All high-income developed nation states have increasingly diverse populations and this phenomenon will become more evident in the 21st
century. Migration to high-income developed nation states is driven by a number of factors including poverty, war with the transgression of human rights, and the consequences of colonialism. Most frequently however within the Canadian context, migration is driven by the country's self-interest and a proactive policy on high immigration, which strives to attract highly skilled immigrants within its goal of admitting 1% of its population of 33 million in each year [1
]. In 2009, Canada admitted 252, 179 permanent residents, with China, the Philippines and India being the top three source countries [2
]. Typically, 25% of immigrants fall into family-class; 65% economic-class; and, the remainder are refugees (5%) and "other", a class reserved for applicants who would not fall into the other categories and for whom there are strong humanitarian imperatives [3
It is therefore axiomatic that nurses in these nations care for diverse ethno-cultural groups and that this may present challenges in respect of nursing care delivery. There is a substantial evidence base in relation to the education and training of nurses (ie. curricula development), and the experiences of patients and clients in relation to reception, or lack thereof, of ethno-culturally appropriate nursing care. However, little attention has been paid to actual ethno-cultural nursing assessment tools and models of transcultural nursing and their empirical underpinnings.
Cultural assessment tools and models of transcultural nursing
Our request from the health care unit called for the identification of a cultural assessment tool; however, within nursing knowledge and theory this type of assessment tool is more commonly referred to as a model of transcultural nursing. Within other disciplines especially the social sciences and mental health fields there are a broad range of theoretical and conceptual frameworks such as those listed in Table and summarized by Collins and Guruge [12
]. While these frameworks have not tended to underpin specific care assessment or delivery tools used in clinical nursing practice, they may assist nurses and health care practitioners in understanding the "social positioning" of the diverse ethno-cultural groups for whom they endeavour to deliver high quality care.
Additional perspectives and frameworks underpinning cultural models of care.
A seminal theorist Leininger [13
], has defined transcultural nursing as "the humanistic and scientific area of formal study and practice in nursing which is focused on differences and similarities among cultures with respect to human care, health, and illness based on people's cultural values, beliefs, and practices, and to use this knowledge to give culturally specific or culturally congruent nursing care to people" [p.60]. Through her work on the Culture Care Diversity and Universality Theory, she developed the Sunrise Model which has been implemented for over 30 years by nurses worldwide for use with various cultural groups [14
]. Cultural assessment models and tools are merely vehicles that enable nurses to deliver effective transcultural nursing care. However, in recent decades nursing scholars and scientists have extensively critiqued the concept of transcultural nursing. Culley [15
] argues that cultural difference, with a large focus on communication difficulties, has been conceptualized in nursing discourse using a culturalist framework thus tending to ignore some aspects of the issues of race, ethnicity and health. She criticizes Leininger's model for its assumption that care and services will be improved by knowledge of different cultures. There is a need to recognize "the very complex ways in which race, socio-economic status, gender and age may intersect."
], p.568] The structural and political aspects within inequality of minority ethnic people are not given primacy within this culturalist approach; moreover, the approach tends to promote culture in a negative manner with potential contribution towards stereotypical attitudes and propagating power unbalances [16
]. Serrant-Green [17
] provides more reflection on the criticism of Leininger's work as minimizing the roles of racism and social inequality in the health status of minority ethnic groups. She further recommends that nursing education stress the diversity within all ethnic communities.
The term cultural competence may be used to describe the capacity of both individual practitioners and health care provision organizations to effectively meet the needs of patients from diverse social, cultural and linguistic backgrounds [18
]. EXTTR Cultural competence is informed by a thorough and in-depth understanding of the factors that configure and shape health experiences of diverse ethno-cultural groups and consequentially demands more than a focus on culture, such that:
• Cultural competence refers to whole systems of care in addition to individual practitioners;
• Cultural competence is must be of concern to every level of staff in a health care organization
• Effective communication is a fundamental dimension;
• Cultural knowledge is significant however, alone maybe insufficient;
• The wider socio-economic and political of the lived experience are as significant as the ethno-cultural orientation
• Cultural awareness and self-reflection are important components; and,
• Sensitivity, cultural humility e.g. the desire to find out more and innovation are key components of service configuration [18
Cultural competence also includes aspects such as good knowledge of communites, strong leadership, innovative and fexible environments and continous good training and support [18
A number of different definitions of cultural competence have been offered and several different models have been suggested, in attempts to identify the key components of culturally competent care and ways in which practitioners and organisations can enhance their performance in this area [19
]. Salway et al [[18
] p.9] pertinently summarize the key dimensions and definitions of cultural competence below; these can be assessed and developed at the level of the individual, team, service, organisation or wider healthcare system:
• "Knowledge about diversity in beliefs, practices, values and world views both within and between groups and communities, thus recognition of similarities and differences across individuals and groups and of the dynamic and complex nature of social identities (sometimes called Cultural Knowledge);
• Acceptance of the legitimacy of cultural, social and religious differences, and valuing and celebrating diversity (sometimes called Cultural Awareness);
• Awareness of one's own identity, beliefs, values, social position, life experiences and so on and their implications for the provision of care (sometimes called Cultural Awareness or Reflexivity);
• Understanding of power differentials and the need to empower service users (sometimes considered part of Cultural Awareness);
• Ability to empathise, show respect and engender trust in service users (sometimes called Cultural Sensitivity);
• Recognition of social, economic and political inequality and discrimination and how this shapes healthcare experiences and outcomes for minority groups;
• Effective communication with appropriate provision and effective use of resources for cross-lingual and cross-cultural communication; and,
• Resourcefulness and creativity to resolve issues arising during the provision of care across difference".
There is evidence that achieving high-quality care and positive health outcomes is heavily dependent on effective communication between patients and care givers [20
]. Communicating effectively and appropriately across language, religious or cultural difference can be challenging with many possibilities for misunderstanding, perceived offence and disempowerment. Inter-cultural communication competence has therefore been identified as an important element in cultural competence [20
]. Achieving such communication competence requires more than speaking the same language, or making provision for interpretation. It requires detailed understanding of and sensitivity to the patient's social and cultural context, attention to power dynamics, awareness of non-verbal cues, and provision of appropriate physical surroundings, empathy and patience. At the organisational level, inter-cultural communication competence must be supported by adequate resources, appropriate staff training (including working with interpreters), and detailed understanding of the linguistic needs of the target populations.
From Leininger's seminal work, other cultural assessment models and tools have been developed to aid nurses in their planning of health care decisions and actions in treating patients from diverse cultures [examples in references [18
]]. Despite this, it is not clearly evident if or how these have been evaluated for their use in clinical environments and if they strive to acknowledge a more multiculturalist view recognizing diversity within all ethnic communities. Furthermore, the complexity of some models may limit their pragmatic use in the care environment.