Christy Bowen

Learning Objectives

By the end of this section, you will be able to:

Describe the guidelines for nursing care of different cultural practices
Explain the importance of cultural competency in nursing
Recognize factors that can affect diversity and inclusion in nursing

The importance of cultural competence cannot be understated. Cultural competence enables a nurse to deliver the highest quality, safest, and most patient-centered care possible. Establishing a culturally sensitive environment is the first step in providing culturally responsive care to patients. An accurate and thorough cultural assessment allows for the gathering of patient-specific cultural information. The pursuit of culturally competent care also requires recognizing the various factors that can affect diversity and inclusion in nursing.

Guidelines for Nursing Care

Providing culturally responsive care integrates an individual’s cultural beliefs into their health care. Begin by conveying cultural sensitivity to patients and their family members with these suggestions:

Set the stage by introducing yourself by name and role when meeting the patient and their family for the first time. Until you know differently, address the patient formally by using their title and last name. Ask the patient how they wish to be addressed and record this in the patient’s chart. Respectfully acknowledge any family members and visitors at the patient’s bedside.
Begin by standing or sitting at least arm’s length from the patient.
Observe the patient and family members in regard to eye contact, space orientation, touch, and other nonverbal communication behaviors and follow their lead.
Make note of the language the patient prefers to use and record this in the patient’s chart. If English is not the patient’s primary language, determine if a medical interpreter is required before proceeding with interview questions.
Use inclusive language that is culturally sensitive and appropriate. For example, do not refer to someone as “wheelchair bound”; instead say “a person who uses a wheelchair.”
Be open and honest about the extent of your knowledge of their culture. It is acceptable to politely ask questions about their beliefs and seek clarification to avoid misunderstandings.
Adopt a nonjudgmental approach and show respect for the patient’s cultural beliefs, values, and practices. It is possible that you may not agree with a patient’s cultural expressions, but it is imperative that the patient’s rights are upheld. As long as the expressions are not unsafe for the patient or others, the nurse should attempt to integrate them into their care.
Assure the patient that their cultural considerations are a priority of their care.

Cultural Assessment

After establishing a culturally sensitive environment, nurses should incorporate a cultural assessment when caring for all patients. There are many assessment guides used for patient interviews that are adaptable to a variety of healthcare 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 Considers to be a problem, the Cause of the problem, how they are Coping with the problem, and how Concerned they are about the problem. Use these questions based on the Four Cs model in nurse-patient conversations to conduct a cultural assessment:

What do you think is wrong? What is worrying you? (In other words, discover what the patient Considers to be the problem and what they call it.)
- Example: A patient with a diagnosis of a sinus infection believes their body is “unbalanced.”
What do you think Caused this problem? How did this happen?
- Example: The patient believes this illness is a punishment for a misdeed.
What are you doing to Cope with this problem? How are you taking care of yourself?
- Example: The patient avoids eating certain foods to treat the illness while also using home remedies such as herbal tea.
How serious is this problem for you? How Concerned are you?
- Example: A patient views the illness as being “God’s will” and states, “It’s in God’s hands.”

Patient Conversations

How Do You Perform a Brief Cultural Assessment?

Scenario: The nurse enters the patient’s room to perform a cultural assessment. The patient is a woman from China who is visiting family in the area and prefers to speak Mandarin. The nurse sets up the video translator to begin the conversation and introduces the translator to the patient.

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 like for 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 have an infection in my lungs. I haven’t been feeling well, and I believe it is because my body is not in balance.

Nurse: What do you think caused this problem? How did this happen?

Patient: My husband died four 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 phlegm.

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 here 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.

Another, more comprehensive cultural assessment tool, inspired by R. E. Spector’s Heritage Assessment Interview, is called the Sample Cultural Assessment Interview and includes these additional questions:

Where were you born? Where were your parents born?
What pronoun do you use (he, she, they)?
In what language are you most comfortable speaking and reading?
Did you grow up in a city or a town or a rural setting?

