Learning Objectives
By the end of this section, you will be able to:
- Explain the concepts of culture and race
- Describe cultural competence and cultural humility
- Discuss the importance of culture to nursing care
A fundamental principle of nursing is that every patient deserves to be respected and valued. This is especially important in a diverse society like ours, which contains individuals from a wide variety of cultural backgrounds. Nurses who consider the impact of culture show respect for each patient’s unique identity, beliefs, and needs. Patients who speak different languages or practice different customs or traditions may also have different ways of expressing themselves and interpreting other people’s behavior. Learning to identify and accommodate these practices allows nurses to establish effective communication, which is essential for proper diagnosis and treatment. Sensitivity and open communication help nurses avoid biases that may impact the quality of their care. A bias is a tendency for or against a thing, person, or group, usually in an unfair manner. Furthermore, respecting the cultures and diversity of all patients is mandated by regulatory bodies and codes of ethics. Patients have the right to receive, and nurses are ethically bound to provide, culturally sensitive care (Office of Minority Health, n.d.). Culturally sensitive nursing care leads to improved health outcomes (Sharifi et al., 2019).
What Is Culture?
The characteristic beliefs, values, customs, traditions, behaviors, history, and artifacts shared by a particular group of people are considered their culture. It consists of a people’s language, religion, social norms, art, cuisine, and many other components of society, and it plays a crucial role in shaping individual perspectives and behaviors, including health practices (Office of Minority Health, n.d.). Therefore, culture is a vital consideration in nursing care. Culturally relevant nursing care acknowledges and incorporates the cultural beliefs, values, and practices of patients into their health-care experience. Through this approach, nurses develop cultural sensitivity, which is the awareness of cultural differences and the potential impact they may have on an individual’s beliefs, behaviors, and experiences. Culturally sensitive nurses recognize and respect their patients’ diverse backgrounds and tailor care to meet each person’s specific needs and preferences.
Differentiating Culture and Race
People sometimes confuse culture with terms such as race or ethnicity. For centuries, people held the belief that people could be divided into distinct racial groups, based on inherited physical characteristics, to justify racism, slavery, and all manner of discrimination. Today scientists reject this notion of race based solely on skin color. Instead, race is considered a social construct used to group people by certain physical, social, or geographic characteristics, such as skin color, language, or country of ancestry. For example, Black Americans practice a wide variety of religions, have different social traditions, and trace their ancestry to different parts of the world including Africa and the Caribbean.
Another social construct, ethnicity refers to shared key cultural traits, including traditions, heritage, and ancestry (Foronda et al., 2016). Nurses should not assume that people who share an ethnicity belong to the same culture. For example, the 2020 U.S. Census identified “Hispanic or Latino” as an ethnicity (Jensen et al., 2021), but this category includes people from any region with a Spanish or Spanish-influenced culture, including Spain, Mexico, Cuba, Puerto Rico, and many other parts of Central and South America and the Caribbean. All these subgroups have their own distinct cultural practices.
A culture based on ethnicity is often considered a primary element of culture, whereas secondary elements extend beyond the physical features and include other features (National Human Genome Research Institute, 2023). Members of a cultural group may share other characteristics, including age, sexual identification, social class, spiritual practices, and geographic location. Culture is also found in specific vocations or places of employment, for example, different companies may have different work cultures. Cultural groups can be found in the categories of marital or family status, political affiliations, levels of education, military service, hobbies, and any number of interests, beliefs, or practices. For example, married couples have a culture distinct from single people, and military members share a unique cultural bond distinctly different from that of the general public.
Generalizations and Stereotypes
A cultural group is made up of individuals who may be different in many ways but who nevertheless share several key traits. Concluding that every individual in a particular cultural group shares the same values, beliefs, or practices is a generalization. A statement may be true of a cultural group in general but not apply to every specific member of that group. For example, it is generally true that members of certain cultures avoid making eye contact with authority figures. A Chinese patient may consider it disrespectful to meet a provider’s eyes, and a Muslim woman may consider it inappropriate to have a male provider (Galanti, 2000). However, nurses should not assume that every Chinese or female Muslim patient feels this way. To do so would be stereotyping.
