4.6: The Significance of Cultural Competence

It is essential for nurses to be able to offer appropriate holistic care to patients from different cultures and to know how the trans-cultural approach is to be put into practice, as it provides guidance on how to behave in the case of these situations.

Transcultural nursing is sensitive to the needs of families, groups and individuals who are representatives of groups with different cultures in a community or society. This sensitive approach provides support for the individual in achieving the well-being and happiness [2].

Culturally sensitive nursing practices involve the identification of cultural needs, the understanding of cultural links between family and individuals to provide care without affecting the cultural belief system of the family, and the use of emotional strategies for caregivers and patients to reach reciprocal goals. Building therapeutic relationships, offering appropriate and responsive care and treatment can be accomplished through transcultural nursing approach [2].

It is necessary for nurses to recognize individuals in their own cultural patterns, examine them in their own culture, and take these into account in the nursing approach [2, 7, 22].

Nursing is a developing profession that can continuously adapt to changing situations. Changes in social rules and expectations, the advent of new medical treatments, and improvements in technical systems have helped shape contemporary nursing practices [4, 44, 45].

Nursing has been significantly influenced by the fact that an increasing number of societies around the world have become multicultural and cultural specific care has been recognized [4].

The concept of cultural competence is a relatively new concept commonly used in the academic disciplines from the beginning of 1989 [4, 46, 47].

In multicultural societies, health care professionals need to be culturally competent, which is expected by the society. Interest in cultural competence has been manifested in the studies conducted on the cultural characteristics of the patients [46].

The nurses’ understanding of the cultures of patient groups is very important for the provision of meaningful effective nursing care [48].

The study performed by Chenowethm et al. titled as the “Cultural Proficiency and Nursing Care: With an Australian Perspective” and Giger and Davidhizar’s study titled as “Culturally Adequate Care: The Afghan, Afghan Origin American and the Importance of Understanding Islamic Cultural and Islamic Religion” can be cited as examples of conducted research on this subject [4, 33, 49].

Providing culturally adequate care is an obligation imposed by increased cultural diversity and disclosure of identities, an understanding of home care and inequalities in health care. Cultural competence is a dynamic, variable and continuous process. Although cultural competence is a basic component of nursing practice, this concept has not been clearly explained or analyzed but defined in many ways. At times, various terms such as “transcultural nursing”, “culturally appropriate nursing care” or “culturally sensitive nursing care” were used instead of the term cultural competence [46].

The literature review reveals that there is a common definition of cultural competence the term among researchers and a general consensus on the term. For example, the concepts of “ethnic nursing care”, “cultural care”, “cultural appropriateness” or “culturally appropriate care” are seen as terms close to cultural adequacy [4, 47].

Cultural competence is the application of knowledge, skills, attitudes, and personal manners anticipated from nurses to provide services and care appropriate to the cultural characteristics of the patients.

Başalan İz ve Bayık Temel reported that Vydelingum [47] made use of Murphy and Macleod-Clark, Bond, Kadron-Edgren and Jones, Spence, Blackford’s findings in his study. In Murphy and Macleod-Clark’s study on ethnocentric views, it was stated by nurses that patients from a minority group were generally regarded as a problem and these patients were perceived as inappropriate for daily routine, and there was lack of holistic care among nurses working to develop a therapeutic relationship with minority groups. Bond, Kadron-Edgren and Jones conducted a study evaluating the knowledge and attitudes of nursing students and professional nurses regarding patients from different cultures. This study has shown that undergraduate and post-graduate nursing programs are partially limited in terms of the knowledge and skills about special cultural groups. Spence, in his study on nurses’ experiences in caring for people from other cultures in New Zealand found that they experienced tension and anxiety when they encountered with an odd case. The subject of cultural well-being and nursing approaches in nursing education was reported in a study carried out by Blackford in Australia. The necessity of care structured under the roof of the white race culture has revealed that it does not consider the health care culture. The lack of cultural adequacy in the care of patients from different cultures has been recognized as an great challenge to all these studies. Cultural conflict has been shown as an output of ethnocentric focus, resulting in a lack of cultural competence, misunderstanding, lack of confidence, communication and obstacles to establishing a positive relationship [4].

The nurse experiencing cultural conflict must first recognize his/her subconscious cultural behaviors in order to understand the reason for the cultural conflict [13].

In a cultural conflict, the nurse can respond negatively from the cultural perspective in the following ways:

• Ethnocentrism: It refers the individual’s interpretation of other cultures in terms of their own culture based on their own cultural heritage.
• Stereotyping: The acceptance of the same characteristics of individuals or group members without considering individual differences.
• Cultural blindness: A symptom of not paying attention to expressing cultural diversity.
• Cultural imposition: The situation emerges at a time when the nurse expects the patient to comply with his/her cultural norms or the norms of the health institution. The nurse may think, “You have to follow my hospital’s rule and comply with our procedures here.”
• Cultural conflict: When a nurse, patient and family have different values, exhibit different behaviors, conflicts may arise in the case of differences in beliefs and traditions. However, the expected professional attitude from the nurse is cultural relativism. Cultural relativism means recognizing and understanding the individual’s culture in its own structure, without referring to other norms and judgments. The nurse approaching the patient with cultural relativism has a clear view of the characteristics of cultures, diversity of beliefs and practices in different environments resulting from different social needs [2].

