while overlooking the dynamism of power relations at the center of culture (Botelho & Rudman, 2009). Anthropologist Clifford Geertz (1973) conceptualizes culture as symbolic experiences in people's lives. This definition of culture is significant because culture is no longer just in people's minds but represented through their daily practices. Teacher educators Sonia Nieto and Patty Bode (2008) contextualize culture within sociocultural and sociopolitical relationships and worldviews “created, shared, [negotiated], and transformed by a group of people bound together by a combination of factors that can include a common history, geographic location, language, social class, religion, or other shared identity” (p. 171). Culture is the product of social activity and power relations.

Gray and Thomas (2006) argue that the pervasive foundational understanding of culture in nursing is essentialist. Although the concept of culture includes the power relations of race and class, difference is considered as objective categories. This definition sorts people into neat classifications and discourages self-reflection in practitioners. These simplistic classifications promote stereotypical understandings of cultural differences as if the differences are naturally inherent to cultural members.

The cultural competence models examined in this article are shaped by multiple definitions of culture. Gee (2014) offers a theoretical tool to examine how culture and competence are socially constructed in these models. Gee defines “figured worlds” as theories grounded in the sociocultural practices and relationships of a group. These worlds are not static but constructed by the context and people. Figured worlds are largely whole or limited explanations or story-lines that oversimplify cultural experience. They build simulations in our minds and mediate between micro- and macro-contexts.

Figured worlds is an apropos theoretical tool for this review because it foregrounds how particular people, roles, and practices are recognizable and significant. Being recognizable takes on specific social and cultural identities ascribed to individuals in society such as being a “patient,” “nursing student,” “nurse,” or “advanced practice nurse.” Although figured worlds unconsciously assist individuals to have a better understanding of the world alongside their experiences, they fail to engage with the complexities and details of cultural communities. Because figured worlds are taken-for-granted assumptions about people, places, and practices, they also can impede change. Accordingly, the analysis of figured worlds can foreground the consequences of how language is used to theorize cultural competence models.

Figured worlds invite the analysis of how cultural competence models shape nursing practices. In addition, figured worlds help to locate how cultural competence frameworks deem what is typical or normal and create storylines for patients and practitioners: these figured worlds communicate particular assumptions about and shape providers' practices and interactions with patients. By analyzing the figured worlds of cultural competence, these worlds and positions (i.e., the ways of participating in these professional relationships) for practitioners and patients as well as inherent contradictions and dilemmas embedded in these models can be located. Each cultural competence framework is shaped by definitions of culture that construct the health care story.

This critical review analyzes six influential cultural competence models in the health care literature and considers how their similarities and differences perpetuate and resist figured worlds of cultural competence; revisits the construct of cultural competence and juxtaposes it with cultural humility (Tervalon & Murray-García, 1998) and relational ethics (Bearskin, 2011); and identifies processes and practices of the cultural models that can contribute to the transformation of cross-cultural nursing. Cultural humility requires ongoing self-reflection, whereas relational ethics demands providers to enact socially just practices that transform multiple social factors that shape nursing. Lastly, we return to the vignette described at the beginning of the article to reconsider the interactions among the participants.

Method of Critical Literature Review

The cultural competence frameworks date back to 1978. In this article, we reviewed a representative collection of cultural competence models in the health care literature using a grounded theory approach (Wolfswinkel et al., 2013) to systematize the review of the literatures as “textual data” through the following processes:

  • Defining criteria for inclusion and exclusion of the research literature.
  • Searching the online resource.
  • Selecting which literature to review.
  • Analyzing the research literature through open and focused analysis.
  • Representing the findings.

We conducted a comprehensive literature search on MEDLINE®, CINAHL®, and Google Scholar using the keyword “cultural competence”; approximately 70 articles were identified. Articles that contributed to theory building in the field were selected. The underpinning assumptions of each model then were mapped out by “plugging in” the theories of culture and figured worlds to “think with theory” (Jackson & Mazzei, 2013), i.e., using theory to think with the textual data and using the textual data to think with theory. These recursive reading practices create spaces to deconstruct and reconstruct the six models, producing new knowledge and practices.

