Understanding Diversity: The Cultural Knowledge Profile of Nurses Prior to Transcultural Education in Light of a Triangulated Study Based on the Giger and Davidhizar Model
Abstract
1. Introduction
- Communication is a continuous process in which one person can interact with another through written or spoken language, gestures, facial expressions, body language, space, or other symbols.
- Space refers to the distance and techniques of showing proximity used in verbal and non-verbal interactions. All communication takes place in the context of space.
- Time is a very important aspect of interpersonal communication. Cultural groups may be oriented towards the past, present or future. Cultures refer to time in terms of clock time or social time—some groups function on the basis of social time.
- Environmental control refers to a person’s ability to control nature and to plan and direct factors in the environment that affect them.
- Social structure is the way in which a cultural group organises itself around a family or community.
- Biological differences are specifically genetic conditions, patterns of growth and development, functioning of body systems, anatomical characteristics of race, skin and hair physiology, incidence of disease, and resistance to disease.
- -
- P (Population): nurses who are master’s students in Poland with professional experience.
- -
- I (Intervention): analysis of self-assessed cultural knowledge in relation to the six dimensions of the Giger and Davidhizar model.
- -
- C (Comparison): a lack of formal cultural preparation (no completed subject ‘Nursing in a multicultural environment’ or postgraduate courses on a similar topic).
- -
- O (Outcome): the identification of their level of cultural knowledge and deficit areas.
2. Materials and Methods
2.1. Design
2.2. Sample and Setting
2.3. Procedure of the Study
2.4. Instrument
2.5. Data Analysis
2.6. Statement of the Ethics Committee
3. Results
Statistical Analyses
- -
- Between space and environmental control (ρ = 0.50);
- -
- Between social structure and environmental control (ρ = 0.36);
- -
- Between social structure and space (ρ = 0.38).
- -
- Cluster 0—“low perception of cultural barriers, pragmatic profile” (n = 17). This was characterised by the lowest scores in all areas (0.1–0.6 codes on average), with no dominant categories. The highest number of codes appeared in the areas: communication and social structure.
- -
- Cluster 1—“profile with high social and communication sensitivity” (n = 12). Respondents in this group scored highest in categories such as communication (average 2.08 assignments), time (1.33), social structure (3.17), and biological factors (1.00). They were characterised by a high awareness of cultural differences related to interpersonal relationships, language, religion, and community influence. This is the group of nurses most sensitive to cultural determinants of care.
- -
- Cluster 2—“critical and experienced profile” (n = 13). The highest scores here were in the categories of communication (2.54), social structure (4.00), biological factors (1.31), and social structure (1.15). Respondents in this cluster strongly emphasised specific barriers—a lack of trust, patients’ religiosity, language difficulties, and the social situation.
- Communication: a lack of language skills—significantly higher in cluster 2, indicating great language difficulties in this group.
- Social structure: belief in the healing powers of nature and God—particularly significant for cluster 2.
- Communication: a lack of trust—clearly raised in clusters 1 and 2.
- Social structure: social situation—plays a greater role in clusters 1 and 2 than in 0.
- Communication: a lack of knowledge of medical phrases—mainly cluster 2.
- Time: the dependence of time on culture—much more emphasised in cluster 1.
- Social structure: the organisation of family life—clearly important for cluster 2.
- Social structure: experiences of other community and family members—key in cluster 2.
- Communication: fear of the unknown—more frequent in cluster 1.
- Biological factors: the colour of skin and mucous membranes—more frequent in cluster 1 and 2.
4. Discussion
Limitations of the Study
5. Conclusions
- Cultural knowledge among the nurses surveyed is fragmentary and often limited to superficial aspects (e.g., language barriers), ignoring deeper cultural determinants (e.g., temporal orientation, territoriality, biological differences).
- Significant gaps in knowledge of issues such as non-verbal communication, cultural meaning of space, and specificity of health assessment in people with a different complexion were identified.
