Globalization and greater diversity in Western populations have lowered the barriers that once separated cultures both internationally and domestically. Frequent and sustained contact between previously isolated cultures is changing the definition and the role of culture in health care in general, and within the nursing discipline in particular. In nursing education, the concepts of cultural competence and cultural safety both represent nursing’s capacity to provide culturally congruent care from two different perspectives. An extensive literature review produced little evidence that a constructivist perspective has influenced existing definitions of culturally congruent care in nursing practice and nursing education. The concept of cultural competence has been criticized for its essentialist roots (Gray & Thomas, 2006; Kirmayer, 2012; Williamson & Harrison, 2010). An essentialist perspective views culture as static and unchanging. Thus, the development of cultural competence is focused on learning cognitive aspects of culture such as values, beliefs, and traditions of a particular group and applying this knowledge in practice (Williamson & Harrison, 2010). Opinions are divided about the feasibility of exporting the concept of cultural safety developed from a postcolonial perspective to different cultural contexts (Mortensen, 2010). Some authors have suggested the need to revise the concept of cultural competence by using a constructivist definition of culture and by focusing on the process that cultural competence represents (Duke, Connor, & McEldowney, 2009; Gregory, Harrowing, Lee, Doolittle, & O’Sullivan, 2010; Lynam, Browne, Reimer Kirkham, & Anderson, 2007).
This article proposes a constructivist definition of cultural competence that builds on existing nursing theories and models. This constructivist definition incorporates Cooper’s (1989) perspective on the cumulative nature of science, and Rodgers and Knafl’s (2000)perspective of a concept as dynamic and evolving. The proposed definition of cultural competence is presented in a continuum of knowledge, not as a shift of knowledge in the field of culturally congruent care. A critical review of the literature about culture, cultural competence, and cultural safety is presented first, followed by a description of our theoretical underpinnings. This background provides a framework for proposing a new definition of cultural competence embedded in a constructivist paradigm.
Critical Review of the Literature
In the following section, we present the conclusions of an extensive critical review of the literature on the definition and applications of the concepts of culture, cultural competence, and cultural safety among nurses and other health professionals. The review was conducted using CINAHL, ERIC, PsycINFO, EMBASE, Medline, and Sociological Abstracts. .
In the health field, two opposing views of culture coexist in the scientific literature: the essentialist view and the constructivist view. The dominant perspective in the health sciences literature is an essentialist view of culture (Garran & Werkmeister Rozas, 2013; Gray & Thomas, 2006). In this view, culture is objective, is stable over time, and clearly defines the differences between people. Many scientific works that refer to culture do so from a Western perspective that emphasizes how religion, nationality, and race influence behaviors related to health and disease. These works view culture as a set of defined values, beliefs, and practices shared by a group, and they associate culture with ethnicity and nationality (Carpenter-Song, Nordquest Schwallie, & Longhofer, 2007). Education based on learning of beliefs, values, or traditions specific to certain cultural groups is consistent with that vision (Garran & Werkmeister Rozas, 2013; Williamson & Harrison, 2010). Gray and Thomas (2006) point out that this approach minimizes the complexities, conflicts, and uncertainties present in every culture. As a result, this approach can hide the diversity within a particular group (Bourque Bearskin, 2011; Carpenter-Song et al., 2007; Lynam et al., 2007). Indeed, many studies have focused on describing the health experiences and care practices among diverse cultural groups (Bray & Goodyear-Smith, 2007; Parker, 2010). Their findings provide insight into the meanings of health and care and into the differences and similarities between cultural groups. When compared and contrasted, these descriptive studies point to the multidimensionality of health experiences and care practices in a culturally diverse environment. However, the issues explored in these studies are most often at the level of the caregiver–patient relationship despite being guided by conceptual models such as the Sunrise model derived from Leininger’s (1991)Theory of Culture Care Diversity and Universality. The influence of the physical, social, political, and historical contexts in these studies is subtle and is rarely taught.
Within a constructivist perspective, culture is understood as the product of social constructions. According to Carpenter-Song et al. (2007), culture is a dynamic relational process of shared meanings that originate in the interactions between individuals. This perspective considers a person in an evolving social context and understands his life and health as a whole rather than the product of specific behaviors or beliefs. The person is considered to be an agent that influences and is influenced by different conditions such as traditions, as well as by a broader sociopolitical context (Lynam et al., 2007). Then, culture must be considered in historical, social, political, and economic contexts (Gregory et al., 2010). Moreover, the will to confront each other’s principles opens the door to expose the prejudices that underlie social inequalities (Cognet & Montgomery, 2007).