Six models ubiquitous in nursing and medical journals from 1978 to 2018 were selected (Table 1). Three of the models (Campinha-Bacote, 1998, 2002, 2011; Leininger, 1978; Purnell, 2002) are central to the dialogue on cultural competence in health care. Leininger's (1978, 1991, 2002) cultural competence model uses an anthropological lens. Purnell's (2002) conceptual model, developed in 1995, incorporates the power relations of race, gender, and class. Campinha-Bacote's (1998, 2002, 2011) model considers cultural competence as a dynamic relational process. The Kim-Godwin et al. (2001) model examines how practitioners' roles and practices influence health care. The models by Purnell (2000, 2002) and Betancourt et al. (2003) recontextualize patients' experiences and health care institutional practices. The Schim et al. (2007) model describes the level of negotiation between patients and providers; this model theorizes cultural competence across a continuum of ongoing learning that is guided by cultural humility (Tervalon & Murray-García, 1998). The Schim and Doorenbos (2010) model situates patient-provider interactions within a sociopolitical context. These models are dialogic, building on and responding to each other (Bakhtin, 1981).

Six Influential Cultural Competence Models

Table 1:

Six Influential Cultural Competence Models

Analysis of Cultural Competence Models

The robust multilayered concepts of culture and figured worlds are thinking tools used in this article to analyze cultural competence frameworks. A figured world is generally a whole or limited explanatory theory or storyline. More specifically, the analysis of figured worlds examines the implicit definitions of culture imbued in these frameworks that shape roles, responsibilities, and relationships of practitioners and patients. Thus, cultural competence models are essentially figured worlds. Although these frameworks are theoretical, they create narratives that influence how providers and patients interact and how providers practice.

In this next section, we analyze the similarities and differences among the cultural competence models and discern how these models perpetuate and resist figured worlds of cultural competence. We reconstruct cultural competence with cultural humility and relational ethical practices.

Similarities Among Cultural Competence Models

These cultural competence models possess commonalities. Most frameworks share a common definition of culture, with some models defining culture more explicitly than others. Most cultural competence models, for example, Schim et al. (2007, 2010) and Purnell (2000, 2002), draw on Leininger's (1991) definition of culture, which theorizes culture as a “learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned ways” (p. 47). This definition is implicitly defined in Campinha-Bacote's (1998, 2002, 2011) framework, which theorizes that continuous encounters with patients contributes to cultural knowledge. The model by Kim-Godwin et al. (2001) also is shaped by this definition.

Definitions of Cultural Competence. Many of the models attempt to define cultural competence. Betancourt et al.'s (2003) framework uses Lavizzo-Mourey and Mackenzie's (1996) definition of culture competence as “an awareness of the integration and interaction of health beliefs and behaviors, disease prevalence and incidence, and treatment outcomes for different patient populations” (as cited in Betancourt et al., 2003, p. 294). This model also draws on sociocultural factors that influence cultural competence within health care settings.

Similarly, Schim et al.'s (2007) model also defines culture competence, using Leininger's (1991) definition that:

…refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor made to fit with individual, group, or institutional cultural values, beliefs, and lifeways in order to provide or support meaningful, beneficial, and satisfying healthcare, or well-being services.

Kim-Godwin et al.'s (2001) framework identifies various definitions of cultural competence but builds on and synthesizes Leininger's definition of cultural competence and the American Academy of Nursing's (1995) and Smith's (1998) definitions as “a complex integration of cultural knowledge, cultural awareness or sensitivity, attitudes, cultural skills, and cultural encounters” (as cited in Kim-Godwin et al., 2001, p. 920). These two definitions of culture competence diverge: one discusses an exhaustive list of abilities for practitioners, whereas the other focuses on the processes of cultural competence.

Several models (e.g., Campinha-Bacote, 1998, 2002, 2011, 2018; Kim-Godwin et al., 2001; Schim et al., 2007) recognize intragroup differences and draw on some constructs from Campinha-Bacote's dimensions of cultural awareness, cultural knowledge, cultural desire, and cultural skills for providers. The architects of these models claim that they are holistic, broad, dynamic, comprehensive, nonlinear, expansive, broad, and flexible.

Similarities Perpetuating Figured Worlds

In examining these cultural competence models closely, these frameworks are essentially figured worlds, i.e., they are storylines that shape the roles, relationships, and responsibilities of the providers and patients in cross-cultural care. For instance, if a framework includes a static definition of culture, there are limited expectations for the interactions between providers and patients (i.e., providers learn about the culture and then their work is complete). Models grounded by complex definitions of culture require that providers assume learner stances and take notice of their interactions and practices with patients.

