3.4: Cultural Competence

The freedom to express one’s cultural beliefs is a fundamental right of all people. Nurses realize that people speak, behave, and act in many different ways due to the influential role that culture plays in their lives and their view of the world. Cultural compe­tence is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.^[1],[2],[3]

Culturally-competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their patients’ cultural beliefs. It takes motivation, time, and practice to develop cultural competence, and it will evolve throughout your nursing career. Culturally competent nurses have the power to improve the quality of care leading to better health outcomes for culturally diverse patients. Nurses who accept and uphold the cultural values and beliefs of their patients are more likely to develop supportive and trusting relationships with their patients. In turn, this opens the way for optimal disease and injury prevention and leads towards positive health outcomes for all patients .

The roots of providing culturally-competent care are based on the original transcultural nursing theory developed by Dr. Madeleine Leininger. Transcultural nursing incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way.^[4] See Figure 3.4^[5] for an image of Dr. Leininger. Read more about transcultural nursing theory in the following box.

Figure 3.4 Madeleine Leininger

Madeleine Leininger and the Transcultural Nursing Theory ^[6]

Dr. Madeleine Leininger (1925-2012) founded the transcultural nursing theory. She was the first professional nurse to obtain a PhD in anthropology. She combined the “culture” concept from anthropology with the “care” concept from nursing and reformulated these concepts into “culture care.”

In the mid-1950s, no cultural knowledge base existed to guide nursing decisions or understand cultural behaviors as a way of providing therapeutic care. Leininger wrote the first books in the field and coined the term “culturally congruent care.” She developed and taught the first transcultural nursing course in 1966, and master’s and doctoral programs in transcultural nursing were launched shortly after. Dr. Leininger was honored as a Living Legend of the American Academy of Nursing in 1998.

Nurses have an ethical and moral obligation to provide culturally competent care to the patients they serve.^[7] The “Respectful and Equitable Practice” Standard of Professional Performance set by the American Nurses Association (ANA) states that nurses must practice with cultural humility and inclusiveness. The ANA Code of Ethics also states that the nurse should collaborate with other health professionals, as well as the public, to protect human rights, fight discriminatory practices, and reduce disparities.^[8] Additionally, the ANA Code of Ethics also states that nurses “are expected to be aware of their own cultural identifications in order to control their personal biases that may interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the patient’s culture…nurses should possess knowledge and understanding how oppression, racism, discrimination, and stereotyping affect them personally and in their work.”^[9]

Developing cultural competence begins in nursing school.^[10],[11] Culture is an integral part of life, but its impact is often implicit. It is easy to assume that others share the same cultural values that you do, but each individual has their own beliefs, values, and preferences. Begin the examination of your own cultural beliefs and feelings by answering the questions below.^[12]

Note

Reflect on the following questions carefully and contemplate your responses as you begin your journey of providing culturally responsive care as a nurse. (Questions are adapted from the Anti Defamation League’s “Imagine a World Without Hate” Personal Self-Assessment Anti-Bias Behavior).^[13]

• Who are you? With what cultural group or subgroups do you identify?
• When you meet someone from another culture/country/place, do you try to learn more about them?
• Do you notice instances of bias, prejudice, discrimination, and stereotyping against people of other groups or cultures in your environment (home, school, work, TV programs or movies, restaurants, places where you shop)?
• Have you reflected on your own upbringing and childhood to better understand your own implicit biases and the ways you have internalized messages you received?
• Do you ever consider your use of language to avoid terms or phrases that may be degrading or hurtful to other groups?
• When other people use biased language and behavior, do you feel comfortable speaking up and asking them to refrain?
• How ready are you to give equal attention, care, and support to people regardless of their culture, socioeconomic class, religion, gender expression, sexual orientation, or other “difference”?

