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Index de Enfermería

versión On-line ISSN 1699-5988versión impresa ISSN 1132-1296

Index Enferm vol.18 no.2 Granada abr./jun. 2009





Cultural diversity is not simply about diversity within recipients of care but also concerns the diversity of care givers*

La diversidad cultural no alude sólo a los destinatarios del cuidado, sino también a la diversidad de los cuidadores



Gina Marie Awoko Higginbottom

Faculty of Nursing, University of Alberta, Edmonton, Canada. Email:



Dr. Mª Nubia Romero, has provided with us with an erudite, considered and thoughtful paper which extends our understanding of the concepts of cultural diversity, nursing care and the contemporary evidence base, specifically she draws upon research evidence and scholarly works from North, South America and Europe.

The purpose of the discussant role, as I understand it is twofold. Firstly, to summarize the given paper and secondly to provide additional perspectives on the phenomena in this case research, nursing care and cultural diversity. My paper will therefore consist of the two aforementioned parts.

Dr. Mª Nubia Romero, begins by outlining the parameters of her paper and indentifying the key constituents which have led to an increased focus on culture, research and nursing practice, She delineates these as being primarily global poverty as the major precursor to global migration, the exclusion of traditional and popular wisdom in health care which I perceive to mean the dominance and primacy of Western biomedical perspectives. Dr. Mª Nubia Romero, highlights the economic burden of contemporary systems of health care and the dogmatism of modern science as contributing to the current and increasing focus on cultural diversity, research and nursing practice through dissatisfaction with the 'status quo'. Central to Dr. Mª Nubia Romero's thesis are the research and theories postulated by Dr Madeline Leininger.1-3 Dr Leininger is regarded by many as the architectress and founder of transcultural nursing practice, a point I will revisit later in this presentation. However, first let us consider the accomplishments of Dr. Mª Nubia Romero's paper.


What is the underpinning empirical methodology?

The empirical methodology that Dr. Mª Nubia Romero utilizes in this paper is that of a critical literature review an accepted and valid methodology, this is distinct from a systematic literature review that adopts a transparent methodology and includes specified steps, articulation of the search strategy parameters of the review and evidence to enable replicability of the review. The methodology adopted in Dr. Mª Nubia Romero's paper means demands that both national literature and international literature are included in the review. In this review Dr. Mª Nubia Romero, has drawn upon the European, North and South American literature and the scope of the review extends from 1988-2007.


Which data are used?

Dr. Mª Nubia Romero's data is drawn from an extensive review of nursing research evidence, and draws upon the literature of a multidisciplinary origin including sociological, pedagogical, socio-economic, socio-cultural and socio-environmental domains and others.

The goal of the paper is to address the question posed in the presentation title.


What are the facets of the exposition?

Dr. Mª Nubia Romero articulates clearly the impact of globalization on nursing practice and the provision of care for others from different cultural groups. She emphasizes how the dominant model of nursing practice has a Euro-American epistemology and ontology and argues that this is manifested in areas of professional nursing practice and is most clearly evident in our professional and academic journals both national and international. She cites the use of English in publication as an exemplar of this manifestation. She has elicited this in the extensive review she has undertaken for the presentation of her paper today.

From this standpoint, Dr. Mª Nubia Romero argues that all other cultural and ethnic groups are regarded in sociological terms as the 'other' as the Euro-American model adopted in the exploration is regarded as the norm and all others are deviant from this norm.

Dr. Mª Nubia Romero argues that dissatisfaction with this has served as a catalyst for the development of models such as Leininger's Culture Care Diversity Model2 which influences many contemporary models of nursing this includes research and pedagogical dimensions and a desire to ensure cognizance of multiculturalism in all these domains of nursing practice. However, it is important to note that 'otherness can be framed in both terms of the care giver and care recipient' I will revisit this concept later in my presentation.

Dr. Mª Nubia Romero particularly highlights the negative influence of 'imperial globalization' and the resultant state control and objectification of patients, clients and their families as increasing commercialization of health care provision the application of the principles of the market economy, result in this objectification of the human condition. This she states creates further fissures between professional and lay perspectives and the lack of acceptance of traditional or popular forms health care wisdom. However, Dr. Mª Nubia Romero asserts that as a profession we as nurses have attempted to draw attention these exclusions.