Focusing on processes highlights the hybrid, dynamic, flexible, and complex nature of culture. It takes several individual and social processes to define, redefine, negotiate, and manage the cultural identity of an individual or of a group (Gray & Thomas, 2006). Thus, culture involves an ongoing process of transmitting and using knowledge that depends on dynamics both within communities and between communities and institutions of the larger society, such as the health care system, as well as global networks. Recognition of the cultural processes in an organization offers an opportunity to question current practices and can lead to change (Gray & Thomas, 2006). In this sense, a culturally diverse context encompasses diversity that can assume many forms in society—such as age, gender, sexual orientation, or socioeconomic status—and is not limited to race and ethnicity.
In the nursing discipline, the concept of cultural competence originates from Leininger’s work on transcultural nursing. Leininger’s (1991)Theory of Culture Care Diversity and Universality is the only theory with a primary focus on culture and caring that has been fully conceptualized and established. Different models in the nursing discipline were developed to translate this theory into nursing practice and to present factors that could influence the phenomenon of care (Campinha-Bacote, 2002; Giger & Davidhizar, 2002; Leininger, 1991; Purnell, 2002). Of these practice models, the definition of cultural competence most cited in the scientific literature is from Campinha-Bacote (1999): “The process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of a client (individual, family or community)” (p. 203).
As much as this work on cultural competence intends to improve the provider–client relationship, it is often associated with an essentialist perspective and culturalist theories (Browne et al., 2009; Gray & Thomas, 2006; Jenks, 2011). An essentialist perspective would be defined by a humanist ontology that obscures the social context and the network of power in which it is located (Gray & Thomas, 2006). According to Browne et al. (2009), culturalism is reflected in care practices that use popular and stereotypical representations of a culture and its social organization to understand the differences between the cultural groups that form a society. The risk is that professionals will see health problems as the result of cultural behaviors, instead of the result of other factors such as a person’s living conditions and socioeconomic factors. This bias avoids questioning Western social practices or challenging the established order related to social and economic inequalities and may contribute to negative social representations of specific cultures (Cognet & Montgomery, 2007; Garran & Werkmeister Rozas, 2013, Jenks, 2011).
The literature on the development of cultural competence espouses the same views. Several authors found a lack of consensus on the content taught in nursing education and how to best integrate cultural competence in nursing education programs (Jenks, 2011; Lipson & DeSantis, 2007; Long, 2012). Learning strategies were often based on an essentialist conception of culture and cultural competence that focuses on ethnicity. Several developmental models are based on the assumption that understanding one’s own culture brings tolerance and respect toward someone else’s (Williamson & Harrison, 2010). However, it is increasingly clear that the mere awareness of the cultural difference is insufficient to bring about transformation in human relationships and does not eliminate ethnic, racial, and cultural discrimination, or potential inequalities (Jenks, 2011). Williamson and Harrison (2010) stress that the emphasis on the differences can lead to strengthening ethnocentric approaches to care. Education based on developing knowledge about different cultures with the goal of reducing prejudice is then challenged. After analyzing education programs and teaching strategies to develop cultural competence among students and nurses, several authors conclude that the conceptualization and implementation of cultural competence are poorly understood among health professionals, students, and patients (Gebru & Willman, 2010; Johnstone & Kanitsaki, 2007b; Long, 2012).
The concept of cultural safety was formalized in 1989 in the postcolonial context of New Zealand (Ramsden, 1990). Maori health professionals were concerned by the poor health status of Maoris compared with the rest of the population, and the lack of a cultural dimension in the education of health professionals. Ramsden (1990), a Maori nurse, developed the concept of cultural safety to examine the interaction between Maori and health care providers and to highlight the imbalances of power (Anderson et al., 2003). According to Anderson et al. (2003), the concept of cultural safety can be situated within a critical postcolonial discourse. The Nursing Council of New Zealand (NCNZ) has incorporated cultural safety in the nursing curricula and in the entry-to-practice examination in 1992 (NCNZ, 2011). The authors mainly use this definition of cultural safety proposed by NCNZ (2011):
The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability.
