Learning Outcomes
By the end of this section, you should be able to:
- 23.2.1 Describe culturally responsive care.
- 23.2.2 Explain the basic concepts of culturally competent nursing care.
- 23.2.3 Discuss the relationship between cultural competence and health outcomes.
- 23.2.4 Describe how valuing and respecting diversity affect health care.
Culturally responsive care fully considers the cultural backgrounds, values, and preferences of individuals, groups, and populations. Culturally responsive care goes beyond being aware of a culture; it involves actively ensuring that all aspects of health care are customized to address the needs and beliefs of the specific population (Schwartz, 2023; Schwartz & Silva, 2023). Nurses who provide culturally responsive care do so by aligning their practice with the values, beliefs, and practices of a client or population. Culturally responsive care improves a nurse’s ability to understand, communicate with, and effectively provide care to individuals from diverse cultural backgrounds, resulting in improved health outcomes for individuals and communities.
Cultural Competence and Culturally Congruent Care
Culturally responsive care is one potential outcome of the dynamic process of cultural competence. Although many definitions of cultural competence exist, this chapter uses the one adopted by the American Association of Colleges of Nursing: “cultural competence encompasses the attitudes, knowledge, and skills necessary for providing quality care to diverse populations” (AACN, 2008, p. 1).
The concept of cultural competence in nursing has its roots in the work of Cross et al. (1989) and has since expanded to encompass critical components for effective cross-cultural interactions, such as cultural awareness, cultural humility, and cultural sensitivity. The idea of cultural competence in nursing care can be traced back to Leininger’s book Nursing and Anthropology: Two Worlds to Blend (1970). As discussed in Transcultural Nursing, the field of transcultural nursing has since grown, generating a major theory, several models, and hundreds of research studies. As a result, professional organizations and educational institutions have begun incorporating cultural competence into their policies, standards, and curricula (Marion et al., 2016).
In 2014 the American Nurses Association formed a work group of 40 expert nurses to review and revise the 2010 version of the nursing scope and standards of practice. The work group reviewed all scope statements and standards in light of the increasing cultural and ethnic diversity in health care and the rise in humanitarian needs. Recognizing the need for nurses to have expert guidance on how to provide culturally congruent care, or care that is aligned with a client’s culture, the work group developed a new Standard 8, Culturally Congruent Practice, to describe “nursing care that is in agreement with the preferred values, beliefs, worldview, and practices of the healthcare consumer” (American Nurses Association, 2015, p. 31). This standard sets expectations for nurses’ education, legal responsibilities, and societal obligations. Cultural congruence is a fundamental part of nursing practice and is integral to the agreement between the profession and society. Standard 8 provides guidance for implementation by practicing nurses (Marion et al., 2016).
The latest research emphasizes the importance of improving nurses’ ability to provide culturally congruent care (Im & Chee, 2021). Culturally congruent care is the implementation of evidence-based nursing practice that recognizes and is consistent with the values, beliefs, worldviews, and practices of clients and populations, with the goal of improving health outcomes (Marion et al., 2016). It is customized to the needs of the client, group, or population. For example, a client with diabetes tells their nurse that they come from a culture with different health beliefs and practices and that they frequently consult with a traditional healer about their dietary choices. To provide culturally congruent care, the nurse prioritizes the client’s beliefs and practices, collaborating with them to identify culturally appropriate foods and traditions, and then incorporates these preferences into the care plan. The nurse can then provide culturally responsive education to the client about their dietary choices and encourage them to continue incorporating healthy practices that are congruent with their culture.
Several critiques of cultural competence have emerged. While some health care professionals consider the process of cultural competence an imperative for reducing health inequities, others argue that it is based on ethnocentrism, a belief that one’s own cultural values, traditions, and practices are superior to those of other cultures (Beser et al., 2021). According to this critique, the ethnocentric orientation of cultural competence can lead to stereotyping and, as a result, perpetuate already existing biases and inequities (Berger & Ribeiro Miller, 2021). Other critics argue that the process of developing cultural competence oversimplifies the complex nature of culture, reducing it to facts and easily acquired knowledge while failing to consider cultural change and variability (Campinha-Bacote, 2018). A recent shift toward culturally responsive care focuses on nurses’ ability to recognize and respond inclusively to diverse perspectives, and it emphasizes the importance of social justice (Day & Beard, 2019).
The Significance of Culturally Responsive Nursing
A nurse’s ability to provide effective, culturally responsive nursing care begins by exploring their own attitudes, beliefs, and values and involves an ongoing reflective process with the aim of providing culturally congruent care (Leininger, 1991, 1999). Nurses are not expected to know everything about every culture; acquiring such knowledge would be impossible. Although it is important for nurses to be aware of the different cultural groups prevalent in the areas where they practice, the only way to be certain of a client’s or population’s beliefs is to approach them with an open mind, inquire about preferences and needs, and listen with empathy and humility.
As the U.S. population becomes more diverse, cultural competence becomes increasingly important in health care. Studies have shown that when nurses provide care that responds to a client’s or population’s health beliefs and behaviors, they demonstrate more empathy, communicate more effectively, and provide more substantive client education (Sharifi et al., 2019). Nurses who practice this way can more readily navigate challenging situations when providing care for diverse populations. They are more likely to be aware of potential biases that can come into play when delivering care and are more likely and better able to take steps to minimize those biases. Building relationships of trust between communities and health care professionals can help ensure that individuals receive the appropriate care they need, regardless of their cultural backgrounds or differences. Incorporating culturally competent care is essential for promoting health equity, particularly for underserved groups that have faced significant health disparities and increased rates of illness and mortality. Culturally competent care therefore serves as a means of advocating for these clients’ health and well-being (Pacquiao et al., 2023).