Unfolding Case Study

Unfolding Case Study #1: Part 9

Refer back to Unfolding Case Study #1: Part 7 to review the patient data.

Nursing Notes	0700: Assessment Patient is awake and alert and reports feeling “much better.” Patient reports anxiety about finances and is worried about being able to feed her family. She states that she makes enough each month to get by, but her mother is getting older and beginning to require more care and medications.
Flow Chart	0700: Assessment Blood pressure: 128/72 mm Hg Heart rate: 87 beats/minute Respiratory rate: 18 breaths/minute Temperature: 99.1°F Oxygen saturation: 97 percent on room air
Provider’s Orders	Discharge after meeting with social worker.

5.

Take action: As part of the assessment, the nurse also conducts a cultural assessment. How would the nurse use the Four Cs of Culture model to conduct the assessment on this patient?

6.

Evaluate outcomes: How would you determine that the patient’s social needs have been addressed sufficiently before discharge home?

Cultural Knowledge

Acquiring cultural knowledge is another important step toward becoming a culturally competent nurse. The term cultural knowledge refers to seeking information about cultural health beliefs, history, customs, and values to understand patients’ worldviews. 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. 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.

Standards of Practice

The Transcultural Nursing Society has developed Standards of Practice for Culturally Competent Nursing Care (Douglas et al., 2011). These twelve standards are intended to serve as a universally applicable guide for nurses in all aspects of culturally competent nursing care:

Social justice: Nurses must promote and advocate for social justice for all.
Critical reflection: Nurses must engage in ongoing, personal, critical reflection of how their cultural beliefs and practices affect their nursing care.
Knowledge of cultures: Nurses must understand diverse cultures and factors that affect health and well-being.
Culturally competent practice: Nurses must use cross-cultural knowledge and skills in implementing culturally competent nursing care.
Cultural competence in healthcare systems and organizations: Healthcare institutions must provide the structure and resources necessary to meet the needs of their culturally diverse patients.
Patient advocacy and empowerment: Nurses must empower their patients to navigate the healthcare system and advocate for inclusion of the patient’s cultural beliefs in their health care.
Multicultural workforce: Nurses must actively work toward having a multicultural workforce in healthcare settings.
Education and training in culturally competent care: Nurses must be educationally prepared to promote and provide culturally congruent health care through formal education, clinical training, and continuing education for practicing nurses.
Cross-cultural communication: Nurses must use culturally competent communication skills when providing patient care.
Cross-cultural leadership: Nurses must strive to influence others to achieve culturally competent care for diverse groups.
Policy development: Nurses must work to establish policies and standards for culturally competent care.
Evidence-based practice and research: Nurses must base their practice on interventions that have been shown to be effective through evidence-based practice.

Complementary and Alternative Therapies

Nonmainstream approaches to health that are used alongside conventional Western medical care are called complementary therapies. When nonmainstream approaches are used in place of conventional Western medical care, they are called alternative therapies (U.S. Department of Health and Human Services [HHS], n.d.a). Conventional therapies are more common than alternative therapies in the United States. Examples of therapies that may be used for complementary or alternative purposes include the use of melatonin for insomnia or acupuncture for muscle pain. It is important for the nurse to perform a thorough medication reconciliation so that complementary or alternative therapies are not missed. Patients may not consider these supplements as “medicines” or “drugs.”

Nutritional/Supplemental Therapies

Nutritional and supplemental therapies involve the use of dietary approaches and supplements to enhance well-being and address health issues. Dietary supplements, such as vitamins and minerals, are taken to supplement the diet and ensure adequate nutrient intake. Herbal supplements, derived from plants, are believed to have medicinal properties. Probiotics, which are beneficial bacteria that promote gut health, are commonly used as supplements. Fish oil supplements, rich in omega-3 fatty acids, are believed to have cardiovascular benefits. It is crucial for individuals considering these approaches to consult with healthcare professionals to ensure they align with their specific health needs and do not interfere with any existing medical treatments. As these products can interact with drugs, it is important to get a comprehensive list from the patient of all supplements they are taking. For example, St. John’s Wort, a common supplement, is known to interact with numerous different common medications including selective serotonin reuptake inhibitors, certain contraceptives, and digoxin (Mayo Foundation, 2021).