- The key findings of the study indicate that the cultural knowledge of the participants was fragmented and simplified, with clear deficits in the areas of non-verbal communication, biological differences, and understanding space in a cultural context. Three distinct profiles of cultural knowledge were identified: pragmatic, socio-reflective, and critical–experienced, highlighting individual differences in the perception and understanding of cultural phenomena in nursing care.
- Implications for nursing practice and education are as follows: These results have important implications for the design of nursing curricula. Instead of universal training, it is necessary to adapt educational content to the level of awareness, experience profile, and reflective readiness of nurses. Identifying knowledge profiles allows for the creation of targeted educational interventions that will more effectively fill knowledge gaps and develop specific competencies. For example, for students with a pragmatic profile, emphasis should be placed on theoretical foundations and awareness of cultural differences; for the profile with high social and communication sensitivity, it will be crucial to develop advanced intercultural communication skills and reflection on attitudes, while for the critical and experienced profile, training in strategies for dealing with complex barriers in care is recommended.
- It is recommended that diagnostic tools (e.g., based on clinical scenarios) be implemented in the early stages of nursing education to identify students’ individual educational needs in terms of cultural competence.
- Training should be practice-oriented, using simulations, case studies, and field experience to equip nurses with specific knowledge of specific cultural dimensions (e.g., non-verbal communication, biological determinants of disease in different populations) and practical tools for effectively adapting care to patient needs (e.g., intercultural communication protocols, guidelines for pain assessment in different cultures). Instead of a general ‘equipping with tools’ approach, nurses should be taught specific techniques and strategies.
- It is advisable to conduct longitudinal studies evaluating the effectiveness of personalised educational programmes. It is also important to expand the research sample to include nurses with different professional experience and from different geographical regions as well as to include the patients’ perspective in the research in order to obtain a more complete picture of the quality of care in a multicultural environment. Further research should also explore the impact of actual clinical experience with patients from different cultures on the development of nurses’ knowledge and skills.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Biological factors |
Description content: A 21-year-old African American woman, married, mother of a 1-year-old girl, was diagnosed with sickle cell anaemia at the age of 10. The disease has remained largely asymptomatic for the last three years. Currently admitted to the ward due to exacerbation of symptoms. Physical examination and history revealed pain and swelling in the joints of the upper and lower extremities, increased body temperature, rapid and shallow breathing, auscultation changes in the lungs, blue and dry lips, delayed capillary return, decreased Hb levels. The patient is lactose intolerant. |
Knowledge question: What are your methods of assessing skin colour in dark-skinned people? |
Environmental control |
Description content: A 27-year-old woman lives with her family, her husband and 6 small children, in a village in a small house without a sewage system. The family nurse visited the family after three of her children were reported to have lice at the school. The woman did not report to the school despite requests to do so. During the visit, the nurse observed a persistent cough in the woman, emaciation, grey and dry skin, and the rapid onset of fatigue during everyday activities. She learned from the interview that this condition has been ongoing for about 2 years. She gave birth to her children alone at home; she had never visited any doctor. She does not use medical care, stating as a reason, “God has sent this disease and he will heal me as He wants. Family is most important to me, I don’t have time to see a doctor. Besides, I don’t believe doctors. My aunt went once and died the next week.” |
