Culturally Competent Nursing Care and Promoting Diversity in Our Nursing Workforce
Nurses will become more knowledgeable about the importance of culturally competent care/diversity and be able to utilize assessment skills in the work setting.
Objectives: (1.0 contact hour)
1. Discuss the rationale for culturally competent nursing care. 2. Identify three practices related to cultural competence. 3. Explain why a diverse nursing profession is important for healthcare.
eople often confuse race and ethnicity. Race refers to human biological variation. With the original categories now expanded into multiple groups, racial mixing has given the concept of race little biological significance. Ethnicity refers to a socially, culturally, and politically constructed group of individuals that holds a common set of characteristics not shared by others with whom its members come in contact. These characteristics can include common ancestry, historical continuity, common language, religion, and interactions with people of the same group. Individuals can demonstrate their ethnic identity through a symbolic aspect of culture such as language or clothing.1 Culture may be defined as “the learned and shared beliefs, values and life ways of a designated or particular group that are generally transmitted inter-generationally and influence one’s thinking and action modes.”2 Culture is a framework that a person uses in viewing the world, including health and the need for care. Successful teaching plans are congruent with patient and family cultural values.3 Core beliefs and value systems are held more strongly when people lose control over aspects of their life due to illness.4 Behaviors associated with response to illness, such as fear, pain, and anxiety, are culturally determined. Adherence to cultural practices and beliefs is complex and depends on acculturation and assimilation into the dominant culture.1 Further, acculturation is also complex, variable, and difficult to measure. It can be at a cultural or group level and a psychological or individual level. Items used to assess acculturation include:
written and spoken language, country where childhood was spent, current circle of friends, and pride in cultural background.5 Listed below are some acculturation outcomes: Assimilation – establishment of relationships in the host society at the expense of the patients’ native culture Integration – retaining cultural identity and establishing new relationships in the host society Rejection – retains cultural identity and rejects the host society Deculturation – patient values neither their native culture nor that of the host society
Ethnocentrism – the belief that one’s ways are the only way Cultural imposition – the tendency to thrust one’s beliefs, values, and patterns of behavior upon another culture Stereotyping – believing that something is the same for everyone in a group The delivery of healthcare includes cultural awareness, skills, and knowledge. It has become imperative because of: 5 • increasing health disparities • population diversity • competitive healthcare market • federal regulations on discrimination • complex legislation
• regulatory requirements • litigious society It is essential for nurses, as part of the healthcare delivery system, to be aware and knowledgeable about the unique cultural issues related to providing care and treatment to people from different cultures. Nurses will need to know how to adapt their delivery of care to meet the diverse cultural needs of each client.6 Use of these skills could involve attitudinal and behavioral changes that will enable nurses to engage patients and families more successfully. Components of a cultural assessment include: 5 1. Where the patient was born and how long have they lived in this country 2. Ethnic affiliation and how strong it is 3. Patient’s major support people 4. Primary and secondary language 5. Non-verbal communication style 6. Religion and its importance 7. Food preferences and prohibitions 8. Economic situation and adequacy 9. Health/illness beliefs and practices 10. Customs and beliefs around birth and death Cultural competence and respect for others becomes especially important for us in the nursing practice because we are patient advocates. In school, we are taught to respect the rights and dignity of all patients. As the world becomes smaller and individuals and societies become more mobile, we are increasingly able to interact with individuals from other cultures. We all begin the process of learning the behaviors and beliefs of our culture at birth. We become assimilated into that culture and the way that we express ourselves is often without conscious thought. Our culture can have a definite and profound effect on how we interact with others, and also how we relate to the healthcare system.7 Diversity is prevalent in our society and the patients and our co-workers in our healthcare system today clearly