Dr. Mª Nubia Romero postulates that the concept of transcultural nursing practice challenges the aforementioned dominance and attempts to foster social justice in health care, by seeking to recognize and address in an equitable manner the issue of 'otherness'. The aim of transcultural nursing practice in Dr. Mª Nubia Romero's analysis is to achieve cultural competence in nursing practice. In her thesis, Dr. Mª Nubia Romero introduces us to the terms 'glocality', and 'pluriverse' which within a post-modern context refers to the existence and acknowledgement of multiple and diverse social realities: socio-cultural, socio-political, socio-economic and socio-environmental configurations. Dr. Mª Nubia Romero asserts that all the papers reviewed for today's presentation contained a manifestation of 'pluriverse'. Whilst this concept is an element of the papers reviewed she is keen to point out the heterogeneous nature of the papers.

Dr. Mª Nubia Romero goes to draw largely on the North American literature in the work of Juliet Lipson4 and Josephina Campina-Bacote5 to explore how academic nurses have researched and attempted to address the health care and nursing needs of population groups who are largely excluded or marginalized in terms of their social status and roles within American society. She goes on to explore in some detail the dimensions of the precepts and axims of the models postulated by Lipson,4 Camphina-Bacote.5 Dr. Mª Nubia Romero claims that these North American theorists (correctly in my opinion) have further developed and enhanced the seminal work of Leininger. However, she questions the direct application of these models to the Latin American context without further critique or indeed in my view to any other global context. How do we know such models are transferable? Not all have been empirically tested. Community nursing and health care in general is configured by complex historical antecedents and a myriad of social, economic, political and cultural factors which may be unique to the nation state.


What does Dr. Mª Nubia Romero conclude?

Dr. Mª Nubia Romero concludes that an increased focus on cultural diversity and nursing care within research and theory was not preempted by the work of Leininger1-3,6,7 but because of the underlying elements of poverty, marginalization and denigration of traditional and popular wisdom, glocal displacements and the inefficiency of health services. This has resulted in a coalescing of a multiplicity of factors that has precipitated a paradigm shift in relation to cultural diversity, nursing care and research.

I would like to commend Dr. Mª Nubia Romero for attaining in her thesis a degree of precision and a depth of critical analysis which is difficult to achieve. She challenges, in her thesis our presuppositions with the breadth and depth of her review, which demands a reconsideration of our current understandings of the phenomena. The intellectual integrity of her paper is axiomatic. The synthesize of her source materials is extraordinary, resulting in an outstanding level of abstraction that challenges our thinking.


Discussant response

As we move into the 21st century it is worth considering the fact that global migration now characterizes life in many nation states. It is highly likely that this phenomenon will not diminish but expand as we move further into the 21st century. This movement and relocation of populations is driven by a complex range of factors, many of which are as Dr Romero states economic arising from poverty and the lack of economic resources this is exemplified in the relocation of my own ancestors from Ireland during the late 18th century to England as a result of famine and the potato blight. But there are additional motivating factors that preempt relocation which Dr. Mª Nubia Romero does not mention such as the transgression of human rights resulting in substantial populations globally who are refugees or asylum seekers seeking refuge in nation states which are viewed as providing a 'safe haven' under the auspices of the Geneva Convention.8 This is exemplified in the plight of the Somali population (and many others).9 These populations often have complex and challenging physical and psychological health care needs. At the other end of the continuum in terms of individual autonomy and desire for relocation, we have the academic brain drain which most notably witnesses the movement of usually some of the most skilled and highly qualified individuals often between developed countries although not exclusively for example the recruitment of nurses10 continues to occur from developing countries to work in developed countries in order to address workforce shortages and labor market deficits. In a Marxist analysis11 relocations of this nature may be regarded as an available yet disposable nursing workforce as often entry visas are permitted for limited periods and these nurses may be required to work in less popular areas of practice. Never the less, these highly skilled populations also contribute to cultural diversity within nation states. As a recent immigrant to Canada from the United Kingdom (UK), I exemplify the latter.

Additionally, some of the movements of populations as alluded to by Dr. Mª Nubia Romero are the legacy of the historical antecedents of a colonial history and the domination, oppression and subjugation of one population group by another, most but not all European nation states share this colonial history and the resultant diverse population profiles.12 Whilst colonialization is referred to by Dr. Mª Nubia Romero within the context of suppression of traditional knowledge and wisdom, no linkage in made her thesis regarding the movement of populations. Again my own personal family history manifests this phenomena as in 1955 my father was invited by the British government to migrant from his birth country in West Africa, Ghana a former colony, to seek employment in Britain.


What do we mean by cultural diversity?