Physical and Psychological Therapies

Physical and psychological therapies include a wide range of modalities, such as acupuncture, massage therapy, meditation, reiki (a Japanese healing technique that involves the transfer of energy through the practitioner’s hands to promote physical and emotional healing), and qigong (a Chinese practice that combines breath control, gentle movement, and meditation to cultivate and balance the body’s vital energy). Cupping, coining (a traditional East Asian healing technique that involves scraping the skin with a smooth-edged tool, such as a coin or spoon, to promote blood flow and release tension), yoga, art, music, and dance also fall into this category. Acupuncture and cupping are two of the more popular alternative and complementary physical therapy modalities. Acupuncture is used to treat pain and multiple other conditions; it is performed by inserting needles at special points in the body. Acupuncture is intended to restore balance and is thought to work by releasing endorphins, the body’s natural painkillers. Cupping is another traditional therapy where cups are placed on the skin to increase blood flow with the aim of helping with stress or muscle aches and pains (see Figure 5.5).

A photograph shows a person's back showing blood marks from cupping.

Figure 5.5 Blood marks such as these are a normal finding on someone after a cupping session. (credit: “Cupping,” by Renato Ganoza/Flickr, CC BY 2.0)

Other Complementary Therapies

There are other complementary therapies that do not fit in either category. These include traditional healers, Ayurvedic medicine, TCM, naturopathy, and homeopathy. Derived from eighteenth- and nineteenth-century European natural healing systems, naturopathy involves a combination of therapies including herbal medicine, diet, acupuncture, and psychotherapy (HHS, 2017). In homeopathy, natural products are used in highly diluted doses to treat illness. Examples include Arnica montana, often used for muscle soreness and injuries, or chamomilla, often used for colic, teething, and childhood irritability. Homeopathic products can still include ingredients that can cause significant drug interactions, so they must be noted on the patient’s chart (HHS, n.d.b).

Cultural Competency

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.

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 toward positive health outcomes for all patients.

Link to Learning

A unique and inspiring discussion about becoming a culturally competent nurse is presented in this video.

Transcultural Nursing

The roots of providing culturally competent care are based on the original transcultural nursing concept developed by nurse and anthropologist, Madeleine Leininger. In transcultural nursing, care incorporates the cultural beliefs and practices of individuals to help them maintain and regain health or face death in a meaningful way. It forms the basis of all culturally competent care.

Theory of Cultural Care Diversity

Leininger’s Theory of Culture Care: Diversity and Universality is also known as the Culture Care Theory (CCT). It provides the framework for transcultural nursing and the development and practice of culturally competent nursing care (McFarland & Wehbe-Alamah, 2019). Leininger states that health care cannot be effectively provided without considering the patient’s cultural background. The theory emphasizes the importance of understanding the cultural values, beliefs, and practices of patients in order to provide appropriate care. According to Leininger, culture is a fundamental component of human life and influences an individual’s perception of health, illness, and health care (McFarland & Wehbe-Alamah, 2019). Therefore, healthcare providers must approach each patient with cultural sensitivity and strive to deliver care that is respectful and tailored to the patient’s cultural needs. The CCT is an important framework for promoting culturally competent care and achieving health equity for all individuals. Using the CCT as a framework, nurses can guide research of discovery and translational research projects for evidenced-based nursing practice. Educational programs can develop nursing courses and curricula to prepare culturally competent nurses. Hospitals and medical facilities can use the framework to guide future culturally competent administrative and leadership policies and procedures.

Factors Affecting Diversity and Inclusion in Nursing

The ANA recognizes specific factors that negatively affect diversity and inclusion in nursing. Explicit bias in the form of discrimination due to gender identity, race, ethnicity, sexual orientation, or socioeconomic status negatively impacts the health status of various populations. Implicit bias affects the relationship between healthcare providers and patients, as well as outcomes, even though it is unintentional (Jolley & Peck, 2022). Awareness of one’s biases is always the first step in combating them.

