Storytelling and Citizen Science for Transcultural Critical Care Nursing: The C4 Framework

Critical Care Context

Critical care environments represent a unique convergence of high stakes and high diversity. Patients admitted to intensive care units (ICUs) or high-dependency units (HDUs) are typically in life-threatening conditions that require continuous monitoring, complex interventions, and rapid decision-making. In such high-stakes environments, cultural and linguistic barriers can critically compromise informed consent, patient–family communication, treatment adherence, and equity in health outcomes. Consequently, transcultural competence is not an optional attribute but an essential dimension of advanced critical care nursing, directly linked to patient safety, ethical practice, and quality of care (Jeffreys, 2021).

Theoretical Domain (C4 Integration Pathway)

Theoretical models of transcultural nursing provide an essential scaffolding for this competence. Leininger’s (1991) theory of Culture Care Diversity and Universality established the principle that culturally congruent care is indispensable to patient well-being. Campinha-Bacote’s (2018) model further conceptualized cultural competence as a dynamic process integrating cultural awareness, knowledge, skills, encounters, and desire. While these frameworks remain central to transcultural nursing, their integration into postgraduate nursing education, particularly within critical care, has often been limited or superficial. Although applicable to a range of complex care settings, the C4 Framework was conceived as a pedagogical intervention within a master’s-level critical care nursing curriculum in Portugal. Its design reflects the specific challenges of teaching transcultural competence in high-acuity clinical domains, where ethical complexity, technological intensity, and cultural diversity intersect. The framework therefore responds primarily to educational gaps in advanced nursing preparation, even as it offers conceptual resources that may inform future applications in clinical practice and research.

Traditional pedagogical approaches, frequently didactic in nature, struggle to bridge the gap between abstract theory and the complexities of advanced critical care nursing practice. This educational gap undermines the preparation of nurses for culturally diverse critical care environments (Salah et al., 2018).

Expanding the Concept of Competence

Recent scholarly debates within transcultural nursing and global health ethics urge a paradigm shift from competence toward humility, safety, and structural awareness. Cultural humility emphasizes critical self-reflection, relational openness, and lifelong learning to counteract power imbalances (Foronda, 2020; Foronda et al., 2016). Cultural safety, originating in Aotearoa, New Zealand, requires attentiveness to systemic inequities and accountability to patients and communities (Curtis et al., 2019; Ramsden, 2002). Structural competency underscores the capacity of health professionals to recognize and respond to the structural determinants of health (Metzl & Hansen, 2014; Neff et al., 2023). Recent theoretical contributions, particularly Foronda’s (2020) theory of cultural humility, position these perspectives within a justice-oriented frame. Together, these evolving perspectives advance transcultural nursing toward participatory, justice-oriented, and reflexive approaches that move beyond static notions of competence. Participatory co-creation, drawing on principles of citizen science, operationalizes cultural care accommodation and negotiation by positioning migrant communities not as passive informants but as active co-designers of curricula.

Global and National Policy Context

Policy frameworks reinforce this evolution. The United Nations’ Sustainable Development Goals (SDG 3: Good Health and Well-being; SDG 10: Reduced Inequalities), the WHO Global Strategic Directions for Nursing and Midwifery 2021–2025 (World Health Organization [WHO], 2021), and the International Council of Nurses’ (ICN) advocacy for culturally safe practice (ICN, 2021) all emphasize equity and inclusivity as priorities for the profession. In Portugal, the National Health Plan 2021–2030 (Direção-Geral da Saúde [DGS], 2021), together with national policies supporting migrant integration and intercultural inclusion, converges with the competencies defined by the Portuguese Order of Nurses to position cultural responsiveness as both a professional obligation and an ethical responsibility.

Aim and Rationale of the Framework

Addressing this gap requires innovative pedagogical strategies that move beyond passive learning to foster active engagement, reflection, and co-creation. This article introduces the Co-Creation for Cultural Competence (C4) Framework, a conceptual model for postgraduate critical care nursing education. The framework integrates storytelling, citizen science, and critical reflection, approaches rarely combined in this field, as supported by recent reviews highlighting the limited integration of participatory, narrative, and reflective pedagogies within nursing education (C. H. Liu et al., 2023). By embedding lived experience directly into curricula, the C4 Framework advances transcultural nursing in novel ways, equipping advanced practice nurses to deliver culturally responsive care and contributing to health equity, safety, and excellence in global health care delivery. This conceptual article did not involve human participants or the use of identifiable data; ethics approval and informed consent were therefore not required.