Leininger's (1978, 1991, 2002) definition of culture is prevalent among many cultural competence frameworks, and parts of her definition of culture reproduce particular figured worlds. It highlights the role of transmission in cultural practices: the term “transmitted” is problematic because it implies static practices and does not consider the dynamism, hybridity, and power at the center of culture. Although the word “patterned” can perpetuate simplistic storylines, it promotes understanding culture as socially constructed, negotiated, and performed.

Although cultural competence is implicitly defined in these frameworks, Leininger's (1978, 1991, 2002) and Betancourt et al.'s (2003) usage of cultural competence is prevalent in the literature. Betancourt et al.'s framework reproduces storylines of cultural competence that require providers to be culturally aware. This is a static conceptualization of cultural competence, as it does not consider the providers' responsibilities to and relationships with patients other than knowing their health beliefs, behaviors, and health histories (Betancourt et al., 2003). Leininger's definition of cultural competence alludes to the providers' responsibility to engage in reflection.

Similarities in Resisting Figured Worlds

Conversely, segments of Leininger's (1978, 1991, 2002) definition of culture resist figured worlds, such as the terms “learned” and “shared.” These cultural dimensions foreground the fact that culture is not a biological phenomenon. The word “shared” complicates the processes of culture, but overlooks that these experiences are also socially made.

In addition, Schim et al. (2007) draw on Dreher and Mac-Naughton's (2002) definition of culture, which includes “political realities.” Schim et al. also acknowledge the complex parts of culture from the patient-and-provider perspective. Furthermore, Betancourt et al.'s (2003) model integrates sociocultural and sociopolitical factors as central to discerning the definition of culture competence. Finally, Leininger's (1978, 1991, 2002) definition of cultural competence considers the relationship between providers and patients beyond providers' awareness of their patients' health beliefs and practices. This shift in practice is essential but not an end goal.

Differences Among Cultural Competence Models

These cultural competence frameworks also possess differences. These diverse practices and processes organize the roles, responsibilities, and relationships of the practitioners and patients. In terms of roles, Schim et al. (2007) draw on the work of Betancourt et al. (2003) in describing the cultural sensitivity dimension. More specifically, Schim et al. (2007) discuss how providers should shift their role to learner rather than assuming a position of having enough cultural sensitivity and culture knowledge. They further redefine cultural competence by using the work of cultural humility (Tervalon & Murray-García, 1998). Cultural competence is not mastery of information about a group; however, it is specifically learned and developed practices that are undertaken with humility (Schim et al., 2007). This cultural competence model resists simplified cultural stories because the providers do not assume a “competent” role. Cultural awareness demands that practitioners have the ability to recognize cultural details but also reevaluate the data on group differences (Schim et al., 2007). This construct turns the providers' gaze to the patient.

Practitioners as learners build on Campinha-Bacote's (2002, 2011) framework on the process of “becoming” culturally aware, possessing cultural knowledge and skills, and engaging in cultural encounters. The process of “becoming” is quite different from being only culturally aware. Multiple cultural encounters help “validate, refine, or modify [nursing students' and practitioners'] existing beliefs about this member of this cultural group” (Campinha-Bacote, 2011, p. 44). The dynamic cultural awareness practices resist simplistic understandings of cultural experiences. Cultural encounters offer many opportunities for cultural engagement and deepened cultural knowledge.

Another important difference among these cultural competence models is Purnell's (2002) recommendation of metaparadigms, which invites providers to examine their practices within multiple contexts by recognizing dominant cultural practices. Kim-Godwin et al. (2001) propose that cultural diversity cannot be ignored and that health care goals are connected to culturally responsive care by providing the appropriate communication and advocacy care and addressing health system practices. Betancourt et al.'s (2003) model focuses on institutional practices to improve cross-cultural care.

Another unique difference among these models is Leininger's (1978, 1991, 2002) application of anthropology by using an ethnographic perspective to provide comparative information to improve cross-cultural care. Ethnographic inquiry offers practitioners tools to better understand the everyday patterns of providers' roles and provider-patient relationships (Frank, 1999). These tools enhance providers' listening and observation practices by immersing themselves in patients' experiences, attending to the qualities or details of patients' lives, gathering multiple sources of data, linking the micro- to the macro-context, and examining cultural meanings and assumptions (Horvat, 2013).

Another important distinction is that Betancourt et al. (2003), Campinha-Bacote (1998, 2002, 2011), and Schim et al. (2007) draw on cultural humility practices. Cultural humility is important because it recognizes that cultural competence is lifelong learning through cultural encounters.