A stereotype is a widely held but oversimplified assumption about a particular group of people. Stereotypes can result from malice or bigotry, as when people hold racist or sexist views, and apply generalizations about a group to individual members of that group. Stereotypes often perpetuate fixed and biased ideas, portraying people in an unfavorable light without considering their individuality. Even when they do not put patients in physical danger, stereotypes can prevent nurses from building meaningful, trusting relationships with the individuals in their care each day. It is important to note that neither stereotypes nor generalizations can represent the full diversity and complexity of individuals within a cultural group. However, generalizations are typically grounded in observed, verifiable evidence, while stereotypes often rely on biases, assumptions, or misconceptions about a particular group.
Cultural Competence in Nursing
Multicultural awareness has become increasingly important for nurses as travel and communication have produced a “smaller,” more interconnected world. Because we do not work in isolated communities where everyone is the same, we must be able to treat diverse populations effectively. This skill is part of cultural competence, which is the ability to effectively interact with individuals from different cultures. For example, nurses exhibit culturally competent care by delivering culturally tailored patient education and health promotion materials to help bridge the gap between health-care information and the patient’s cultural beliefs and practices, enhancing their understanding, compliance, and self-management skills.
Link to Learning
Review this tool kit for cultural competence in nursing provided by the American Association of Colleges of Nursing.
Evolution of Cultural Competence
The emergence of cultural competence as a concept in the nursing profession began with approaches such as the Sunrise Model, developed by Madeline Leininger in 1991, and Josepha Campinha-Bacote’s Process of Cultural Competence in the Delivery of Healthcare Services, developed in 2002 (Leininger & McFarland, 2006; Campinha-Bacote, 2011). (See 2.2 Cultural Assessment for more information on these models.) As more nurses realized not only the necessity but also the value of delivering culturally relevant and sensitive care, the objective of cultural competence began to be incorporated into nursing curricula and professional standards (Marion et al., 2016). Some state boards of nursing have made cultural competence training a requirement for licensure, and nurse researchers are increasingly exploring evidence-based practices to guide culturally competent care (Gradellini et al., 2021; Long, 2012, 2016). Consequently, the utilization of resources like cultural assessments, cultural competence training programs, and cultural brokering services expanded. A cultural broker is a person who translates sociocultural differences between cultures. This could include nuances related to body language, expression, systems differences across cultures, or even how an experience may be viewed from a certain cultural lens. Cultural brokering goes beyond simple language interpretation.
Cultural Humility
An attitude of openness, self-reflection, and lifelong learning regarding cultural differences is called cultural humility (Nguyen et al., 2020). Nurses with cultural humility recognize and challenge their own biases, practice respectful and nonjudgmental attitudes, and strive for equitable and patient-centered care. They also acknowledge the inherent power imbalances that exist in health-care settings. Nurses should be aware of the historical and systemic factors that contribute to health-care disparities among diverse populations, such as systemic racism and mistrust of health-care systems. By actively disrupting power imbalances, nurses can advocate for equitable care, promote social justice, and work toward reducing health-care disparities.
Elements of Cultural Humility
To effectively practice cultural humility, nurses must cultivate the essential elements listed in Table 2.1 (Nguyen et al., 2020).
