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Culture Shifts: From Cultural to Structural Theorizing in Nursing

Drevdahl, Denise, J.

doi: 10.1097/NNR.0000000000000262

Background As a discipline, nursing emphasizes the importance of culture to care. Cultural competence is seen in nursing practice, education, and research as essential for addressing health disparities—particularly racial and ethnic disparities. There now is broad consensus that the causes for health disparities lie beyond the individual and are found in the structures of society. Current cultural competency theories and conceptual models, however, focus on the individual and do little to address the social/structural determinants of health.

Approach Reviewing the literature on cultural competency, current theorizing on culture and healthcare in nursing, and critiques of this theorizing is summarized. Emerging models that highlight the structural features of society influencing health are described.

Key Points Cultural competency theorizing has been embraced in nursing, but its effectiveness in reducing health disparities has yet to be demonstrated. A shift in how the discipline addresses health disparities is needed. New theoretical approaches, such as fundamental causes theory, the health impact pyramid, ecological models, and structural competency, emphasize larger social determinants of health and should be more fully utilized in nursing.

Implications Nurse theorists need to clarify the usefulness of the emerging theories to the discipline, nurse educators should incorporate structural theories and concepts into curricula, practicing nurses will want to include structural screening assessment tools in their provision of care, and nurse researchers will need to develop skills in conducting and measuring the impacts of structural interventions.

Denise J. Drevdahl, RN, PhD, is Professor, Nursing Program, University of Washington Tacoma.

Accepted for publication June 22, 2017.

The author would like to thank Mary K. Canales, Shawn M. Kneipp, the anonymous reviewers, and the Editor for their thoughtful comments.

The paper was accepted under the Editorship of Susan J. Henly.

The author has no conflicts of interest to report.

Corresponding author: Denise J. Drevdahl, RN, PhD, University of Washington Tacoma, Nursing Program, 1900 Commerce Street, Campus Box 358421, Tacoma, WA 98402 (e-mail:

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