Knowledge question: Why do you think the woman is not receiving medical care? |
Time |
Description content: A 37-year-old Italian woman was admitted to the ward because of low glucose levels. Six months earlier, she was diagnosed with insulin-dependent diabetes. The patient has been prescribed insulin to be administered twice daily. The patient was admitted to the ward due to symptoms of hypoglycaemia: drenching sweating, feeling hungry, dry mouth, nausea, vomiting, restlessness, irritability and nervousness, muscle weakness, feeling tired and sleepy. The interview shows that similar episodes have also occurred in the patient before. After taking insulin, she often ate the wrong meal or at the wrong time. She does not pay too much attention to the time she takes insulin and the time she takes a meal. She pays no attention to punctuality. |
Knowledge question: Is there a relationship between time and culture, and, if so, what? |
Social structure |
Description content: A 24-year-old Roma woman was admitted due to pains in the lower right abdomen. Appendicitis was diagnosed. The patient was operated on. After surgery, she was transferred to the surgical ward in good general condition, with normal life parameters. During her stay in the ward, the patient was accompanied by relatives. Family members took turns and constantly stayed with the patient despite her quick return to self-care. The members of distant and immediate families who circulated and stayed in the sick room and in the ward made it difficult to organise nursing care. |
Knowledge question: What influences interactions between members of the same ethnic group? |
Space |
Description content: A 56-year-old man from Germany, an engineer of an international corporation, was admitted with severe chest pain. The patient was admitted to the cardiology department with suspected myocardial infarction. Immediately after the man’s arrival in the ward, his wife appeared with family portraits, flowers, and other personal belongings. It is forbidden to keep personal belongings in the intensive care room, so the wife was informed to take her husband’s personal belongings. After 2 days, the patient’s condition improved enough to be moved from the intensive care room to a room with another patient. After the transfer, the nurse observed that the patient was restless, somewhat withdrawn, and had difficulty expressing his needs and feelings. |
Knowledge question: How could illness and hospitalisation compromise the patient’s personal sense of privacy and autonomy? |
Communication |
Description content: A 37-year-old woman was admitted to the department for arterial hypertension. The woman had recently moved to Poland from Mexico. The nursing staff have a problem with communication because the patient does not speak Polish, knows just a few Polish words, mixes Polish with her own language, and does not understand medical terminology, requests, and questions addressed to her. When trying to communicate, she is very loud, gestures emphatically, repeats the same words several times. The patient is terrified and anxious because of the hospitalisation. The hospital reminds her of death, and she is afraid that she will die here. |
Knowledge question: What problems do nursing staff encounter when looking after someone who does not speak their language? |
References
- Červený, M.; Kratochvílová, I.; Hellerová, V.; Tóthová, V. Methods of increasing cultural competence in nurses working in clinical practice: A scoping review of literature 2011–2021. Front. Psychol. 2020, 24, 936181. [Google Scholar] [CrossRef]
- Kwame, A.; Petrucka, P.M. A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nurs. 2021, 20, 158. [Google Scholar] [CrossRef]
- Osmancevic, S.; Großschädl, F.; Lohrmann, C. Cultural competence among nursing students and nurses working in acute care settings: A cross-sectional study. BMC Health Serv. Res. 2023, 23, 105. [Google Scholar] [CrossRef]
- WHO. Available online: www.who.int/news-room/feature-stories/detail/who-recommends-considering-cultural-factors-to-develop-more-inclusive-health-systems (accessed on 14 February 2024).