The nurse delivering the nursing service will have undertaken a process of reflection on his or her own cultural identity and will recognize the impact that his or her personal culture has on his or her professional practice. Unsafe cultural practice comprises any action, which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual. (p. 7)
There is consensus in the literature that the person or group experiencing the insecurity determines the definition of cultural safety (Anderson et al., 2003; Johnstone & Kanitsaki, 2007a). Cultural safety requires a partnership between two people of different cultures. This partnership can also be established between an individual and an organizational structure. It involves creating a space for dialogue and a power sharing to joint action (Wilson & Neville, 2009).
In nursing, cultural safety is used primarily in education and clinical practice in New Zealand. However, as Johnstone and Kanitsaki (2007a) point out, there is limited evidence that the introduction of cultural safety in nursing education and practice has had an impact on the health outcomes of the Maori population. There are some international contributions to the understanding of cultural safety from Australia and Canada. Viewpoints on the possibility of exporting the concept to Australia are divergent, and few authors consider it appropriate given the context of its development (Johnstone & Kanitsaki, 2007a, 2007b). In Canada, Anderson et al. (2003) believe that cultural safety is applicable to the Canadian context of multiculturalism, stated in the country’s policies. Although the concept is applied to diverse populations and social groups, the majority of writings on this topic are related to the health care of First Nations (Dion-Stout & Downey, 2006).
Several authors claim that it is possible to develop cultural safety through nursing education (Harding, 2013; Ramsden, 1990; Richardson & Carryer, 2005). Different teaching strategies are described in the literature (Gibbs, 2005). Such strategies would involve the development of capacities that go beyond knowledge of cultural customs and attempt to identify the causes of historical, social, cultural, political, and economic inequalities in health and care.
Most criticisms of the work on cultural safety relate to its application (Gerlach, 2012). Johnstone and Kanitsaki (2007b) argue that the understanding and application of cultural safety by patients and health professionals are limited. Gerlach (2012) highlights the difficulty of assessing the use of cultural safety by students and nurses.
To summarize, the literature review conducted on culture, cultural competence, and cultural safety reveals a conceptual problem. According to Toulmin (1972), a conceptual problem arises when there is a gap between the current understanding of a concept and the intellectual objectives related to it. By now, neither definition adequately reflects the idea of culturally competent care in nursing and nursing education from a constructivist perspective. Moreover, knowledge on the two concepts of cultural competence and cultural safety is developed in parallel and not in an integrated fashion.
We propose that the development of knowledge on the concept of cultural competence be continued in the practice and teaching of culturally congruent nursing care, although with a modified definition of the concept to fit a constructivist perspective. According to Guba and Lincoln (1994, 2005), the constructivist ontology rejects the idea of a single reality and favors instead the idea of multiple, socially constructed realities. Hence, culture is considered to be a social construct in a specific historical context. This concept of culture departs from a behavioral perspective of culture, by focusing on the contextual significance of health experiences. The constructivist epistemology is transactional and subjectivist. Individual constructions of reality are refined by interactions between the actors in those realities (Guba & Lincoln, 1994). Encouraging nurses to understand the complexity of a person within a broader context is part of a constructivist perspective. It is based on shared ideas and dialectical interactions between professionals and between professionals and patients. These interactions do not obscure power relations between individuals or between individuals and structures as they focus on critical thinking and interpersonal awareness.
Grounded in this constructivist perspective, the proposed definition borrows from the literature of both cultural competence and cultural safety concepts. Writings on cultural safety were a response to criticisms of an essentialist view of cultural competence. Using a definition of culture that integrates power relations and social context works on cultural safety highlights the social mandate of nurses (which is often overshadowed by their complex working conditions). The constructivist perspective of Guba and Lincoln (1994, 2005) makes it possible to integrate a critical standpoint in the proposed definition. Constructivism as defined by Guba and Lincoln (1994, 2005) is closely linked to a postmodernist paradigm. It recognizes the existence of power relations and their influence on social relations and the construction of realities. For these reasons, we consider it is appropriate to integrate cultural safety into a constructivist definition of cultural competence. Some authors also come to this conclusion (Duke et al., 2009; Johnstone & Kanitsaki, 2007a). After analyzing the concept of cultural safety and assessing its possible application in Australia, Johnstone and Kanitsaki (2007a) propose integrating it within the conceptual framework of cultural competence. These authors see cultural safety as the result of a culturally competent practice. This view of a continuum from cultural competence to cultural safety is also present in the writings of Duke et al. (2009). These authors suggest that cultural competence in a constructivist perspective leads to culturally safe care. These suggestions were considered while conceptualizing the constructivist definition of cultural competence presented below.