demonstrate that fact. The development of cultural competence in the nursing practice first requires us to have an awareness of the fact that many belief systems exist. At times, the healthcare practices of others may seem strange or meaningless. The beliefs that others have about medical care in this country, and sometimes their aversion to it, may be difficult for us to understand.8 Cultural competence of the healthcare workforce and the healthcare delivery system is increasingly tied to improved client outcomes and quality of care provided. Financial reimbursement for care provided to clients can be negatively affected if there is not a system in place to support the culturally competent delivery of care. Cultural competence is the ability to provide effective care for patients who come from different cultures. It requires sensitivity and effective communication in nursing, both verbally and non-verbally. A culturally competent clinical nurse: 9 • Develops an awareness/sensitivity to their own cultural heritage • Recognizes own values and biases and how they may affect patients • Demonstrates comfort with cultural differences • Knows specifics about the cultural groups they work with • Respects and is aware of the unique needs of specific women, men and children • Understands that diversity exists within and between cultures • Makes an effort to understand others’ points of view • Demonstrates flexibility and tolerance, is nonjudgmental • Maintains a sense of humor • Demonstrates a willingness to relinquish control • Promotes cultural practices that are potentially helpful The federal government is one of the main purchasers of healthcare services through Medicare and Medicaid. These programs require their contractors to be culturally diverse and deliver culturally competent service and care. Medicare and Medicaid are significant sources of revenue for healthcare institutions, and these regulations are binding on providers who accept these funds.9 Efforts to improve client outcomes and culturally centered care have been championed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The national accrediting body for hospitals was represented on the committee that developed the National Standards on Culturally and Linguistically Appropriate Services. Its collaboration with government agencies led to additional cultural competency mandates being integrated within Joint Commission standards that ultimately impact all healthcare organizations. For example, Joint Commission Performance Standards: RI 2.10 Section B states, “Each patient has a right to have his or her cultural, psychological, spiritual and personal values, beliefs, and preferences respected.” 9
Addressing Challenges and Barriers to Cultural Competency Barriers to cultural sensitivity in the nursing profession can include stereotyping, discrimination, racism, and prejudice. There are situations in which we may portray a lack of sensitivity without realizing it, unintentionally offending someone. Simple steps such as addressing patients by their last name or asking how they wish to be addressed demonstrate respect.7 Here are other simple ways to promote respect: • Never make assumptions about other individuals or their beliefs. Ask questions about cultural practices in a professional and thoughtful manner, if necessary. • Find out what the patient knows about health problems and treatments. Show respect for the patient’s support group, whether it is composed of family, friends, religious leaders, etc. • Understand where men and women fit in the patient’s society. In some cultures, the oldest male is the decision-maker for the rest of the family, even with regard to treatment decisions. • Most importantly, make an effort to gain the patient’s trust for a stronger nurse-patient relationship. This may take time, but all will benefit if this is accomplished. If the patient does not speak your language, attempt to find someone who can serve as an interpreter. Some of the barriers to culturally competent care include: 5 • Characteristics that influence a caregiver’s ability to provide this care include: education level, multicultural exposure, personal attitudes and values, and professional experience • Communication barriers include: lack of knowledge, fear, distrust, racism, bias, nursing rituals, and language barriers (using friends or family for interpretation is not recommended) • Healthcare environment: this barrier includes bureaucracy, non-supportive administration, lack of educational opportunities to promote cultural diversity, and rigid policies and procedures • Standards from JCAHO in 2000 suggest that understanding the cultural context in which patients live is important in understanding their response to illness/ hospitalization, and is necessary for planning appropriate medical and nursing care.9
