2.4: Culturally Competent Care
By the end of this section, you will be able to:
- Discuss transcultural nursing and culturally competent care
- Describe a cultural assessment
Nurses are aware of cultural differences and are interested in making patients feel supported and safe. Culturally competent health-care providers take time to assess the person’s spiritual, emotional, and cultural needs and integrate them into the plan of care. The Cultural Care Theory, the Transcultural Assessment Model, and the Four Cs of Cultural Assessment guide nurses in determining interventions that value traditions and allow the person to trust the health-care system.
Transcultural Nursing
As you have learned, cultural competence is a lifelong process of applying evidence-based nursing while respecting the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes. Culturally competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their patients’ cultural beliefs. Cultural competence takes motivation, time, and practice to develop and evolves throughout the nursing career. Culturally competent nurses have the power to improve the quality of care, leading to better health outcomes for culturally diverse patients.
The theoretical roots of culturally competent care are found in the original transcultural nursing concept developed by Dr. Madeleine Leininger, a nurse and anthropologist (Leininger, 1988). The concept of transcultural nursing incorporates cultural beliefs and practices of people to help them maintain and regain health or to face death in a meaningful way. This theory forms the basis of all culturally competent care.
Dr. Leininger developed the Culture Care Theory , which states that health care cannot be effectively provided without considering the person's cultural background (Leininger, 1988). The theory emphasizes the importance of understanding the people's cultural values, beliefs, and practices to provide appropriate care. According to Leininger, culture is a fundamental component of human life and influences a person’s perception of health, illness, and health care. Therefore, health-care providers must approach each person with cultural sensitivity and strive to deliver care that is respectful and tailored to the person's cultural needs. Culture Care Theory is an important framework for promoting culturally competent care and achieving health equity for all people.
The Transcultural Assessment Model
Giger and Davidhizar (2002) developed the Transcultural Assessment Model as a way for nurses to assess and provide care for culturally diverse people. According to this model, each person is unique. Assessment should consider the following six cultural phenomena: communication, personal space, social organization, time orientation, environmental control, and biological variations.
- Communication. This includes the language, tone, and nonverbal cues used by the person and the health-care provider. Communication styles vary across cultures and can impact the effectiveness of health-care interactions.
- Personal space. All communication occurs in the context of space. There are four distinct zones of interpersonal space: intimate, personal, social and consultative, and public (Hall, 1966) (Figure 2.3.) This includes the physical and emotional distance between the person and the health-care provider. Cultural norms around personal space and touch vary across cultures.
- Social organization. This includes the person's cultural values and beliefs related to family, community, and social roles. Cultural expectations around family involvement in health-care decisions, for example, vary across cultures.
- Time orientation. Time is an important aspect of interpersonal communication. This includes the person's cultural beliefs and practices related to time, such as punctuality and the perception of time as linear or cyclical.
- Environmental control. This includes the person's cultural beliefs and practices related to controlling their environment, such as beliefs about the causes of illness and the use of traditional healing practices.
- Biological variations. These include the person's cultural beliefs and practices related to biology, such as beliefs about the causes of illness and the use of alternative therapies. Cultural beliefs regarding pain management and the use of medication can also vary across cultures.
Patients and Personal Space
The amount of space that a person surrounds themselves with to feel comfortable is influenced by culture. For example, for some people, it would feel awkward to stand 4 inches away from another person while holding a social conversation, but for others, a small personal space is expected. There are times when a nurse must enter a person’s personal space, which can cause emotional distress for some people. The nurse should always ask for permission before entering a personal space and explain why and what is about to happen.
Patients may also be concerned about their modesty or being exposed. A person may deal with the violation of their space by removing themselves from the situation, pulling away, or closing their eyes. The nurse should recognize these cues as an expression of cultural preference and allow the person to assume a position or distance that is comfortable for them.
Like cultural influences on personal space, touch is also culturally determined. This has implications for nurses because it may be culturally inappropriate for a male nurse to provide care for a female patient and vice versa. In some cultures, it is also considered rude to touch a person’s head without permission.
Cultural Traditions Surrounding Nutrition
In some cultures , certain food is classified as taboo. For example, in Indonesia, persons who are pregnant and breast-feeding are prohibited from eating certain fruits, meat, and fish; soda, coconut water, and cold beverages are also considered taboo (Tobing et al., 2019). People in rural Zulu communities also consider certain fruits taboo, and consuming sweets, ice, and alcohol may be prohibited; for postpartum recovery, their culture recommends soft porridge, all fruits and vegetables, beetroot, and tea (Ramulondi et al., 2021). In areas of Asia, after birth, people can eat rice, but meat is taboo until after 2 months postpartum; however, persons in areas of food insecurity are allowed to eat some taboo foods earlier than 2 months postpartum (Smith et al., 2021). Many cultures recommend postpartum foods that consist of easy-to-digest, high in protein and fats, warm cooked, brothy foods (soups and stews) that are nourishing and hydrating.