Implicit within Dr. Mª Nubia Romero's paper is the acceptance of the term cultural diversity as universal concept with a shared global meaning; but this may not be the case. What exactly does cultural diversity mean? And how can we establish a conceptual definition? Is the term simply a conflation of the terms culture and diversity or does the term hold an inimitable and unambiguous meaning? Defining culture is fraught with complexities and difficulties, the term has been and continues to be contested, is then self-evident that the term cultural diversity is contested. Yet, if we fail to undertake a full conceptual analysis, confusion and misunderstanding can ensue.

Does the term having the same meaning in all geographical locations? In other words is this term transferable to all nursing contexts globally, or are understandings of cultural diversity contextual and situational, if so what are the determining factors and how do they differ from those which exist within and between nation states.

What of the temporal dimensions? Have the semantic understandings remained constant throughout time or are understandings of the cultural diversity within the nursing context evolving and changing over time. These are questions that require further reflection and analysis.

The office of the United Nations High Commissioner for Human Rights13 have articulated a Universal Declaration on Cultural Diversity They state in Article 1 that:-

"Cultural diversity: the common heritage of humanity

Culture takes diverse forms across time and space. This diversity is embodied in the uniqueness and plurality of the identities of the groups and societies making up humankind. As a source of exchange, innovation and creativity, cultural diversity is as necessary for humankind as biodiversity is for nature. In this sense, it is the common heritage of humanity".

This statement highlights the dynamic nature of cultural diversity and the taken for granted assumptions when we become immersed in a specific cultural context. The temporal dimensions mean what that what our nursing foremother's outstanding figures such as Mary Seacole14 and Florence Nightingale (incidentally both of whom nursed in cultural contexts other than their birth countries) perceived to be a culturally diverse society is very different in the 21st Century. The care of individuals, groups and societies is at the heart of community nursing practice, this is an irrefutable concept regardless of the nation state in which community nursing is practiced. In this sense it is incumbent upon us to be concerned for and be cognizant of the cultural diversity within our own profession and client groups. It is clear that cultural diversity within nursing practice is set to increase rather than decrease in many nation states this is not simply a case of increasing cultural diversity within our client groups. Shortfalls in the nursing labor market are addressed via the recruitment of nurses from developing countries.9 Whilst the British National Health Service (NHS) for example has established an 'Ethical Clause'13 that prevents the direct recruitment form developing countries we know that the number of nurses from countries outside the UK is increasing.

The Royal College of Nurses (RCN) in the UK state that in the "early to mid 1990s about one in ten of the annual new entrants to the UK nursing register were from non-UK sources.14 By 2000/2001 this had risen to almost four in ten of total initial registrations, and in then 2001/2002 for the first time ever there were more overseas additions to the register than there were UK registrants. This means that one in 12 nurses in England has come from abroad, with the figure for London rising to one in four, around 28%".15 It is therefore clear that cultural diversity in nursing is not simply a question of providing care for clients, patients and families; we need to acknowledge, take account of and respond in a positive way to diversity within our profession.

However, global cultural diversity is not a 21st century phenomenon. Consider the Roman Empire which dominated Eastern, Western Europe and North Africa circa 5th century.16 All citizens of the Empire were considered Romans, so considerable cultural diversity existed. Some of you may be surprised to learn that Lucius Septimius Severus was the first emperor to be born in Africa and rule Britain and other parts of Europe, 193 to 211. His first wife Paccia Marciana is described in the literature as an African woman of Roman origin. This level of cultural diversity has existed throughout history. The Ottoman Empire (1299 to 1922)17 was also a multi-ethnic and multi-religious Turkish-ruled state which, at the height of its power (16th - 17th centuries), spanned three continents. The empire was at the centre of interactions between the Eastern and Western worlds for six centuries. What is clear from a historical perspective is that the dynamics of cultural diversity, power, domination and subjugation of people are inextricable.

So cultural diversity it seems it is characteristic of human existence: but what does it mean? Does the term refer to the population groups for whom we care for? or does it refer to the diversity of the nursing workforce or both.


Responses to cultural diversity and community nursing practice

Dr. Mª Nubia Romero has drawn upon in her paper on the perspectives offered by Madeleine Leininger1-3,18 Leininger was in the vanguard of a movement that viewed the focus on the provision of care for various cultural groups within society as imperative. Leininger was originally an anthropologist before training as a nurse and she studied with Margaret Mead one of the outstanding anthropologists of the 20th century. Whilst is clear that Leininger made a fundamental and seminal contribution to the field of transcultural nursing care, her work in recent decades has been heavily critiqued and the contemporary relevance questioned, her work has been contested over past decades by various authors such as Bruni19 in 1988, Swendson & Windsor20 in 1996 and others.

