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Models of Transcultural Care - Cultural Competence

Giger and Davidhizar's model of Transcultural Nursing

(Giger & Davidhizar, 1999)

Giger and Davidhizar's model focuses on Assessment and Intervention from a transcultural perspective. In this model, the person is seen as a unique cultural being. Thus 3 concepts underpin the unique cultural being: Culture, Ethnicity and Religion.

From the wider literature on cultural values, beliefs and practices, Giger and Davidhizar have extracted and explained in their model six areas of human diversity and variations.

These are:

Communication
Communication is a theme that recurs all the time whenever we are interacting with others or the environment. Communication is the essence of being, and therefore a very important aspect of our professional skills. In order to understand the person as a unique cultural being, detailed assessment and intervention aim to provide care that is culturally competent. Giger & Davidhizar (1999) present communication in the context of the uniqueness of the individual, and support this with the literature. The factors that influence communication can be seen as universal to everyone. However, the culture specific influences are associated with verbal, non-verbal, and the personal aspect of communication. Among the factors affecting verbal communication, the importance of the use of language in assigning meanings to the inner and outside worlds in different cultures is highlighted. Some of linguistic features of verbal communication that are detailed include vocabulary, names, and grammatical structure. The socio-cultural and personal aspects of verbal communication, such as voice qualities, rhythm, speed, pronunciation are explained, whilst the meaning of silence in different cultures is outlined with some useful examples. The meanings of touch in communication, and cultural differences and sensitivities are considered with respect to facial expressions, eye movement or eye contact and body posture. Personal qualities such as warmth and humour are also discussed.

The influences of cultural values, beliefs, practices on communication styles and skills, and the knowledge of these in the cultural care of individuals and families are beneficial to outcomes of care.

Giger & Davidhizar (1999) provide a set of guidelines for communicating and relating to patients from different cultures (p.34). The central role of communication in establishing rapport and a therapeutic relationship requires the health professional to adapt communication approaches to meet the cultural needs of patients in a non-threatening manner. Erroneous perceptions of roles and power, particularly when the patient is vulnerable, can hinder effective communication. The patient who speaks a different language, or is unwilling to discuss issues about health that may be culturally sensitive, needs communication approaches that meet with the cultural expectations of the patient.

Giger & Davidhizar (1999) suggest ways of enhancing communication in the care of patients from different cultures.

Space
We perceive space through our senses with the help of the biological structures that make up our body. We perceive environments that are internal and external to our body in terms of space. Perceptions involve very complex mechanisms at different levels of our biological and mental functioning. The interpretations of what we see, hear, smell, taste and feel are however given meaning through what we have learned these to mean during our socialisation. The meanings we give to our perceptions are important factors in determining our responses to the cues in the space external to our body. For example, those with all their senses intact, combine their sense of touch with their sense of distance to manoeuvre to sit in a chair.

Giger and Davidhizar’s model considers the relationships between visual and tactile space from a cross-cultural perspective. Touch assumes specific significance of purpose and meanings in the context of the activity, and relationship with others. As such, there are cultural implications for our perceptual worlds. How we perceive shape, size, distance, and depth are to some extend influenced by our cultures. Giger and Davidhizar consider the cultural aspects of spatial behaviour and their implications. The notion of territoriality is explored and explained in terms of personal space and proximity to others, material objects in the external environment, and body movement or position.

Spatial behaviour of patients and health professionals as well as the internal structural designs of hospital wards and departments convey needs that reflect cultural influences.

When assessing patients, observation of the response to body contact, patterns of behaviour within the ward or department, or during examination, response to the presence of other patients, proximity with family members, and other emotional reactions may reveal the cultural meanings attached to space.

Social organisation
Under the social organisation theme, Giger and Davidhizar (1999) recognise that their culture should be considered in its totality. They suggest that in order to understand culture-specific behaviours, ‘culture must be viewed and analysed as a totality - a functional, integrated whole whose parts are interrelated yet interdependent. The components of culture such as politics, economics, religion, kinship, and health systems, perform separate functions but nevertheless mesh to form an operating whole’ (p. 65).

Under social organisation, Giger and Davidhizar include for consideration family groups as systems, with structures and characteristics, which in turn reflect their function at different levels. They adopt three criteria to examine and explain family systems: kinship, function, and location. Each one of these criteria serves the purpose of identifying differences and similarities within and across cultures. Religious affiliation is linked to social systems.

In general, the influences of social organisation systems on individuals and groups of people cannot be underestimated. With respect to life opportunities in a multicultural context, social organisation systems may discriminate against certain groups on the basis of ethnicity, religion, politics and socio-economic status.