Constructivist Definition of Cultural Competence
The constructivist definition of cultural competence proposed in this article is intended to reflect global trends, not just the majority perspective. Hence, we define cultural competence as follows:
A complex know-act grounded in critical reflection and action, which the health care professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care.
Cultural competence is a complex know-act because it affects the cognitive, emotional, behavioral, and environmental dimensions of a person. It involves knowledge, skills, and know-how that, when combined properly, lead to a culturally safe, congruent, and effective action. This definition draws on a constructivist perspective of learning and competence in education. In this definition, learning is an active process and learners construct and reconstruct the information to learn (Tardif, 2006). Prior knowledge is questioned, and new knowledge is integrated in a dialectical relationship of thinking and action (Duke et al., 2009). A person’s ability to learn varies depending on the different contexts and situations encountered (Tardif, 2006); learning is a process that changes both the learner and the environment, and it allows the development of competencies. As defined by Tardif (2006), a competence is a “complex know-act based on the mobilization and combination of knowledge, skills, attitudes and external resources that is adequately applied in specific families of situations” (trans., p. 22). A family of situations is a group of different professional situations presenting similar problem. This definition of competence is consensual among several authors of the second generation of the competency-based approach to nursing education (Goudreau et al., 2009). It emphasizes the evolutionary, developmental, contextual, combinational, and integrative characteristics of any competence.
The integration of cultural safety as a goal in the definition makes it possible to consider the perception and satisfaction of the care recipient on the outcome of cultural competence. Cultural safety “draws attention to personal processes and practices as well as the larger institutional and societal structures” (Browne et al., 2009, p. 173). It should be understood in this definition as a way to integrate a critical standpoint from which the health professional can reflect on his or her practice and on issues related to social justice.
The ability to provide congruent care refers to the caregiver’s ability to show flexibility and openness in different situations and to transfer knowledge from learning situations to new situations with similar problems. The nurse must engage in an ongoing process that requires developing a new way of thinking and provide care that will change over time and across contexts encountered (Duke et al., 2009). The development of cultural competence is therefore an evolutionary process that leads to the development of new resources and their unique and unusual combination in practice. The development of a competence requires long-term work and continues throughout life. In this definition, health experience encompasses all health domains, including promotion of health, prevention of disease, and curative levels of care.
Efficiency is also central to the definition of cultural competence although it is not usual to find this concept in a constructivist perspective. Tardif (2006) stresses that an “effective action is thus a necessary and inevitable outcome of a competence” (trans., p. 19). Since a competence is contextual and evolutionary, efficiency remains dynamic and related to the context of the action. Calvillo et al. (2009) argue that the care must be of a certain quality to be effective, and to say that a nurse is culturally competent. Quality refers to the provision of care and services that increase the likelihood of desired health outcomes that are consistent with current professional knowledge (Institute of Medicine, 1990). Following the Institute of Medicine definition, efficiency refers to the professional’s or the organization’s perspective on quality care.
Cultural competence defined as dynamic and complex, varying according to the individual and the social contexts is in line with the constructivist ontology described by Guba and Lincoln (1994, 2005). Moreover, because the constructivist epistemology is transactional and subjectivist, the interrelations between individuals are central to the construction of meanings and realities. The definition presented in this article suggests that understanding a culture and developing cultural competence occurs through human interactions. The partnership between the caregiver and the person living the health experience, families, and communities is crucial in the proposed definition. It focuses on the space created by the professional and the individual, families, or communities involved. Carpenter-Song et al. (2007) point out that, through dialogue, it is possible for people to transform and enrich their perspective by promoting a common understanding of the context in which they find themselves. As care is the result of dialogues and interactions between the professional and the patient, the dominant hierarchy of knowledge is questioned. The space created should allow partnership and power sharing for a joint action.