The one difference that reproduces figured worlds was the term “cultural group,” which was noted in Kim-Godwin et al.'s (2001) model as being synonymous with “ethnic group.” This classification does not recognize intragroup diversity as well as acknowledge that nonethnic groups (e.g., deaf and LGBTQ communities) are also cultural groups, too.

In the next section, we reframe cultural competence by enlisting the processes and practices across these six models that are compatible with a robust understanding of culture. Cultural humility and relational ethical practices guide this exploration.

Reframing Cultural Competence: Processes and Practices

This critical literature review shows that cultural competence models are problematic: they oversimplify patients' everyday experiences and undermine the importance of the interactions between practitioners and patients. The models also dismiss historical and sociopolitical factors, as well as the power relations that largely shape these interactions (processes) and health care practices in the first place. Competency implies that practitioners can master cultural experiences beyond their own backgrounds. Competency of culture is an oxymoron: cultural understanding demands ongoing learning because culture is multiple, dynamic, and complex.

This critical literature review supports the reframing of the cultural competence models to processes and practices. Processes signify that interactions among providers and patients are constructed by many historical and sociopolitical factors, whereas practices signify the decisions that health care providers make on a patient-by-patient basis have social and health consequences. We propose that some of the processes and practices in these six cultural competence models are promising and can be enlisted for transforming nursing practices.

Promising Practices of Cultural Competence Models

This critical literature review demonstrates that these six cultural competence models offer the following opportunities: recasting culture; reconsidering practice through an anthropological lens; recontextualizing nursing and health care within sociopolitical factors (metaparadigm); reflecting on the social processes between practitioners and patients; and rethinking health care practices (metapractice). Although we describe these layers in isolation from each other to foreground their possibilities, it is important to note that they are interconnected. A nuanced definition of culture that considers how its “web of meaning” (Geertz, 1973); dynamism; permeability; and historical, sociopolitical, economic, and geographical factors that have a hold on culture/power relationships (Botelho, 2015; Botelho & Rudman, 2009) inform these processes and practices.

Leininger's (1978, 1991, 2002) framework offers an anthropological lens that provides the following concepts: the close relationship between culture and care across the continuum, emic and etic knowledge, comparative method, the historical perspectives of cultural group, and culture's impact on patients' lives. Although these are promising cultural practices and processes, they need a multicontext perspective. Leininger's model requires that providers have an awareness of patients' insider (emic) understanding of their culture and providers' understanding and awareness of the providers' outsider (etic) understanding. By examining Purnell's (2002) multicontext approach, metaparadigm practices contribute to an understanding of patients within broader and multiple contexts, acknowledging patients' experience is shaped by individuals, families, communities, and health, social, and global factors. In addition, Purnell's model acknowledges the differences inside, between, and among cultures, and the presence of power relations among providers and patients. These power relationships are important to recognize because this awareness of culture/power affects the quality of cross-cultural care and health. These parts of Purnell's model invite practitioners to reconsider their practices, interactions with patients, and institutional health practices.

Elements from Betancourt et al.'s (2003) and Kim-Godwin et al.'s (2001) frameworks are promising for reshaping and reexamining processes and practices at multi-institutional levels by examining the organizational, structural, and clinical barriers and offering interventions that can reframe relationships or interactions among patients and providers. In addition, it is imperative to have a community of practitioners that is socioeconomically and linguistically diverse. In addition, Kim-Godwin et al.'s model offers diversity initiatives that pay close attention to practitioners' communicative and advocacy practices, and patients' lived experiences.

In Campinha-Bacote's (1998, 2002, 2011) model, she acknowledges there is diversity within cultural groups. She argues that the process of cultural understanding is a process of becoming; it is ongoing work that originates from a desire to learn about patients' cultural experiences and a strong commitment to provide socially just health care. Campinha-Bacote (2011) theorizes a dynamic process of becoming culturally responsive, in which she builds on cultural humility (Tervalon & Murray-Garcia, 1998) and theorizes cultural encounters. More recently, Campinha-Bacote (2018) proposes the construct “competemility” that represents the “synergistic relationship” between cultural competence and cultural humility.