Conceptual Framework

The proposed framework for transcultural nursing education in critical care is grounded in the seminal models of Madeleine Leininger’s (1991) theory of Culture Care Diversity and Universality and Campinha-Bacote’s (2018) Process of Cultural Competence in the Delivery of Healthcare Services. Leininger’s theory emphasizes that culturally congruent care is indispensable for well-being and identifies three modes of action: (a) cultural care preservation/maintenance, (b) cultural care accommodation/negotiation, and (c) cultural care repatterning/restructuring, through which nurses can safeguard beneficial practices, promote shared decision-making, and transform care patterns that may otherwise perpetuate inequities. Campinha-Bacote’s model complements this foundation by framing cultural competence as a dynamic, ongoing process that integrates five interdependent domains: (a) cultural awareness, (b) cultural knowledge, (c) cultural skills, (d) cultural encounters, and (e) cultural desire. These interdependent concepts constitute the theoretical foundation of the framework, ensuring both its conceptual coherence and practical applicability. Together, these theoretical models provide both an epistemological foundation and a practical orientation for preparing postgraduate nurses to deliver equitable and responsive care in high-acuity environments. In high-acuity critical care, the translation of transcultural theory into practice is constrained by clinical urgency, technological intensity, and time pressure, which limit opportunities for relational engagement. The C4 Framework addresses these constraints by providing pedagogical pathways that enable culturally congruent care under conditions of rapid escalation and uncertainty. Within this framework, citizen science is conceptualized as the structured participation of migrant communities as active partners in curriculum co-production rather than as passive research subjects.

The resulting C4 Framework, integrating these theoretical and pedagogical dimensions, is illustrated in Figure 1. This conceptual model visually aligns Leininger’s modes of care and Campinha-Bacote’s domains of competence with the three pedagogical strategies described below.

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Figure 1.

The co-creation model for cultural competence (C4) Framework.

From Theoretical Foundations to Pedagogical Praxis

The integrative strength of the framework lies in situating storytelling, participatory co-creation, and critical reflection within Leininger’s modes of care and Campinha-Bacote’s domains of competence. This design ensures that postgraduate critical care nursing students are not only exposed to theoretical constructs but are also given structured opportunities to embed them in practice. The approach is supported by evidence from nursing education demonstrating that theory-guided and concept-based curricula enhance the integration of theory and practice, foster professional identity, and improve clinical reasoning in complex care settings (Giddens et al., 2015). In critical care specifically, competency-based educational models such as the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care illustrate how aligning educational strategies with patient and nurse characteristics contributes to improved outcomes (AACN, 2016).

Table 1 summarizes the alignment of Leininger’s and Campinha-Bacote’s theoretical domains with the pedagogical components of the C4 Framework, illustrating how storytelling, participatory co-creation, and structured reflection translate transcultural theory into postgraduate critical care education.

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Table 1.

Mapping of Theoretical Domains to Pedagogical Strategies and Learning Outcomes in the C4 Framework.

Theoretical foundation	Leininger’s Culture Care Theory	Campinha-Bacote’s cultural competence model	Pedagogical strategy in the C4 Framework	Primary learning focus/outcome
Cultural Care Preservation/Maintenance	Safeguarding beneficial cultural practices; honoring patient values and beliefs	Cultural Awareness and Cultural Desire, recognizing personal biases and fostering motivation to engage with diversity	Storytelling and Narrative Pedagogy	Development of empathy, self-reflection, and understanding of diverse worldviews; strengthening culturally responsive communication
Cultural Care Accommodation/Negotiation	Promoting shared decision-making and mutual adaptation between nurses and patients	Cultural Knowledge, Skills, and Encounters, applying theory to real interactions	Participatory Co-creation/Citizen Science	Experiential learning through collaboration with migrant communities; co-design of curricula grounded in lived experience; enhanced dialogical competence
Cultural Care Repatterning/Restructuring	Transforming care patterns that may perpetuate inequities	Integration of all five domains into reflective praxis	Structured Critical Reflection	Recognition and redress of systemic inequities; development of ethical judgment, reflexivity, and structural awareness
Cross-cutting Dimensions	Alignment with transcultural ethics and emancipatory education	Continuous dynamic process of competence development	Integration of Storytelling, Co-creation, and Reflection	Formation of culturally safe, equitable, and critically aware advanced practitioners

Note. Table 1 complements Figure 1 by operationalizing the C4 (Co-Creation for Cultural Competence) Framework. It aligns the three pedagogical strategies, storytelling, participatory co-creation, and structured critical reflection, with Leininger’s modes of cultural care and Campinha-Bacote’s domains of cultural competence. The table illustrates how each strategy translates transcultural theory into specific learning outcomes for postgraduate critical care nursing, emphasizing co-creation, reflexivity, and equity as foundations of culturally safe practice.