The definition also points out the relationship of the caregiver with his or her environment. Contexts and social processes are also considered part of the care. Meleis (1996) argues that every health experience should be understood by taking into account social, political, historical, and structural contexts, to go beyond individual and group differences. Considering the social and political dimensions of care avoids the pitfall of culturalist explanations taking into account the dynamism of culture and its multiple variations across age, gender, sexual orientation, or social status to name a few. The nurse is historically and culturally connected with others and with society. To put her preconceptions and prejudices in the care relationship aside requires a conscious effort. The professional must reflect and expand her vision of the power structures that can influence the social representations of the care, health, and culture. She could also reflect on the impact of these representations on individuals and on society. This critical reflection also allows the professional to question current practices and to propose changes for the improvement of efficiency and quality of care, and, on a larger scale, equality and social justice. To perform this critical reflection, it is essential to recognize the health impacts of social, health, and power inequalities, as well as economic and political injustices. Knowledge of these inequities does not refer to ethnospecific content but rather to various contexts that influence the health of a population.
Cultural Competence in the Nursing Discipline
The characteristics of the proposed constructivist definition of cultural competence correspond to the unitary-transformative (UT) paradigm in nursing as defined by Newman, Smith, Pharris, and Jones (2008). Within the UT paradigm, the conceptualization of health moved toward the experience as a whole and “the relationship emerged as the central focus of the discipline” (Newman et al., 2008, p. 17). Cultural competence as complex know-act fits into the UT paradigm since it considers dialogue and interactions as a starting point for the construction of common meanings. Newman et al. (2008) add that the commitment of the nurse in this relationship is to understand a person’s experience. The attitude of openness and flexibility central to cultural competence promotes that commitment. It also allows the nurse to continually adapt her care given the dynamic and evolving nature of culture. The UT paradigm considers that change is constant and every phenomenon represents a unique pattern. The proposed definition of cultural competence not only involves the nurse’s relationship with the person living a health experience but also the person’s relationship with her environment and societal structures. According to Newman et al. (2008), nurses are not neutral; they bring their own knowledge, as well as their personal and professional experiences, to the relationship. Patients bring similar attributes to the relationship. As proposed in the definition of cultural competence, creating a space for dialogue and awareness of prejudices in the relationship follows this nursing perspective. The action of the nurse is based on critical thinking and reciprocity. Her goal is to understand the experience of the person in his uniqueness and to recognize a pattern that can then guide her actions.
The proposed constructivist definition also raises the question of how to integrate cultural competence in nursing education. Since the development of a competence is the constant revision of knowledge, attitudes, and skills, education must provide occasions for cumulative learning, not just one course or one international immersion experience. It is important for educators to plan the curriculum so that students can learn a theoretical perspective and be in contact with diverse clienteles in health care settings to apply concepts in clinical practice. Since the development of cultural competence is a process of reflection and action according to the proposed definition, health care organizations could promote and facilitate the participation of nurses and students in interdisciplinary group discussions about concrete situations encountered in a culturally diverse context. Multiple perspectives would then be challenged and the resulting learning embedded in the relevant social context. Grounding the nurses’ and students’ reflections and discussions in their actual practice and previous life experiences allows building bridges between their existing knowledge and new information. It has the potential to help them go beyond the relationship with the patient and take into account the social and political dimensions of care in their practice. Thus, as mentioned by Calvillo et al. (2009), the development of cultural competence will be triggered in an educational environment that stimulates the learner’s commitment and ethical behavior in understanding and solving complex problems (Calvillo et al., 2009). Education is not about giving a recipe to nurses and students but trying to develop a critical sense of their practice and of the health care system in general.
The proposed constructivist definition aligns with the current evolution of the concept of cultural competence and aims to reduce the gap between the definition and its application. The mental constructions or concepts are highly relevant to the development of basic knowledge in a discipline (Rodgers & Knafl, 2000). Adopting a constructivist perspective makes possible the development of the concept of cultural competence by considering different ways of knowing in the discipline. Therefore, the proposed definition has a potential role in the development of knowledge in both nursing practice and education. It provides a framework for the promotion of social justice in the nursing discipline and for questioning past and current clinical practices. Cultural competence in a constructivist paradigm that is oriented toward critical, reflective practice can help develop new knowledge on the role of nurses in preventing and reducing health inequalities. It can also lead to a comprehensive ethical reflection about the social mandate of health care professionals. The proposed definition of cultural competence makes the connection between the field of competency-based education and the nursing discipline. Guided by the constructivist paradigm and the unitary-transformative nursing paradigm, it is located in a continuum of knowledge in the field of culturally congruent care. It is a starting point for the development of knowledge that reflects current trends in the definition of culture, cultural competence, and cultural competence.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Social Sciences and Humanities Research Council of Canada (SSHRC) and the Ministère de l’Éducation du Loisir et du Sport (MELS) of Quebec.