In 2000, I attended Dr Leininger's Postmasters Program in Transcultural Nursing Care at the University of Omaha, Nebraska and experienced facilitation of the program by the theorist herself in order to make my own evaluations. It is true to say that many aspects of the model are promoted for application in a mechanistic fashion. Leininger's model was conceptualized in 1978; but we must evaluate the model in relation to the evolution of academic nursing and the social, economic and political context of the day. In 1978, very few nurses studied at doctoral level or were engaged in empirical research. Leininger's work was innovative. However, 30 years later perhaps Leininger's model has less contemporary relevance and more relevant models have emerged which not only take account of important cultural dimensions, but are cognizant of the prevailing ideologies in society such as racism and the very real power dimensions between various population groups in pluralistic societies. We know from the work of Krieger21-24 in the US, that racism damages health.

The concept of transcultural nursing has been criticized by Serrant-Green (2001),25 Cooney26 (1994) and others. Serrant-Green in particular challenges the fundamental precepts of transcultural nursing, in that she suggests that the concept assumes that the care giver is of white European or North American origin in other words a member of the dominant group in the given society and that the recipient is a non white, non-English speaking patient of ethnic minority origin. We know that, for example in the UK black and ethnic minority nurses are over represented in the nursing profession as whole and this profile will continue to increase as shortfalls in the nursing labor market continue. However, Dr Romerio did in her presentation indicate how others had enhanced Leininger's seminal work mentioning the work of theorists such as Josephina Camphina Bacote,27 and others including Giger & Davidhizar,28 Purnell,29 and Papadopoulos.30

Whilst the scholarship and expert knowledge in Dr. Mª Nubia Romero's paper is self evident, she does however draw heavily upon the North and South American literature and research evidence from Europe. My major criticism would be that she has neglected to include research from the antipodean region. There exists a considerable body of nursing research evidence that has emanated particularly from New Zealand which further expands our understanding of cultural diversity, nursing care and research specifically the notion of 'cultural safety' within the context of nursing care. It is a deficit of Dr. Mª Nubia Romero's thesis, that these perspectives are not included, as she herself emphasizes herself the dominance of Euro-American perspectives on transcultural care.

Irihapeti Ramsden was a leading nurse in New Zealand of Maori origin she conceptualized the notion of 'cultural safety'.31-34I was fortunate to attend in 2001 the Transcultural Nursing Conference in the Gold Coast Australia where both Irihaptei and Madeleine Leininger gave keynote addresses and it was absolutely evident that divergences between the two theorists approaches existed and that the Culture, Care, Universality theory developed by Leininger was considered to be culturally inappropriate and unsafe for Maori people.34

-Cultural Safety is an educational framework for the analysis of the power relationships between health professionals and those they serve.

-The concept challenges specifically the historical, social and political processes on Maori health inequalities.36

-Cultural Safety has been part of the New Zealand core nursing and midwifery curriculum since 1994.

-A culturally safe education involves nurses becoming aware of themselves as bearers of culture.

-Awareness of historical power relations, social and political processes.

These latter points are most significant and I am not sure that application of Leininger's model of Culture, Care, Diversity with an emphasis on culture rather than the broader socio-political dimensions that impact upon clients, patients, families and communities lives enables these issues to be taken account of. Yet, these are the very issues that shape and define the health experience in a very profound way. The introduction of cultural safety into the nursing curriculum in New Zealand34 was met by unconstructive and sometimes vicious press coverage. Ramsden's ideas were threatening and challenging to many within dominant European community - The Pakeha in New Zealand.

My own research has focused much more on the notion of ethnic identity and health inequities,37-40 culture being an important dimension of the multiple complex social identities we hold. The intersection of social class (or poverty) and ethnicity is crucial in determining the health status of population groups. Recent research in the UK by Nazroo & Karlsen41 has indicated that perhaps all ethnic inequalities that exist in the UK can in fact be explained by social class differences, which may provide some insight into why a focus on culture alone cannot be entirely useful.

Ethnicity as a concept that is different from the concept of 'race' has risen to prominency in health related research, literature, health, and social care service provision.42 However, it is worthy of note that this increased focus is characterized by a lack of consistency and terminology.43,44 The concept of ethnicity moves beyond perceptions of 'phenotype' into a complex coalition of the sharing of culture, values, traditions and perceptions of belonging that interface with every aspect of the lived human experience.40 This is distinct from nationality or old understandings of the concept of 'race' and is not necessarily related to geographical locations or national state boundaries.