Understanding of the social organisation systems and their impact on the lives of people in culturally diverse communities can enable us to deliver care and services that is empowering and sensitive to needs.

Time
Time is perceived, measured and valued differently across cultures. Giger & Davidhizar discuss the concept of time with reference to the lifespan in terms of growth and developments, perception of time in relation to duration of events, and time as an external entity, outside our control.

The measurement of time is discussed with respect to the clock and other astronomical concepts. Practical aspects of measurements are considered, and the lunar calendar should be added to the concepts of tropical time such as seasonal events, solar time, and the Gregorian calendar. The timing of Ramadan according to the lunar calendar is an example, see lifespan, within this resource.

Cultural variations in the perception of social time and clock time are explained, as are the implications of time in human interactions. Cultures also vary in their emphasis and orientation to the past, present and future. These differences may influence interactions as the worldview of time itself may impact on the values placed on relationships with others, and oneself and the environment.

Environmental control
Giger and Davidhizar (1999) adopt a broad definition of the concept of environment, suggesting that it is more than just the place where one lives, and involves systems and processes that influence and are influenced by individuals and groups. These theorists think of environmental control as ‘the ability of an individual or persons from a particular cultural group to plan activities that control nature’. (p.115). The human systems and processes interact with the environment. The relationship between the individual or human groups is a dynamic one, each influencing the other in terms of beliefs and practices about health and illness. The environments that cultural groups have lived in have influenced their beliefs about disease and illness, and the remedies that have evolved in those environments.

Giger and Davidhizar (1999) include health practices, values that influence these health care practices and the locus of control as one of these values across cultures.

Folk medicine and models or systems of health care that have relevance to particular cultural groups have emerged over generations, and are part of the groups’ means of exercising environmental control in illness. Alternative therapies vary across cultures. Some of these have found expression in different cultures and exist alongside the medical model of treatment and care.

Religious beliefs and experiences influence beliefs about healing and the power of healing. Religious systems influence the everyday lives of people. A wide range of rituals and taboos can be observed across religious groups. Religious considerations influence the perception of the individual and the natural environment, food, clothing, and medical interventions such as blood transfusion among others.

Giger and Davidhizar (1999) construct the assessment of individual or persons around the cultural beliefs and practices that mark events such as pregnancy, birth, and responses to illness through the lifespan.

Biological variations
Giger and Davidhizar (1999) outline biological variations across ethnic groups. The need to understand the biological variations is necessary in order to avoid generalisations and stereotyping people. They argue that knowledge of biological variations can enable the nurse to provide care that is culturally competent and non-harmful.

They also outline these biological variations in terms of dimensions such as body structure, body weight, skin colour, internal biological mechanisms such as genetic and enzymatic predisposition to certain diseases, drug interactions and metabolism.

Some of the categories they list are questionable, since they do not take into consideration the full extent of the interactive relationship between environmental and biological factors in determining human characteristics.

Applications
The model provides a comprehensive structure and organisation of the six broad areas of human thinking, beliefs and activities where cross-cultural similarities and differences may be observed. These six areas enable individual and group characteristics to be understood and explained without losing sight of the diversity and universality that exists within and across ethnic and cultural groups. The six areas are further subdivided to accommodate concepts that are specific to cultural discourse.

The model proposes a framework that facilitates that assessment of the individual. A set of questions are constructed under each of the six areas to generate information that assist planning of care that is congruent with the individual’s needs.

The model also represents a learning tool that can be utilised to explore issues about any of the six broad areas in practice. It encourages flexibility and the involvement of the patient as an equal partner in the cultural assessment of needs.

It can facilitate explanatory models of health and illness. The use of the model has been reported in various studies, some of which are cited in the references related to this model at the end of this section.

Critical Overview
The six areas are easy to relate to as they represent themes that can be understood at several levels, individual and groups, cultural and societal. There are concepts incorporated under each of these areas that could be categorised differently under separate categories. For instance, under social organisation, religious groups are introduced. From a transcultural perspective, religious beliefs determine and influence a number of practices that are related not just to religious observance, but also how they influence health and illness behaviours. Religion and spirituality, and their cultural expressions, can be a separate theme.

The six areas borrow from a wide range of biomedical and social science disciplines. The breadth and depth of understanding of the concepts may not lend themselves to application, unless one is fully conversant with the area of knowledge. For instance, the idea of time and its meanings in different cultural contexts may not be fully appreciated.

Assessment and intervention require previous knowledge of the cultural heritage and values, beliefs and practices of the patient. Limitations of individual nurses may be exposed, however the need to learn may act as an incentive.

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