The Process of Developing Cultural Competence

Dr. Josephine Campinha-Bacote is an influential nursing theorist and researcher who developed a model of cultural competence. The model asserts there are specific characteristics that a nurse becoming culturally competent possesses, including cultural awareness, cultural knowledge, cultural skill, and cultural encounters.^[14]

Cultural awareness is a deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, attitudes, practices, and problem-solving strategies of a patient’s culture. To become culturally aware, the nurse must undergo reflective exploration of personal cultural values while also becoming conscious of the cultural practices of others. In addition to reflecting on one’s own cultural values, the culturally competent nurse seeks to reverse harmful prejudices, ethnocentric views, and attitudes they have. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures. Although cultural diversity training is typically a requirement for health care professionals, cultural desire refers to the intrinsic motivation and commitment on the part of a nurse to develop cultural awareness and cultural competency.^[15]

Acquiring cultural knowledge is another important step towards becoming a culturally competent nurse. Cultural knowledge refers to seeking information about cultural health beliefs and values to understand patients’ world views. To acquire cultural knowledge, the nurse actively seeks information about other cultures, including common practices, beliefs, values, and customs, particularly for those cultures that are prevalent within the communities they serve.^[16] Cultural knowledge also includes understanding the historical backgrounds of culturally diverse groups in society, as well as physiological variations and the incidence of certain health conditions in culturally diverse groups. Cultural knowledge is best obtained through cultural encounters with patients from diverse backgrounds to learn about individual variations that occur within cultural groups and to prevent stereotyping.

While obtaining cultural knowledge, it is important to demonstrate cultural sensitivity. Cultural sensitivity means being tolerant and accepting of cultural practices and beliefs of people. Cultural sensitivity is demonstrated when the nurse conveys nonjudgmental interest and respect through words and action and an understanding that some health care treatments may conflict with a person’s cultural beliefs.^[17] Cultural sensitivity also implies a consciousness of the damaging effects of stereotyping, prejudice, or biases on patients and their well-being. Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the patient and their family members. When a patient experiences nursing care that contradicts with their cultural beliefs, they may experience moral or ethical conflict, nonadherence, or emotional distress.

Cultural desire, awareness, sensitivity, and knowledge are the building blocks for developing cultural skill. Cultural skill is reflected by the nurse’s ability to gather and synthesize relevant cultural information about their patients while planning care and using culturally sensitive communication skills. Nurses with cultural skill provide care consistent with their patients’ cultural needs and deliberately take steps to secure a safe health care environment that is free of discrimination or intolerance. For example, a culturally skilled nurse will make space and seating available within a patient’s hospital room for accompanying family members when this support is valued by the patient.^[18]

Cultural encounters is a process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

By developing the characteristics of cultural awareness, cultural knowledge, cultural skill, and cultural encounters, a nurse develops cultural competence.

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1. Centers for Disease Control and Prevention. (2020, October 21). Cultural competence in health and human services. https://npin.cdc.gov/pages/cultural-competence↵
2. Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3↵
3. Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100↵
4. Murphy, S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association: JMLA, 94(2 Suppl), e143–e151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/↵
5. “Leininger.jpg” by Juda712 is licensed under CC BY-SA 3.0↵
6. Murphy, S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association: JMLA, 94(2 Suppl), e143–e151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/↵
7. Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100↵
8. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/ ↵
9. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵
10. Gillson, S., & Cherian, N. (2019). The importance of teaching cultural diversity in baccalaureate nursing education. Journal of Cultural Diversity, 26(3), 85–88. ↵
11. Gavin-Knecht, J., Fontana, J. S., Fischer, B., Spitz, K. R., & Tetreault, J. N. (2018). An investigation of the development of cultural competence in baccalaureate nursing students: A mixed methods study. Journal of Cultural Diversity, 26(3), 89-95. ↵
12. Zeran, V. (2016). Cultural competency and safety in nursing education: A case study. Northern Review, 43, 105–115. https://thenorthernreview.ca/index.php/nr/article/view/591↵
13. Anti-Defamation League. (2013). Imagine a world without hate: Anti-Defamation League 2012 Annual Report. https://www.adl.org/media/4528/download. ↵
14. Transcultural C.A.R.E. Associates. (2020). The Process of Cultural Competemility. http://transculturalcare.net/the-process-of-cultural-competence-in-the-delivery-of-healthcare-services/↵
15. Anti-Defamation League. (2013). Imagine a world without hate: Anti-Defamation League 2012 Annual Report. https://www.adl.org/media/4528/download. ↵
16. Gillson, S., & Cherian, N. (2019). The importance of teaching cultural diversity in baccalaureate nursing education. Journal of Cultural Diversity, 26(3), 85–88. ↵
17. Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3↵
18. Brooks, L., Manias, E., & Bloomer, M. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007↵