Ethnicity is therefore defined by a shared understanding and identity in a specific context or environment including culture. This internal definition of ethnicity is of course mediated by the external definition of the wider socio-structural processes in terms of health experience. Although we all have the right to self-determination, the external definition is more powerful in determining the health experience and consequentiality is more profound in terms of life experience.44,45 Which is precisely why as community nurses and researchers we need insight and understandings of these complex social phenomena?

Complex sociological theories over past decades have attempted to critique, analyze and explain social relations between groups of individuals, the influence of societal structures and the relationship of 'race' (I have elected to use quotation marks around the term 'race' to signify the contested nature of the term), ethnicity and culture to wider societal structures.42-45 In some instances this has also included revisiting original and seminal perspectives in order to provide new and contemporary insights.46-49 The significant point being that sociological perspectives offer a perspective, explanation or critique, not necessarily a definitive answer on issues of 'race' and ethnicity.

However, as we move further into the 21st century with increasing movements of populations, many of us hold multiple cultural and ethnic identities; we cannot claim to hold a single ethnic or cultural identity, as our ancestries are complex. The key question is how as community nurses and researchers we acknowledge and respond to this increasing complexity.

Modood50 et al has highlighted the notion of 'fused ethnicities' as a consequence of colonialism, immigration, movement of populations, fusing of cultures. His work within the UK context explains how fusion of this nature is exemplified in the exposure and influence of the 'British' ways of life, and institutions in many countries over several hundred years, especially within the Indian sub-continent. In this sense individuals and communities did not need necessarily migrate to experience this exposure, but are already familiar with the cultures of their colonizers. Additionally, there are those who create new identities and ethnicities for themselves, refusing to accept old orders and understanding.

The sociological and theoretical debates in this domain focus on the concepts of cultural essentialism, hybridity and diaspora.51,52 The difficulty with these terms is again the lack of a shared definition.53 For example, the term 'diaspora' has been used by Gilroy54 and Hall55 with variations in meaning. Similarly the term 'hybridity' is a contested term.53 The similarity between cultural essentialism, hybridity and diaspora is that rather than structural issues being a central concern as in antiracism, they focus on culture and identity. Diaspora is associated with the concept of transnationality54 the migration and re-location geographically to countries other than the birth country. Therefore the concept would appear to have not only historical relevance to those populations that have migrated but also a contemporary relevance in relation to refugees and asylum seekers.

The original Greek meaning of diaspora is the spreading of seeds across territories, the implication that these seeds (people) will form new roots in the new environment. In this sense the term 'diaspora' embraces a past history in the sense of where people have come from and the influence of the new location. Whilst the seeds have spread, they can only become mature if the environment is conducive to their development.52 Anthias & Lloyd53 claim the notion of diaspora also has considerable influence on those who already occupy the environment and must influence the host population in some way. Therefore, the culture and identify of the host community is influenced by the migrant communities; good examples of this exist in the UK in terms of the influence various ethnic groups have on diet and other elements of popular culture such as music.

In 1946, William Gilbert presented the first comprehensive survey of groups in the United States (US) with multiple ethnic and cultural backgrounds. He estimated that there were at least 50,000 persons who were from complex ethnic and cultural backgrounds of European, African and Aboriginal ethnic origin.56 Gilbert listed ten major groups with multiple ethnic and cultural heritage several related groups. Again, this is not a new phenomenon we that is people of multiple ethnic and cultural heritages have existed for many centuries, though we are often denied the opportunity to self-assign our ethnic and cultural identity.

Whilst these considerations may not on a daily basis be pertinent for the individuals or communities themselves, considerable misunderstandings can occur, for those of us involved in the provision of professional nursing practice and research.



In conclusion whilst it is important to recognize and acknowledge what research tells us in relation to research, nursing care and cultural diversity. It is imperative we take an inclusive approach embracing not just Euro-American perspectives, but drawing on the wisdom of academic nurses globally including colleagues in Australia, New Zealand and other nation states. Within this, we must acknowledge the increasingly complex ethnic identities our patients and our peers hold and indeed that we hold as academic and community nurses. Those who hold multiple ethnic origins may have particular skills in moving between and within different cultural and ethnic groups.

Cultural diversity is not simply about diversity within recipients of care but also concerns the diversity of care givers. In terms of the research evidence base I would suggest that it may be more important to focus on what the research does not tell us, as some of the research silences and paucity of knowledge may be much more revealing than that which is articulated on the topic of culturally diversity and nursing care. A focus of this nature may make transparent the implicit assumptions held about research evidence, nursing and cultural diversity. These assumptions if not deconstructed may distort reality.



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