Nursing care and outcomes Leininger found that (a) nursing care that incorporates cultural values and practices will be positively related to patient satisfaction with nursing care, (b) patient compliance to treatment will be greater when the treatment plan incorporates the patient’s cultural values and beliefs, and (c) conflict will result if nursing care conflicts with patients’ belief systems.10 Transcultural nursing care can help to improve
adherence with the treatment plan, reduce relapses, and decrease overall costs for healthcare.11 A culturally competent nurse must develop cultural sensitivity. “Cultural sensitivity can be defined in the broadest sense to be an awareness and utilization of knowledge related to ethnicity, culture, gender, or sexual orientation in explaining and understanding situations and responses of individuals in their environment”.12 It is critical to assess each patient individually and not make cultural assumptions about a patient’s beliefs or health practices. Asking the patient and family to define what they perceive as the cause of illness13 and what health practices the patient continues to follow will allow for development of an individualized culturally sensitive teaching plan. In assessing cultural beliefs, multiple areas should be considered, including the patient’s perception of illness and treatment, the social organization including family, communication behaviors, expression of pain, folk healthcare beliefs, past experience with care, and language. Family is defined in some cultures as the immediate nuclear family, while other cultures define family as the extended family, which may include close friends and neighbors. After making this determination, the nurse then identifies who the healthcare decision-maker is for the patient. The decision-maker could be the patient, the head of the household, or the entire extended family. All key players must be involved in the decisions since they will reinforce or block healthcare behaviors.14 There are vast differences in culturally defined communication behaviors. Before discussion of personal information, it is important to understand cultural practices related to nonverbal communication during conversation, communication practices related to the opposite gender, and cultural practices of social conversation. In some cultures, individuals maintain eye contact while listening, while in other cultures individuals avoid eye contact. Misinterpretation of these behaviors can lead to miscommunication. Some cultures have gender taboos regarding “private” issues and with whom it is appropriate to speak. There are cultural variances in the tolerance of interruptions and in the preference for social conversation before discussing personal information. Knowledge of culturally determined communication behaviors can avoid misunderstandings.15 Cultural beliefs related to illness affect how and when healthcare is sought and what health practices will be followed. Often individuals will follow traditional health practices before seeking the medical professional as a last resort. An understanding of cultural influences on healthcare
practices enables the nurse to effectively individualize the teaching plan. Presenting the information in the learner’s cultural context16 and including certain folk practices, if not detrimental, will strengthen the plan of care for the patient. The individual’s or family’s past experience with healthcare providers influences the client’s adherence and continuation of use of healthcare services. Understanding these experiences from the patient’s perspective can strengthen the relationship, and misconceptions and culturally offensive behaviors can be avoided.17 Finally, the nurse assesses issues related to language. When English is the second language, individuals may have more difficulty speaking and understanding English during times of stress and illness. Therefore, patients and families may need an interpreter during a health crisis or during times of increased anxiety, but they may not need an interpreter during less stressful times. National Standards for Culturally and Linguistically Appropriate Services in Health Care were created by the Office of Minority Health in 2001.18 RNs should be sensitive to when and who to use as an interpreter. The U.S. population is growing and becoming increasingly diverse. The U.S. Census Bureau predicts by the middle of the 21st century, the average U.S. resident will trace his ancestry to Africa, Asia, the Pacific Islands, Latin America, or Arab countries.19 Nurses in the United States are caring for a progressively more diverse population. In 2008, ethnic and racial minority groups accounted for about one third of the United States population. According to the United States Census Bureau, people from ethnic and racial minority groups – namely Hispanic, black, Asian, American Indian, Native Hawaiian and Pacific Islander – will together