| Element | Description | Example |
|---|---|---|
| Self-awareness | Nurses must engage in continuous self-reflection to recognize their own cultural biases, assumptions, and limitations. By doing so, nurses become more open to learning about other cultures and challenging their preconceptions. | A nurse who has treated many Chinese American patients begins seeing an increasing number of recent immigrants from China. The nurse recognizes these new patients have different cultural backgrounds and therefore may not respond positively to approaches that have previously worked with Chinese American patients. |
| Openness to learning | Nurses practicing cultural humility approach encounters with individuals from diverse cultures as learning opportunities. They acknowledge gaps in their knowledge and actively seek reliable information about different cultures, including beliefs, traditions, values, and health-care practices. | The nurse admits they do not know enough about Chinese culture to provide culturally competent care to the recent immigrants. After discussing the issue with several Chinese American colleagues at the hospital, they are directed to several relevant books, podcasts, and websites. |
| Respectful communication | Effective communication is crucial for cultural humility, Nurses should strive to engage in active listening, using open-ended questions and empathetic responses to understand patients’ cultural experiences and health-care needs. They should also be prepared to request translators to bridge language gaps. | The nurse does not speak Mandarin Chinese, the language spoken by her new patients. However, the hospital has contracted with a translation service, and the nurse is able to ensure an interpreter is always present for appointments, either virtually or in person. |
| Nonjudgmental attitude | Culturally humble nurses know enough about specific cultures to make reasonable generalizations about patients from those cultures. However, they refrain from stereotyping individuals based on their culture, and they do not negatively judge behavior that they do not sufficiently understand. | The nurse is accustomed to having warm, collaborative relationships with her Chinese American patients, particularly the younger ones who were born in the United States. The nurse is therefore surprised when younger patients from China remain distant, even guarded, after multiple appointments, but they assume the patients have understandable reasons for this behavior, and they remain positive during visits. |
| Collaborative partnership | Cultural humility promotes a collaborative partnership between nurses and patients. Nurses acknowledge patients as experts on their own culture, value patients’ input, and actively involve them in making decisions regarding their care. | After several months, the nurse is pleased to find her efforts paying off. Her new patients are asking more questions about their health care, and while they still tend to defer to their providers’ judgments, the nurse has used information from their conversations to help shape their treatment plans. With more time and positive reinforcement, the nurse believes the patients will become increasingly comfortable as active collaborators in their care. |
What Cultural Humility Achieves
Cultural humility is a vital part of the effort to promote patient-centered care and eliminate health-care disparities (Danso, 2018). In the context of nursing practice, cultural humility achieves several important outcomes relevant to these goals. First, it fosters respectful, nonjudgmental interactions with patients from diverse cultural backgrounds. Nurses practicing cultural humility recognize the inherent value of everyone’s culture and avoid making assumptions or stereotypes based on cultural differences. This approach builds trust, strengthens nurse-patient relationships, and encourages open communication. The concept of cultural safety, which aims at creating an environment that is safe, respectful, and affirming for individuals of all cultures, particularly those from marginalized or oppressed backgrounds, also extends to the larger health-care system. Nurses bring cultural safety to the organizational and societal levels when they advocate for inclusive practices and policies that respect the rights and dignity of all individuals, and when they challenge discriminatory practices or barriers that may exist within their community. The following are examples of advocating for cultural safety:
- insisting that health-care providers use a language line or medical interpreter that speaks the patient’s native language when providing information or obtaining consent
- collaborating with dietary services to offer a patient culturally appropriate food choices
- involving family members in decision-making
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Recognize the patient and family as a full partner in providing coordinated and compassionate care based on respect for the patient’s preferences, values, and needs.
Knowledge: The nurse will integrate understanding of the multiple dimensions of patient-centered care and recognize how diverse backgrounds function as a source of patient and family values.
Skill: Provide patient-centered care while maintaining respect and sensitivity to their values. The nurse will do as follows:
- Complete a cultural assessment to determine the patient’s values, preferences, and expressed needs.
- Document any patient requests in the medical record.
- Coordinate with ancillary staff in order to meet patient needs.
- Utilize resources as appropriate, such as a medical interpreter, to communicate with the patient and family.
Attitude: The nurse will respect and encourage patient expression of values and willingly support patient-centered care when a patient’s values are different.
Impact on Health-Care Delivery
Culture influences an individual’s beliefs, values, attitudes, and behaviors in all aspects of their life, including health and health care. It shapes their understanding of illness and wellness, as well as their perceptions of health-care providers and expectations of health-care services. By recognizing and acknowledging these cultural beliefs, health-care providers can engage in open and respectful discussions with clients and accommodate a patient’s cultural preferences. Some cultures may prioritize natural or herbal treatments over pharmaceutical interventions or have specific dietary requirements (e.g., Jewish people may keep kosher, Muslim people may eat halal food, and Hindu people may not eat beef). Another example is a primary nurse who adjusts medication administration times to accommodate prayer times for a religious patient.
Cultural norms and values also affect patients’ communication styles, expressions of pain or discomfort, and attitudes toward sharing personal information. Health-care providers need to be aware of these cultural nuances to ensure effective communication and care delivery.