Betancourt et al. (2003) and Schim et al. (2007) also acknowledge the notion of cultural humility, that is, practitioners make room for their patients. Although Schim et al. recognize that competency does not entail expertise in the delivery of cross-cultural care, they appreciate that competency changes over time in response to diverse groups. Betancourt et al. propose “cultural responsiveness,” “cultural sensitivity,” “cultural effectiveness,” or “cultural humility” as alternatives; however, there is no consensus on which term best describes the practice of providers as learners. Schim et al.'s framework argues that interactions between practitioners and patients are negotiated.

In many ways, processes and practices from the six models offer ways to reframe practitioners' work with patients in multiple contexts. These six cultural competence models generate some processes and practices that complicate culture and cross-cultural work. They recognize the multiple social factors that influence the teaching of nursing and delivery of health care and patients' health experiences. Nurse educators and providers also take stock of their lived experiences because these circumstances influence their interactions with nursing students, patients, and their delivery of care, respectively.

Cultural Humility and Relational Ethics as Cultural Respect

Competency denotes a specific level of proficiency in clinical practice; however, as previously mentioned, “competency” in cross-cultural care is impossible. Alternatively, cultural humility is a guiding construct because it invites practitioners to engage in reflection (Tervalon & Murray-García, 1998). Within self-reflection processes and ongoing learning, it is imperative not only to gather as much cultural information about patients but also to be committed to ongoing reflection on personal experiences, nursing practices, and interactions with patients. This constant self-reflection can help practitioners examine their assumptions about patients' experiences.

We enlist Bearskin's (2011) relational ethics to call attention to the micro, meso, and macro dimensions of health care as providers enact socially just practices. Self-reflection “reawakens” providers to the power relations reflected in health care (relational ethics) and demands ongoing respect for patients' health and cultural practices (cultural respect). We are not suggesting that cultural humility should substitute cultural competence (Tervalon & Murray-García, 1998) or blend with cultural competence (Campinha-Bacote, 2018). Cultural competence masks the process of lifelong learning. For us, cultural humility and relational ethics offer multilayered understandings for ongoing critical reflection and practices that require cultural respect. Cultural respect demands a commitment to patients, ourselves, and lifelong learning. Cultural respect is a commitment to understanding patients' health in context through knowing, being, and doing.

Patients are the authors of their life stories. Practitioners need to let go of their specialist role and embrace a learner stance. For example, using alternative styles of interviewing patients shows them that providers are flexible and value their plans and perspectives, creating time and space for patients to narrate their health care storylines. For community-based care and advocacy, it is key for practitioners to experience settings outside clinics and hospitals, and gain more experiences within the community. Health care institutions need to offer in-house educational programs that will support the staff and restructure the overall delivery of care.

Revisiting the Case Vignette with Cultural Respect

In the final section of this article, we revisit the case vignette described at the beginning and use some of the processes and practices named through this critical literature review. We will reconsider what the practitioner and nursing student could have done differently during their interaction with the patient and her family member; what the practitioner and nursing student could reflect on the patient's examination; and what they could do differently when they care for culturally and linguistically diverse patients. We offer some guiding questions to critically reflect on the exchange represented in the vignette as well as analytical tools for critically engaging with the research and professional nursing literatures.

The social processes initiated by the practitioner in the vignette are excellent examples of nursing practice shaped by cultural competence models that assume the patient is a member of a timeless, bounded, and static cultural group. The implicit definition of culture does not acknowledge the patient's hybrid identities and multiple experiences. The practitioner should have apologized to the patient after this interaction and accepted full responsibility for her mistake. This follow-up microinteraction, however, is complicated: What would be the professional impact of this public apology? Would it undermine the nurse's authority and expertise as the mentor of a nursing student? What would it look like if she apologized and then used this microinteraction to learn from and with her nursing mentee?

The practitioner could have participated in this exchange differently. First, she could have observed and listened to how the patient and her son communicated with one another as well as taken note of their preferred language use within the health care setting (but the system has to provide time to allow this interaction to happen). Second, she should have consulted with the patient directly in English instead of her son; the practitioner assumed that the patient only spoke Spanish. In checking in with the patient, the provider would have created a space to negotiate the patient's health care experience. Third, the provider also should have considered her interviewing style and assessed whether she allows patients to tell their own stories. Fourth, she should consider her language use and body language, asking herself if they communicate her genuine interest in and respect for the patient.

What could the nursing student Christina have done? What are her options as a nursing student? How might she participate in this microinteraction? How might she approach her mentor with her observation and possible suggestions? In what ways can mentors welcome nursing students to participate fully in these micromoments? How might ground rules for engagement support these complex micromoments in care? In what ways can nursing programs support clinical placements as mutual mentoring opportunities?