During menopause, many people in South Asia eat mostly plant-based diets and experience fewer hot flashes, night sweats, and changes due to lack of estrogen (Vohra, 2021). Some Spanish women eat a Mediterranean diet featuring olive oil, fruits, fish, white meats, and alcohol. Their low consumption of sugars and processed meats is associated with less menstrual pain, shorter cycles, and less bleeding (Onieva-Zafra et al., 2020). A Malaysian belief is that only rice and cassava root should be eaten during menstruation due to fear of bad health or bad luck. In some areas of India, menstruating persons cannot eat sour foods like curds, tamarind, or pickles in fear they will disturb or stop their menstrual flow (Syed Abdullah, 2022).
Cultural Nursing Assessment
Nurses providing culturally competent care integrate the patient’s cultural beliefs into their health care by showing respect and creating an environment that is culturally sensitive. The following interventions support culturally sensitive care:
- Introduce yourself by name and role when entering the room and initially meeting the person and their family. Acknowledge any family members or visitors. Address the person using their title and last name. Ask how they wish to be addressed and what their preferred pronouns are and document those preferences in the record.
- Stand at least an arm’s length from the patient.
- Observe how the person and family members communicate nonverbally, such as by eye contact, spacing, touch, and other behaviors, to determine the level of nonverbal communication to follow.
- If English is not the patient’s primary language, document their preferred language in the record and note if a medical interpreter is needed.
- Politely ask questions about their culture and beliefs to minimize or avoid misunderstandings.
- Ask if any limitations exist on who can care for a patient. For example, many patients who are Muslim will prefer a same-gender care provider (Attum et al., 2023).
- Show respect for the patient’s cultural beliefs and values. Integrate their cultural beliefs into nursing care as much as possible.
- Reassure the patient that providing culturally competent care is a priority for all health-care workers.
After establishing a culturally sensitive environment, nurses should incorporate a cultural assessment when caring for all patients. Many assessment guides used for patient interviews are adaptable to a variety of health-care settings and are designed to facilitate understanding and communication.
The Four Cs of Culture model is an example of a quick cultural assessment tool that asks questions about what the patient C onsiders to be a problem, the C ause of the problem, how they are C oping with the problem, and how C oncerned they are about the problem.
1. What do you think is wrong? What is worrying you? (In other words, discover what the patient C onsiders to be the problem and what they call it.)
2. What do you think C aused this problem? How did this happen?
3. What are you doing to C ope with this problem? How are you taking care of yourself?
4. How serious is this problem for you? How C oncerned are you?
Using “The Four Cs of Culture” to Perform a Cultural Assessment
Scenario: The nurse enters the person’s room to perform a cultural assessment. The person is from China but just moved to the area to live with family. Their preferred language is Mandarin. The nurse sets up the video translator to begin the conversation and allows the translator to introduce themselves to the patient.
Dialogue:
Nurse: Hi, I’m Travis, and I’m going to be your nurse today. Can you please tell me your name and date of birth?
Patient: Mei Wang, January 2, 1947.
Nurse: What would you like me to call you?
Patient: Mrs. Wang is fine.
Nurse: Mrs. Wang, I’m here to do a cultural assessment, which involves asking you a few questions. It should take less than 15 minutes. Is that okay?
Patient: Yes, that is fine.
Nurse: What do you think is wrong? What is worrying you?
Patient: The doctors are telling me that I need a hysterectomy because of fibroids. I know this happened because my body is not in balance.
Nurse: What do you think caused this problem? How did this happen?
Patient: My husband died 4 months ago, and I left China to live with my son and his family here in the United States. I miss my husband, and everything here is so different compared to what I’m used to.
Nurse: Have you been trying things at home to make yourself feel better? How have you been coping?
Patient: I’ve been making some special food. A lot of soup and other foods with ginger, onion, garlic to help with the abdominal pain.
Nurse: How serious is this problem for you? How concerned are you?
Patient: I’ve never been in the hospital before, so I’m worried, but I think the doctors are good and will get me home. I want to make sure that my family can bring me food from home, though. I don’t like the hospital food. My food from home is much better for me.
Nurse: I’ll check with your doctor to see if your family can bring your food from home; I’ll tell them how much better you like it, okay? My assessment is done for now. Do you have any other questions for me?
Patient: Not right now. Thank you for talking to me.