- Liang, H.Y.; Tang, F.I.; Wang, T.F.; Yu, S. Evaluation of nurse practitioners’ professional competence and comparison of assessments using multiple methods: Self-assessment, peer assessment, and supervisor assessment. Asian Nurs. Res. 2021, 15, 30–36. [Google Scholar] [CrossRef]
- Leininger, M. Quality of life from a transcultural nursing perspective. Nurs. Sci. Q. 1994, 7, 22–28. [Google Scholar] [CrossRef] [PubMed]
- Giger, J.; Davidhizar, R.E.; Purnell, L.; Harden, J.T.; Phillips, J.; Strickland, O. American academy of nursing expert panel report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. J. Transcult. Nurs. 2007, 18, 95–102. [Google Scholar] [CrossRef]
- El-Messoudi, Y.; Lillo-Crespo, M.; Leyva-Moral, J. Exploring the education in cultural competence and transcultural care in Spanish for nurses and future nurses: A scoping review and gap analysis. BMC Nurs. 2023, 22, 320. [Google Scholar] [CrossRef] [PubMed]
- Edensor, T. National Identity, Popular Culture and Everyday Life, 1st ed.; Routledge: Abingdon, UK, 2002. [Google Scholar] [CrossRef]
- Cross, T.; Bazron, B.; Dennis, K.; Isaacs, M. Towards A Culturally Competent System of Care; Georgetown University Child Development Center: Washington, DC, USA; CASSP Technical Assistance Center: Washington, DC, USA, 1989; Volume 1. [Google Scholar]
- Polacek, G.N.L.J.; Martinez, R. Assessing Cultural Competence at a Local Hospital System in the United States. Health Care Manag. 2009, 29, 98–110. [Google Scholar] [CrossRef] [PubMed]
- Leininger, M.M. Culture Care Diversity and Universality: A Theory of Nursing; National League for Nursing Press: New York, NY, USA, 1991. [Google Scholar]
- Purnell, L. The Purnell model for cultural competence. J. Transcult. Nurs. 2002, 13, 193–196. [Google Scholar] [CrossRef]
- Campinha-Bacote, J. A model and instrument for addressing cultural competence in health care. J. Nurs. Educ. 1999, 38, 203–207. [Google Scholar] [CrossRef] [PubMed]
- Papadopoulos, I.; Tilki, M.; Taylor, G. Transcultural Care: A guide for Health Care Professionals; Quay Books: Limerick, UK, 1998; ISBN 1-85642-051 5. [Google Scholar]
- Giger, J.N.; Davidhizar, R. The Giger and Davidhizar Transcultural Assessment Model. J. Transcult. Nurs. 2002, 13, 185–188. [Google Scholar] [CrossRef]
- Liu, T.T.; Chen, M.Y.; Chang, Y.M.; Lin, M.H. A Preliminary Study on the Cultural Competence of Nurse Practitioners and Its Affecting Factors. Healthcare 2022, 10, 678. [Google Scholar] [CrossRef]
- Antón-Solana, I.; Tambo-Lizalde, E.; Hamam-Alcober, N.; Vanceulebroeck, V.; Dehaes, S.; Kalkan, I.; Kömürcü, N.; Coelho, M.; Coelho, T.; Casa Nova, A.; et al. Nursing students’ experience of learning cultural competence. PLoS ONE 2021, 16, e0259802. [Google Scholar] [CrossRef]
- Elo, S.; Kyngäs, H. The qualitative content analysis process. J. Adv. Nurs. 2008, 62, 107–115. [Google Scholar] [CrossRef] [PubMed]
- Munoz, S.R.; Bangdiwala, S.I. Interpretation of Kappa and B statistics measures of agreement. J. Appl. Stat. 1997, 24, 105–112. [Google Scholar] [CrossRef]
- Ličen, S.; Prosen, M. The development of cultural competences in nursing students and their significance in shaping the future work environment: A pilot study. BMC Med. Educ. 2023, 23, 819. [Google Scholar] [CrossRef]
- De-María, B.; Topa, G.; López-González, M.A. Cultural Competence Interventions in European Healthcare: A Scoping Review. Healthcare 2024, 12, 1040. [Google Scholar] [CrossRef] [PubMed]
