This paper examines the importance of cultural competence in nursing and healthcare settings, with a particular focus on elderly Americans in nursing and old-age homes. Drawing on Jean Watson's theory of caring relationships, the Purnell Model for Cultural Competence, and the American Academy of Nursing Expert Panel's twelve standards of culturally competent practice, the paper evaluates how well nursing homes currently meet each standard. It also highlights the growing demographic challenge posed by America's aging population, the nutritional and social risks facing the elderly, and the consequences — both positive and negative — of culturally sensitive or insensitive care environments.
The paper demonstrates applied framework analysis: it takes established theoretical models (Watson's theory, the Purnell Model, and the AAN Expert Panel standards) and systematically evaluates how well current nursing-home practice meets each criterion. This technique shows how to move from abstract theory to practical assessment, making it a useful model for nursing and health-studies students writing policy or practice-focused papers.
The paper opens with a theoretical grounding in Watson's humanistic nursing philosophy before pivoting to demographic data on the aging U.S. population to establish stakes. It then introduces the Purnell Model as the central evaluative framework, followed by the longest section — a numbered, criterion-by-criterion assessment of the twelve AAN standards as applied to old-age homes. The paper closes by describing the observable outcomes of culturally competent (or incompetent) care and reconnects to Watson's concept of the "caring moment."
Basic knowledge in nursing or medical studies is not sufficient on its own. As Watson argues, there is a need to instill the humanistic aspect into the profession. Watson believes that a nurse must establish a caring relationship with patients, display unconditional acceptance of the patient regardless of their condition, treat patients as holistic beings, treat patients with positive regard, and promote health through knowledge and intervention. She also emphasizes the importance of spending uninterrupted time with patients — moments she calls "caring moments" (Vanguard Health Systems, 2011).
In order to effectively achieve and implement the ideas in Watson's theory of culturally competent care, it is important to critically examine the cultural diversity among the aging American population. Cultural diversity among the elderly is considered to be one of the biggest challenges — alongside nutrition — that older people face. According to the American Speech-Language Hearing Association (ASHA) (2011), culture shock will not only affect the lifestyle of the elderly but will also affect the dining habits of those affected. This issue touches both nursing-home comfort and the nutrition of elderly people. There is therefore a need for a high level of interpersonal communication skills to enable effective transcultural interaction with the aging population.
The elderly can be effectively considered a vulnerable group for several reasons. In 2008, there were 39 million people aged 65 and above in America, accounting for slightly over 13% of the population. It is estimated that by 2030, there will be around 72 million Americans in this age group — the point at which all baby boomers will have reached age 65 or older. This will represent a significant 20% of the entire American population. However, a longer life for this generation does not come easily or cheaply. Inflation and rising annual healthcare costs make it increasingly difficult for senior citizens to maintain a robust lifestyle. It is estimated that in 1992, the annual healthcare cost per elderly person was $9,224; this rose to $15,081 by 2006, and this trend is projected to continue rising each year (National Institute of Aging, 2008). This sizable and marginalized population deserves issues affecting them to be addressed immediately and effectively.
The two predominant issues facing aging Americans today are poor nutrition — and the resulting health conditions — and inadequate home care facilities that are not culturally sensitive. Regarding poor nutrition, heart disease remains the highest cause of death among the elderly and is even more serious among the very frail and old. One of the major known contributing factors is the type of nutrition to which elderly people are subjected. The Federal Interagency Forum on Aging-Related Statistics (2010, p. 17) indicates that the number of elderly people suffering from obesity has been increasing every year since 1988, and from 2000 onward has leveled off rather than declining.
Regarding cultural incompetence within nursing homes — and within the wider American population — most Americans are too busy to spare time for the elderly. Preoccupied by career and financial pursuits, they seek care homes where their elderly relatives can retire with dignity and live comfortably after their active years. Unfortunately, for the majority of Americans, this turns out to be ironic: their elderly relatives do not end up in the comfort or care they anticipated. The elderly are often placed in the hands of culturally incompetent nurses who mistreat them with little or no regard for their cultural backgrounds and needs. There is a pervasive assumption that one approach to elderly care fits all. No attention is given to race, previous place of residence, social background, psychological disposition, or the many other factors that constitute culturally competent nursing care.
One of the most renowned models for cultural competence is the Purnell Model for Cultural Competence. It is one of the most comprehensive models available, covering the global society, the community, the family, and the individual. It also explains various cultural domains — twelve in total — which do not stand alone but apply in tandem when caring for patients, including the elderly. The model also incorporates ideas drawn from administrative, organizational, family development, and communication theories. The twelve domains are: heritage; family roles and organization; communication; workforce issues; biocultural ecology; high-risk behaviors; pregnancy and childbearing practices; death rituals; spirituality; healthcare practices; and healthcare practitioners (Larry Purnell, 2005).
Given the breadth and diversity it encompasses, the Purnell Model is well suited to the care of frail and elderly Americans who require a comprehensive care system in order to live happy lives in care homes or in their own residences. It is worth noting, however, that these cultural standards exist within economic, political, and social systems. As a result, various health organizations hold different definitions of culturally competent care for their patients. Nevertheless, certain baseline considerations cut across most cultures. These are the focus here, in line with both the Purnell Model and the twelve standards outlined by the American Academy of Nursing Expert Panel (2009), which present interlaced standards of culturally competent practice.
1. Social Justice: Professional nurses are required to promote social justice for all, and leadership skills are to be developed by nurses to advocate for socially just practices. This tenet of cultural competence has been widely met within care homes for the elderly, giving patients the sense that their rights are respected and their social well-being is considered. This adherence can in large part be attributed to the legislation that has accompanied the establishment of such old-age homes over time.
2. Critical Reflection: This standard requires nurses to critically reflect on their personal beliefs, values, and cultural assumptions so that they can identify how these affect the culturally congruent nursing care they provide. This standard is rarely met within old-age homes. Nurses there often hold deeply ingrained values and beliefs that they are unable to set aside within the short timeframes of their interactions. This negatively impacts elderly residents, who feel their own values are undermined when those of the nurse appear to override them.
3. Transcultural Nursing Knowledge: Nurses are required to have a broad understanding of the traditions, values, practices, and heritage of varying populations, societies, and communities. This knowledge is intended to enable the provision of culturally competent care for patients from diverse backgrounds. This remains a challenging standard for many nurses in old-age homes, leaving elderly residents feeling that their traditions, beliefs, and cultural identities are neglected or looked down upon.
4. Cross-Cultural Practice: This standard requires nurses to apply their cross-cultural knowledge in order to deliver culturally competent care. It has yet to be fully met within old-age homes, partly because the sheer diversity of cultural backgrounds makes it challenging to know which practices are acceptable within each community. An additional complication is that cultural practices may change as a person ages, making it difficult to identify which practices remain consistent over time and which evolve.
5. Healthcare Systems and Organization: Organizations must provide the resources and structures that enable nurses to meet and evaluate the cultural needs of their patients. Within old-age homes, this standard has been widely met, acquainting much of the nursing workforce with the needs of the patients in their care.
The Federal Interagency Forum on Aging-Related Statistics. (2010). Older Americans 2010: Key indicators of well-being. Retrieved July 6, 2013, from
Vanguard Health Systems. (2011). Overview of Jean Watson's theory. Retrieved July 6, 2013, from
WHO Regional Office for South-East Asia. (2006). Promoting the application of research findings in health development. Retrieved July 6, 2013, from http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344/Section1350_5241.htm
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