If Christina did not approach her mentor, how might she be guided to reflect on and use this experience to inform her practice? If the mentor-mentee relationship does not allow for dialogue about complex issues, Christina could keep a two-column practice journal: describe the situation in column one and consider how she would handle the situation in column two. In the second column, she can capture next steps, using questions as placeholders for new learning.

After this encounter, the practitioner could model self-study and consider: what happened in the interaction; compile a two-column list of questions about what worked and what did not work; and consider what she would do differently next time (Table 2). The practitioner could share her experiences with Christina and colleagues, and enlist their help through dialogue, which would deepen the practitioner's understanding of the microinteraction. The nurse and Christina could gather information about the community in which the patient resides. She and her colleagues could request institutional support to explore how providers can be more culturally curious. Finally, the practitioner and her colleagues could engage in research to investigate cultural humility and relational ethical initiatives in other institutions and in the research literature (Table 3), and how these initiatives influence health of culturally diverse groups.

Guiding Questions for Critical Reflection

Table 2:

Guiding Questions for Critical Reflection

Critical Reading of Research and Professional Literature

Table 3:

Critical Reading of Research and Professional Literature

Cultural respect fosters reframing processes and practices of cross-cultural care through ongoing inquiry and critical reflection to inform practitioners' understandings, interactions, and practices. Reframing through cultural respect contributes to promising practices that are connected to social interaction and professional learning that are historically and sociopolitically contextualized.

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Six Influential Cultural Competence Models

ModelCultural Competence Theorized
Leiningera (1978, 1991, 2002)Use an anthropological lens to understand relationship between culture and care
Campinha-Bacotea (1998, 2002, 2011)Understand dynamic and diverse relational processes
Purnella,b (2002)Recast patients' health within a broader context shaped by race, gender, and class power relations
Kim-Godwin et al. (2001)Take stock of how practitioners' roles and practices influence health care
Betancourt et al.b (2003)Recontextualize patients' experiences and the multiple levels of health care institutional practices
Schim et al. (2007)Negotiate interactions between patients and providers in context

Guiding Questions for Critical Reflection

In what ways do I dominate the conversation? In what ways do I allow space for patients to narrate their story through my words and body language?

Am I listening enough? Observing enough? How do I listen and observe? What are my practices?

How do patients and family members interact? How do they use language?

How does the structure of the setting shape social interaction?

In what ways do I consider my patients' unique circumstances? Do I lump them together and base my interaction on previous experiences with members from their cultural group(s)?

In what ways do I oversimplify my patients' cultural experience and not notice intragroup differences?

What are my experiences with other members from this cultural community?

What other information do I need to gather about patients' background?

Do I have the resources to communicate with all my patients?

In what ways do I reflect on my practice after patients leave my office?

In what ways do clinic, hospital, insurance, and state policies shape the care I provide?

In what ways are clinic, hospital, insurance, and state policies enacting racism, classism, sexism, and other power relations?

What opportunities exist to advocate for the cultural communities that I serve in my health care context, community, state, and nation?

In what ways do these sociocultural factors have a hold on my patient's health?

What are my own cultural experiences? How do they shape my practice? What do I know and don't I know about my cultural background? What do I want to know?

Critical Reading of Research and Professional Literature

Define criteria for inclusion and exclusion of literature for review

Search to retrace the scholarly dialogue by searching nursing databases and Google Scholar

Select the literature to be reviewed

Analyze through open review (read and reread, and take note of patterns) and focused review (plug in theory such as culture and figured worlds); consider the patterns across articles:

What figured worlds are these articles constructing for practitioners and patients? How do these simplistic narratives position practitioners and patients?

In what ways can these storylines be reconstructed through cultural respect?

Represent what you learned (findings) and share through informal conversation, presentation, and publication

Authors

Dr. Botelho is Associate Professor, Language, Literacy, and Culture, College of Education, University of Massachusetts Amherst, and Ms. Lima is Nurse Practitioner, urban and suburban settings, Massachusetts.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Maria José Botelho, EdD, Associate Professor, Language, Literacy, and Culture Concentration, College of Education, University of Massachusetts Amherst, 813 North Pleasant Street, Amherst, MA 01003; email: mbotelho@educ.umass.edu.

Received: August 05, 2019
Accepted: January 17, 2020

10.3928/01484834-20200520-03

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