- O’Brien, E.M.; O’Donnell, C.; Murphy, J.; O’Brien, B.; Markey, K. Intercultural readiness of nursing students: An integrative review of evidence examining cultural competence educational interventions. Nurse Educ. Pract. 2021, 50, 102966. [Google Scholar] [CrossRef]
- Jin, E.; Kang, H.; Lee, K.; Lee, S.G.; Lee, E.C. Analysis of Nursing Students’ Nonverbal Communication Patterns during Simulation Practice: A Pilot Study. Healthcare 2023, 11, 2335. [Google Scholar] [CrossRef] [PubMed]
- Wanko Keutchafo, E.L.; Kerr, J.; Baloyi, O.B. A Model for Effective Nonverbal Communication between Nurses and Older Patients: A Grounded Theory Inquiry. Healthcare 2022, 10, 2119. [Google Scholar] [CrossRef] [PubMed]
- Patterson, M.L.; Fridlund, A.J.; Crivelli, C. Four Misconceptions About Nonverbal Communication. Perspect. Psychol. Sci. 2023, 18, 1388–1411. [Google Scholar] [CrossRef]
- De Rigal, J.; Des Mazis, I.; Diridollou, S.; Querleux, B.; Yang, G.; Leroy, F.; Barbosa, V.H. The effect of age on skin color and color heterogeneity in four ethnic groups. Ski. Res. Technol. 2010, 16, 168–178. [Google Scholar] [CrossRef]
- Sommers, M.S.; Zink, T.M.; Fargo, J.D.; Baker, R.B.; Buschur, C.; Shambley-Ebron, D.Z.; Fisher, B.S. Forensic sexual assault examination and genital injury: Is skin color a source of health disparity? Am. J. Emerg. Med. 2008, 26, 857–866. [Google Scholar] [CrossRef] [PubMed]
- Paatela, S.; Pohjamies, N.; Kanste, O.; Haapa, T.; Oikarainen, A.; Kääriäinen, M.; Mikkonen, K. Registered nurses’ cultural orientation competence for culturally and linguistically diverse nurses in the hospital setting: A cross-sectional study. J. Adv. Nurs. 2024, 80, 707–720. [Google Scholar] [CrossRef] [PubMed]
- Erkkilä, P.; Koskenranta, M.; Kuivila, H.; Oikarainen, A.; Kamau, S.; Kaarlela, V.; Immonen, K.; Koskimäki, M.; Mikkonen, K. Ethical and cultural competence of social- and health care educators from educational institutions—Cross-sectional study. Scand J. Caring Sci. 2023, 37, 642–653. [Google Scholar] [CrossRef] [PubMed]
- Urgun, D.; Seidel, J.; Vangeli, E.; Borges, M.; de Oliveira, R.F. Exploring the impact of cross-cultural training on cultural competence and cultural intelligence: A narrative systematic literature review. Front. Psychol. 2025, 16, 1511788. [Google Scholar] [CrossRef]
- Shepherd, S.M. Cultural awareness workshops: Limitations and practical consequences. BMC Med. Educ. 2019, 19, 14. [Google Scholar] [CrossRef]
1. Biological factors 1.1 Colour of skin and mucous membranes 1.2 Texture of the skin and mucous membranes |
2. Communication 2.1 Lack of knowledge of the language 2.2 Lack of understanding of medical phrases 2.3 Lack of knowledge of non-verbal communication 2.4 Lack of trust 2.5 Fear of the unknown |
3 Space 3.1 No privacy 3.2 Feeling of dependence on medical staff 3.3 Inability to control one’s own behaviour |
4 Social structure 4.1 Tradition 4.2 Common symbols, values, and behaviours 4.3 Sense of community |
5 Time 5.1 Dependence of time on culture 5.2 No time dependence on culture |
6 Environmental control 6.1 Financial situation 6.2 Experiences of other community and family members 6.3 Organisation of family life 6.4 Low level of health knowledge 6.5 Lack of family behavioural patterns for health 6.6 Belief in the healing powers of nature and God 6.7 Lack of trust in healthcare |
Cultural Phenomena Identified by Giger and Davidhizar | Segments | % |
---|---|---|
Environmental control | 120 | 33.99 |
Communication | 69 | 19.55 |
Social structure | 55 | 15.58 |
Space | 45 | 12.75 |
Time | 35 | 9.92 |
Biological factors | 29 | 8.22 |
Total | 353 | 100 |
Cultural Phenomena | Codes | Mean (M) | Standard Deviation (SD) |