outnumber non-Hispanics over the next four decades. Minorities, now 37 percent of the U.S. population, are projected to comprise 57 percent of the population in 2060. The total minority population would more than double, from 116.2 million to 241.3 million over that period (U.S. Census Bureau, 2012). It is essential to have a nursing workforce that will reflect the population of the United States to deliver cost-effective, quality care and improve patients’ satisfaction and health outcomes, especially among ethnic and racial minorities.20 Significant health disparities exist among ethnic and racial minorities for various health outcomes, including maternal mortality.21 The Healthy People 2020 goal of reducing/ eliminating health disparities in health outcomes will only be achievable if we have a proper understanding of the factors associated with the poor health outcomes. Nurse researchers from ethnic and racial minority groups have an understanding of the experiences of others in their ethnic and racial groups, which positions them to make relevant contributions to designing and conducting studies among minorities.22
The importance of promoting diversity in the nursing workforce is acknowledged by various nursing agencies and health organizations, including the American Association of Colleges of Nursing (AACN, 2013). Diversity in the nursing workforce provides opportunities to deliver quality care which promotes patient satisfaction and emotional well-being.20 Nursing’s leaders recognize a strong connection between a culturally diverse nursing workforce and the ability to provide quality, culturally competent patient care. Though nursing has made great strides in recruiting and graduating nurses that mirror the patient population, more must be done before adequate representation becomes a reality. The need to attract students from underrepresented groups in nursing – specifically men and individuals from African American, Hispanic, Asian, American Indian, and Alaskan native backgrounds – is gaining in importance given the Bureau of Labor Statistics’ projected need for more than a million new and replacement registered nurses by 2020.23
US Census 2008
A report released by the Sullivan Commission on Diversity in the Healthcare Workforce in September 2004 stated: “The fact that the nation’s health professions have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of millions of Americans. Today’s physicians, nurses, and dentists have too little resemblance to the diverse populations they serve, leaving many Americans feeling excluded by a system that seems distant and uncaring.” 24 Diversity self-awareness occurs when we reflect on our own cultural identity, realize our own cultural values and beliefs, and recognize the differences within our own cultural group(s). Diversity awareness refers to an active, ongoing conscious process in which we recognize similarities and differences within and between various cultural groups. Diversity assessment necessitates cultural assessment of patients and cultural sharing among healthcare professionals. Ignoring diversity and providing culturally incongruent nursing care can adversely affect patient outcomes and jeopardize patient safety. Malpractice cases today may
involve issues concerning cultural incompetence. (Equally negligent is a nurse who does not assess patients for folk medicine use.) Legal and ethical principles demand that all health professionals provide culturally competent care or face charges of negligence and malpractice. Culturally competent care begins with a thorough cultural assessment that is routinely integrated within the health assessment. Developing cultural competence and assisting other health professionals should be emphasized in new employee orientations, on-going in-service educational programs, and staff meetings.25 Everyone belongs to one or more cultural groups; it’s important to acknowledge that diversity is ever changing, not static. Without appropriate diversity awareness, background knowledge, individual appraisal, and sensitivity, nurses’ interactions with co-workers may adversely impact the workplace environment, collaboration, and patient outcomes. Initiatives such as MNMERG – Multicultural Nurses Mayo Employee Resource Group in Minnesota, and CLCDN – Clinical Leadership Collaborative in Diversity Nursing at Massachusetts General have been very successful with resource and mentoring programs.26 Many other national resources are devoted to enhancing diversity in nursing, for example the New Careers in Nursing scholarship program supported by the Robert Wood Johnson Foundation and the American Association of Colleges of Nursing, Johnson & Johnson’s Campaign for Nursing’s Future/ American Association of Colleges of Nursing Minority Nurse Faculty Scholarship Program, and the U.S. Department of Health and Human Services diversity grant programs. We oftentimes think of diversity as only ethnicities, but the expanded definition of diversity or differences can include values, gender and even sexual orientation. This increase in diversity in the nursing workforce along with cultural competence will be an advantage in delivering quality nursing care in all healthcare settings. As nursing continues to advance along the current shift in demographics and ongoing disparities in healthcare, a concerted effort is justified to diversify the nation’s healthcare workforce. The nursing profession in particular will be challenged to recruit and retain a culturally diverse workforce that mirrors the nation’s population changes. n