Implementation Considerations

Implementing the C4 Framework in master’s-level critical care curricula requires deliberate planning across logistical, ethical, and evaluative domains. Attending to these conditions enhances feasibility and credibility, strengthening the framework’s status as a pioneering contribution to transcultural nursing education consistent with competency-based expectations in graduate programs (American Association of Colleges of Nursing, 2026).

Implications for Nursing Education

The United Nations’ Sustainable Development Goals (SDG 3: Good Health and Well-being; SDG 10: Reduced Inequalities) and the International Council of Nurses emphasize preparing a workforce capable of delivering culturally safe, equitable care (ICN, 2021; United Nations, 2015). The C4 Framework operationalizes these priorities through participatory pedagogy that moves beyond knowledge transmission toward co-creation with communities. In master’s-level programs, curated storytelling and structured reflection strengthen empathy, professional identity, and clinical reasoning (C. H. Liu et al., 2023; Moreau et al., 2018), while concept-based, theory-guided design improves transfer to complex settings (Giddens et al., 2015). Aligned with competency-based expectations (American Association of Colleges of Nursing, 2026), the framework supports the Portuguese Order of Nurses’ emphasis on advanced competencies, ethical practice, and responsiveness to population needs.

Implications for Advanced Nursing Practice

Critical care requires rapid, ethically complex decisions under conditions of acuity and diversity. Embedding lived experience into training equips advanced practice nurses to negotiate meaning, adapt interventions, and steward culturally congruent communication in high-stakes encounters. Competency-focused approaches link nurse/patient characteristics with outcomes and offer a structure for ICU-relevant capability building (AACN, 2016). Evidence from critical care education underscores the value of communication training and reflective debriefing for improving team performance and family conferences; systematic use of professional interpreters and equity-sensitive indicators further supports safe, inclusive care (Mendez et al., 2020; Office of Minority Health, U.S. Department of Health and Human Services, 2013).

Implications for Health Policy

The C4 Framework aligns with European and Portuguese policy agendas prioritizing equity, participation, and migrant integration, including the National Health Plan 2030 (DGS, 2021). By institutionalizing citizen participation within postgraduate curricula, it offers a practical pathway for policy translation, strengthening trust, legitimacy, and cultural responsiveness across services. The framework further aligns with ICN’s call for nurses as leaders of health-system transformation and with WHO guidance on community engagement, reinforcing nurses’ capacity to shape organizational and intersectoral change. In the Portuguese context, integrating the C4 Framework into advanced nursing education provides a concrete mechanism to operationalize national policy goals by embedding participatory governance and cultural responsiveness within postgraduate training.

Implications for Research and Knowledge Development

As a pioneering integration of citizen science within nursing education, the C4 Framework establishes a programmatic research agenda. Mixed-methods designs can assess effects on learner outcomes (e.g., IAPCC-R/IAPCC-HCP; TSET), simulation performance, and ICU process indicators; implementation studies can examine fidelity, feasibility, and sustainability; and comparative longitudinal research can test transferability across institutional and cultural contexts. Emerging evidence supports reciprocal benefits of citizen-science approaches in nursing and the development of structured models for education and practice (Torró-Pons et al., 2024), collectively strengthening the evidence base for participatory and emancipatory pedagogies in advanced clinical training. Beyond empirical evaluation, the framework’s originality lies in its epistemological reorientation. Whereas storytelling, citizen participation, and critical reflection have typically functioned as adjunct methods in nursing education, their integration within Leininger’s modes of care and Campinha-Bacote’s processual domains reconceptualizes cultural competence as a collective, dialogical construction of meaning. This methodological shift strengthens transcultural nursing’s capacity to engage with structural inequities and cultural complexity in high-acuity contexts, positioning the framework as a distinctive theoretical contribution rather than a pedagogical variation.

Theoretical Implications

The C4 Framework advances transcultural nursing theory by moving beyond the predominantly descriptive or assessment-oriented application of Leininger’s Culture Care Theory and Campinha-Bacote’s model. By embedding these theoretical foundations within participatory and narrative pedagogies, it reconceptualizes cultural competence as a dialogical, relational, and co-produced process rather than a static set of individual attributes. This epistemological shift reorients the field from a focus on what nurses should know about others toward how knowledge is co-created with communities, extending transcultural nursing from cultural adaptation to cultural co-production. In doing so, the framework strengthens the discipline’s capacity to engage with global health inequities and structurally embedded forms of exclusion in high-acuity care contexts.