---|---|---|---|
Biological factors | Colour of skin and mucous membranes | 0.67 | 0.667 |
Texture of the skin and mucous membranes | 0.14 | 0.346 | |
Communication | Lack of knowledge of the language | 0.89 | 0.314 |
Lack of understanding of medical phrases | 0.19 | 0.396 | |
3 Lack of knowledge of non-verbal communication | 0.08 | 0.276 | |
Lack of trust | 0.19 | 0.396 | |
Fear of the unknown | 0.56 | 0.497 | |
Space | No privacy | 0.69 | 0.517 |
Feeling of dependence on medical staff | 0.31 | 0.461 | |
Inability to control one’s own behaviour | 0.25 | 0.433 | |
Social structure | Tradition | 0.22 | 0.478 |
Common symbols, values, and behaviours | 0.67 | 0.527 | |
Sense of community | 0.64 | 0.480 | |
Time | Dependence of time on culture | 0.94 | 0.229 |
No time dependence on culture | 0.03 | 0.164 | |
Environmental control | Financial situation | 0.42 | 0.546 |
Experiences of other community and family members | 0.44 | 0.497 | |
Organisation of family life | 0.39 | 0.541 | |
Low level of health knowledge | 0.56 | 0.550 | |
Lack of family behavioural patterns for health | 0.17 | 0.373 | |
Belief in the healing powers of nature and God | 0.75 | 0.433 | |
Lack of trust in healthcare | 0.61 | 0.487 |
Cultural Phenomena | Biological Factors | Communication | Space | Time | Social Structure | Environmental Control |
---|---|---|---|---|---|---|
Biological Factors | 1.0 | −0.05 | −0.3 | 0.18 | −0.16 | 0.01 |
Communication | −0.05 | 1.0 | 0.34 | −0.24 | 0.17 | −0.01 |
Space | −0.3 | 0.34 | 1.0 | 0.07 | 0.38 | 0.5 |
Time | 0.18 | 0.24 | 0.07 | 1.0 | 0.14 | 0.19 |
Social Structure | −0.16 | 0.17 | 0.38 | 0.14 | 1.0 | 0.36 |
Environmental control | 0.01 | −0.01 | 0.5 | 0.19 | 0.36 | 1.0 |
Profile Name | Defining Characteristics | Dominant Categories | Knowledge Depth |
---|---|---|---|
Pragmatic | Focus on practical communication and biological needs; limited conceptual reflection. | Communication, Biological Factors | Basic/factual |
Socio-Reflective | Emphasis on family, community, and social norms; includes moderate cultural sensitivity. | Social Structure, Environmental Control | Intermediate/contextual |
Critical–Experiential | Demonstrates self-awareness, critical thinking, and contextualised understanding of diversity. | Environmental Control, Communication, Time | Advanced/reflective |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Lesińska-Sawicka, M.; Roszak, A. Understanding Diversity: The Cultural Knowledge Profile of Nurses Prior to Transcultural Education in Light of a Triangulated Study Based on the Giger and Davidhizar Model. Healthcare 2025, 13, 1907. https://doi.org/10.3390/healthcare13151907
Lesińska-Sawicka M, Roszak A. Understanding Diversity: The Cultural Knowledge Profile of Nurses Prior to Transcultural Education in Light of a Triangulated Study Based on the Giger and Davidhizar Model. Healthcare. 2025; 13(15):1907. https://doi.org/10.3390/healthcare13151907
Chicago/Turabian StyleLesińska-Sawicka, Małgorzata, and Alina Roszak. 2025. "Understanding Diversity: The Cultural Knowledge Profile of Nurses Prior to Transcultural Education in Light of a Triangulated Study Based on the Giger and Davidhizar Model" Healthcare 13, no. 15: 1907. https://doi.org/10.3390/healthcare13151907
APA StyleLesińska-Sawicka, M., & Roszak, A. (2025). Understanding Diversity: The Cultural Knowledge Profile of Nurses Prior to Transcultural Education in Light of a Triangulated Study Based on the Giger and Davidhizar Model. Healthcare, 13(15), 1907. https://doi.org/10.3390/healthcare13151907