1. Lipson, Juliene, Dibble, Suzanne, and Minarick, Pam - editors: Culture and Nursing Care, UCSF Nursing Press, 7th Edition, 2000, Chapter one, Culturally Competent Nursing Care, pgs. 1-5. 2. Leininger, M. (2002). Transcultural nursing and globalization of healthcare importance, focus, and historical aspects. In M. Leininger & M.R. McFarland (Eds.), Transcultural nursing (3rd ed., pp. 3-43), New York: McGraw-Hill 3. Price, J.L., & Cordell, B. (1994). Cultural diversity and patient teaching. Journal of Continuing Educational Nursing, 25, 163166. 4. Thomas, N.D. (2001). The importance of culture throughout all of life and beyond. Holistic Nursing Practice: The Science of Health and Healing, 15(2), 40-46. 5. Kathleen R. Simpson, Pat A. Creehan - 2013 AWHONN's Perinatal Nursing http://books.google.com/ books?isbn=1451179103 6. Eshleman, J., & Davidhizar, R. (2006). Strategies for developing cultural competency in an RN-BSN program. Journal of Transcultural Nursing, 17(2), 179-183 7. NurseTogether.com Cultural Competence in the Nursing Practice, Lanette Anderson on Wed, Oct 10, 2012 8. http://www.nursetogether.com/cultural-competence-nursingpractice#sthash.3Kobq6o7.dpuf 9. Joint Commission Resources. (2006). Providing culturally and linguistically competent health care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. 10. (Cater & Spence, 1996, and Leininger & McFarland, 2002, as cited in Leininger & McFarland, 2006). 11. Leininger, M.M. (1985). Transcultural care, diversity, and universality: A theory in nursing. Nursing & Health Care, 6, 208212. 12. American Nurses Association. (2004). Nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Publishing. 13. Rankin, S.H., Stallings, K.D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia: Lippincott, Williams & Wilkins. 14. Thomas, N.D. (2001). The importance of culture throughout all of life and beyond. Holistic Nursing Practice: The Science of Health and Healing, 15(2), 40-46. 15. Osborne, H. (2005). Health literacy from A to Z: Practical ways to communicate your health message. Boston, MA: Jones and Bartlett Publishers 16. 2005 Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Elsevier Mosby. 17. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education Inc. 18. U.S. Census Bureau (2012). U.S. census bureau projections show a slower growing, older, more diverse nation a half century from now. Retrieved from http://www.census.gov/ newsroom/releases/archives/population/cb12-243.html 19. Why Diversity in the Nursing Workforce Matters. May 7, 2013, 11:00 AM, by Adejoke Ayoola 20. (Martin, Hamilton, Sutton, Ventura, Mathews, Kirmeyer, & Osterman, 2010; Rosenberg, Geller, Studee, & Cox, 2006). 21. U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. (2nd ed.) Washington, DC: U.S. Government Printing Office. 22. Martin J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Mathews, T. J., Kirmeyer, S., & Osterman, M. J. K. (2010). Births: Final data for 2007. National Vital Statistics Reports 58(24), 1-8 23. www.census.gov/newsroom/releases/archives/population/cb12243.html 24. Missing Persons: Minorities in the Health Professions, at http:// www.aacn.nche.edu/Media/pdf/SullivanReport.pdf 2008 25. Becoming Better Nurses through Diversity Awareness www. nsna.org/Portals/0/Skins/.../Imprint_NovDec08_Feat_Jeffreys. pdf by M Jeffreys 26. Jacobs, Julie, Workplace initiatives that promote diversity and inclusion, Minority Nurse, Spring 2015, pgs. 42-43.
Culturally Competent Nursing Care and Promoting Diversity in Our Nursing Workforce POST-TEST DIRECTIONS • Carefully read the entire article. • This CE is free for MNA members and $20 for non-members. • Complete the evaluation and post-test response form and make your payment ONLINE. OR • Complete the evaluation and post-test response PDF FORM and mail or fax to: Mail: Michigan Nurses Association, 2310 Jolly Oak Road, Okemos, MI 48864 Fax: 517-349-5818
AWARDING OF CE Participants who achieve a minimum passing score of 80% (8 correct answers) will receive a certificate awarding 1.0 contact hours. Certificates will be mailed within six weeks of receipt of evaluation and post-test. Participants who do not achieve a passing score will have the option to retake the test at no additional cost.