Cultural Self-Awareness

A person’s understanding of their own culture and its impact on self is referred to as cultural self-awareness. Understanding self is a crucial step in forming a broader understanding and acceptance of other cultures (Lu & Wan, 2018). To develop cultural awareness, people can educate themselves about diverse cultures, learn to recognize and avoid stereotypes, and engage in cross-cultural communication and interaction. It is important to note that cultural awareness is not a one-time achievement but an ongoing process that requires continuous learning and adaptation. Cultural self-awareness can help us understand what shapes our own values and beliefs and recognize our place in a larger multicultural society.

Ethnocentrism

The belief that one’s culture (or race, ethnicity, or country) is better than and preferable to another’s culture is termed ethnocentrism. An example would be a nurse telling a patient that conventional Western medical treatments are better than traditional healing remedies. Appropriate cultural self-awareness can help the nurse avoid ethnocentrism. Designing interventions that are relevant to and respectful of the patient’s culture is one way to avoid ethnocentrism. Other ways to avoid ethnocentrism include avoiding generalizations or stereotypes about diverse cultures. Approach cultural differences with an open mind, a readiness to learn and understand, and a willingness to consistently engage in each patient interaction with cultural humility and active-listening.

Six Cultural Phenomena

There are other cultural considerations that can affect efforts to increase diversity and inclusion in nursing, which Giger and Davidhizar identify in their Transcultural Assessment Model (2002). The Transcultural Assessment Model was developed as a way for nurses to assess and provide care for culturally diverse patients. This model states that each individual is unique and should be assessed according to six cultural phenomena:

Communication: This includes the language, tone, and nonverbal cues used by the individual and the healthcare provider. Communication styles can vary across cultures and can impact the effectiveness of healthcare interactions.
Personal space: All communication occurs in the context of space. There are four distinct zones of interpersonal space intimate, personal, social/consultative, and public (Figure 5.6) (Hall, 1966). This includes the physical and emotional distance between the individual and the healthcare provider. Cultural norms around personal space and touch can vary across cultures.

A diagraph shows a silhouette of a man standing in a circle labeled “intimate space.” This circle is surrounded by a larger circle labeled “personal space.” This circle is surrounded by a larger circle labeled “social space.” This circle is surrounded by a larger circle labeled “public space.”

Figure 5.6 There are four zones of interpersonal space that vary depending on cultural norms. How much space is acceptable varies across cultures. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Social organization: This includes the individual’s cultural values and beliefs related to family, community, and social roles. Cultural expectations around family involvement in healthcare decisions, for example, can vary across cultures. Another example is local, state, or government agencies that all share the same values, beliefs, and interests.
Time orientation: Time is an important aspect of interpersonal communication. This includes the individual’s cultural beliefs and practices related to time, such as punctuality and the perception of time as linear or cyclical. For example, the past, present, and future have different meanings and value to different cultures.
Environmental control: This includes the individual’s cultural beliefs and practices related to controlling their environment, such as beliefs around the causes of illness and how it is directly impacted by one’s environment.
Biologic variations: This includes the individual’s cultural beliefs and practices related to biology, such as beliefs around the causes of illness and the use of alternative therapies. Cultural beliefs around pain management and the use of medication can also vary across cultures.

Cultural Context

Patients and Personal Space

The amount of space that a person surrounds themself with to feel comfortable is influenced by culture. For example, for some people, it would feel awkward to stand four inches away from another person while holding a social conversation, but for others a small personal space is expected when conversing with another. There are times when a nurse must enter a patient’s personal space, which can cause emotional distress for some patients. The nurse should always ask for permission before entering a patient’s personal space and explain why and what is about to happen.

Patients may also be concerned about their modesty or being exposed. A patient 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 for what they are, an expression of cultural preference, and allow the patient to assume a position or distance that is comfortable for them.

Similar to cultural influences on personal space, touch is also culturally determined. This has implications for nurses because it may be 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.

5.3 Cultural Practice in Nursing