Culturally Sensitive Care, There are Three Major Approaches Reducing Cultural Conflicts to Minimum. These are Listed Below

1. The individual/patient’s own perspective and cultural beliefs must be respected and recognized.
2. The nurse should be competent and authorized to carry out professional actions and make decisions.
3. The nurse should help the individual to develop new patterns to lead a satisfying and healthy life in the case of harmful behaviors [50].

The nursing care plan must be individual, holistic and contemporary. Interpreters or religious leaders may need to be included in the caring plan if there are any linguistic problems. The patient’s view on the cause of his or her illness is also a key element in planning the care [49].

In preparing the nursing care plan, basic principles related to culturally sensitive nursing practices can be followed.

Basic Principles Related to Culturally Sensitive Nursing Practices are Described Below

• The importance and influence of the culture should be considered,
• Cultural differences should be valued and respected,
• Cultural influences in the manners of individuals should be understood,
• An empathic approach should be put into action towards individuals with cultural diversity,
• Individuals’ cultures should be respected,
• Health professionals should be patient with individuals in cultural issues,
• Individuals’ behaviors should be thoroughly analyzed,
• Cultural knowledge should be increased and enhanced,
• Adaptation and orientation programs about cultural diversity should be offered [2, 7, 22].

Scope of Cultural Nursing Practice

The scope of cultural nursing practice can be:

• identification of cultural needs
• understanding the cultural connections of the individual and the
• using emotional strategies for the caregivers and the patients to reach the reciprocal goals

Thus, the cultural approach will guide the nurses in planning nursing interventions. In this case, nursing care can be provided without harming the cultural belief system of the family [13, 51].

This short review provides the basis for a deeper cultural assessment that the nurse can do in the future. The nurse has the opportunity to communicate effectively with the individual through brief cultural assessment data collected [7, 13, 22, 52].

Nurses should make cultural evaluations when they first communicate with individuals. This evaluation may be in-depth, or a brief review that will form the basis for an in-depth assessment to be done later. In a brief review, several questions about health practices, diet, religious preference, ethnic background and family can be asked to the individual. This short review provides the basis for a deeper cultural assessment to be done by the nurse in the future. Thıs, the nurse has a chance to communicate effectively with the individual through brief cultural data [7, 13, 22, 52].

Data Collection

1. Demographic data
   • Regional population density
   • Population density entering the region
   • Age distribution of the residents in the region
   • Distribution of demographics such as education, job, income etc.
   • The national origin of the population living in the region
2. Traditional health beliefs
   • Definition of illness
   • Definition of health
   • Health-related behaviors
   • Reasons for your illness
   • Poor eating habits/nutrition
   • Bad eating arrangements
   • Viruses, bacteria and other organisms
   • A punishment/curse from Allah (the God)
   • Being affected by the evil eyes
   • Magic, charm, spell or jealousy
   • Witchcraft
   • Environmental changes
   • Sorrow or loss
   • Excessive or little labor
3. Methods for maintaining health
4. Health protection methods
5. Methods of restoring health-home treatments/household recipes
6. Utilization of health care resources and visitations
7. Traditional healers favored by sick people
8. Health beliefs and practices related to childbirth
9. Health beliefs and practices related to raising children
10. Traditional practices and ceremonies arranged for dying individuals and related to death

In addition to recognizing the cultural characteristics of the community, by depending on these data, nurses should recognize traditional medicines, places of worship and sacredness, and other such organizations and, if possible, should visit and observe such places in order to identify the service group.

Issues to be Considered Which Enable Nurses to Make Cultural Assessment Include the Following

1. The nurses should be knowledgeable about the community receiving care services provided by themselves.
2. The nurses should identify the social gathering environments such as schools, hospitals, places of worship of the community they serve care.
3. The nurses should define the specific areas they want to focus on prior to cultural evaluation.
4. The nurses should determine the strategies that can help them collect data about cultural values.
5. The nurses should define the items that may act as bridges between the cultures.
6. The nurses should be able to ask appropriate questions without hurting the individuals.
7. The nurses should cooperate with colleagues and other health workers.
8. The nurses should discuss with the community leaders, whether official or non-official, about cultural characteristics deemed important in the lifestyle of the society.
9. The nurses should not resort to unethical traps to make an early generalization based on the cultural data of the society.
10. The nurses should be honest, open and sincere towards the individuals and the self.
11. The nurses should obtain both objective and subjective data and verify them to be correct before implementing nursing care [7, 13].

Additionally, the nurses should at least learn some relevant vocabulary and common phrases used in caregiving that will facilitate communication [7, 13].

Trans-cultural Nursing Focuses on Four Major Concepts Below

1. Nurses are transcultural care personnel.
2. An individual is considered as a cultural asset and cannot be separated from his/her own cultural heritage and background.
3. Environment is a structure or framework
4. Transcultural care is a sensitive nursing care service addressing to the needs of individuals from different cultural groups [18].

A manual of guidelines has been prepared by International Nurses Association (ICN), American Nursing Academy, Transcultural Nursing Association, with the aim of creating a common language for nursing practice all over the world and providing a holistic and cultural content care that respects social equality, justice and individual differences. There are 12 items in the manual given in the following:

1. Social Justice and Equality
2. Critical Perspective
3. Cultural Awareness
4. Cultural Based Care
5. Cultural Based Health Care Systems and Organizations
6. Patient Advocacy and Empowerment
7. Multicultural Workforce
8. Cultural Based Care in Education and Training
9. Intercultural Communication
10. Intercultural Leadership
11. Policy Development
12. Evidence Based Practices and Research [3, 53].