By understanding their clients’ unique cultural needs, nurses can provide more effective and personalized care that encourages client collaboration and engagement. Culturally responsive care facilitates better communication between nurses and clients, improved health management, increased adherence to treatment plans, and greater client satisfaction, all of which can lead to improved health outcomes.
Social Determinants of Health and Health Inequities
Effective culturally responsive care relies on nurses’ understanding of the social determinants of health, which are the conditions in which people are born, grow, work, live, and age, along with the wider set of forces and systems shaping the conditions of daily life that influence health outcomes. As discussed in The Social Determinants of Health, these conditions include income, education, housing, environment, employment, and access to health care. Social determinants of health can create significant health inequities (Office of Disease Prevention and Health Promotion [ODPHP], n.d.-b). The unequal distribution of health care services, quality of care, and health status among groups is based on factors such as race, ethnicity, culture, gender, ability, and socioeconomic status.
Health inequities are persistent across the United States. These inequities can follow a person from before birth throughout their lifespan, affecting the health and well-being of communities as well as individuals. Although their causes are systemic, health inequities are preventable. Culturally responsive nurses employ an understanding of the roots of health inequities to reduce them.
For example, some communities with high poverty levels are considered “food deserts,” areas where access to affordable and nutritious food is limited or nonexistent. Food deserts can occur due to a lack of grocery stores or farmers markets in the area, inadequate transportation options, or low income levels that make it difficult for residents to afford fresh, healthy food (Figure 23.2). Food deserts are a serious public health concern because they can contribute to various health problems, including obesity, diabetes, and heart disease.
A nurse who recognizes and considers the client’s environment will understand the impact of a food desert on the local community and can provide education and resources to help people obtain nutritious food and make healthier choices. They can also advocate for increased availability of nutritious foods in places such as corner stores, promote the incorporation of healthy foods into school meal programs, and work with clients to identify foods that are important to their cultural backgrounds and traditions.
Health inequities became especially apparent during the COVID-19 pandemic, when Black, Hispanic, Native American/Alaskan Indian, and Native Hawaiian/Pacific Islander individuals had a 1.5 times greater risk of contracting the infection than White individuals and were twice as likely to die. Various factors contributed to the higher disease and death rates, including greater exposure to the pathogen for essential workers, greater proportions of people living in crowded conditions, less access to health care, and a greater burden of chronic diseases (Alcendor, 2020).
Racial and ethnic minority groups endure higher rates of morbidity and mortality from chronic diseases. For example, the tuberculosis rate among Native Americans is nearly fifteen times greater than that among White Americans, at 4.4 vs. 0.3 cases per 100,000 people (Schildknecht et al., 2023). Life expectancy for Native Americans is 7 years lower than the national average, at 71.8 vs. 78.8 years (Arias et al., 2021). A higher proportion of rural adult Black and American Indian or Alaska Native individuals (40.3 percent for both groups) report having multiple chronic health conditions compared with non-Hispanic White individuals (36 percent). Individuals with chronic conditions need more health care and interact more frequently with health care providers and services; those without a primary care provider are less likely to have their chronic conditions managed. Although chronic illness is more prevalent among racial and ethnic minorities, in rural areas, for example, only 61.5 percent of Hispanic and 63.7 percent of Native American individuals report having a primary care provider.
Younger Black adults live with and succumb to health conditions typically seen in White Americans in old age. For example, 33 percent of Black adults aged 35 to 49 have diagnosed hypertension, compared with 22 percent of White adults in the same age group (Centers for Disease Control and Prevention [CDC], 2017). Diabetes rates show an even greater disparity: 10 percent of Black adults have diabetes compared with 6 percent of White adults. Among children, asthma prevalence in Black children (18.1 percent) and Native American/Native Alaskan children (18.0 percent) is nearly twice that of White children (9.5 percent), and it is alarmingly high among children of Puerto Rican descent (23.6 percent) (Asthma and Allergy Foundation of America, 2020). Early onset of these conditions leads to greater morbidity and earlier mortality. The challenges presented by structural racism and the social determinants of health are covered in more detail in Unit 2, Issues and Challenges of Population Health.
Culturally Responsive Care and Health Inequities
Culturally responsive care increases client satisfaction, reduces health inequities, and leads to improved outcomes. By promoting respect and understanding between nurses and clients, cultural humility and culturally responsive care can help reduce inequities because the client is more likely to understand, collaborate, and follow the recommended care plan, regardless of their background or circumstances.
Consider this example of the effects of culturally responsive care. Although Black newborns are more than twice as likely to die as White newborns (1,090 vs. 490 deaths per 100,000 births), this number is halved when the physician providing care to the newborn is also Black. This difference may be due to Black providers’ recognition and understanding of the unique challenges and needs of babies born to people already prone to poorer health outcomes (Greenwood et al., 2020).
Health outcomes also improve when community preferences and needs are considered. Native Americans experience multiple structural inequities, including discrimination, poverty, forced relocation, and a history of trauma, all of which play a role in the high rates of substance misuse among some Native populations. In addition to these challenges, Native American communities often have limited access to quality health care services, including substance misuse treatment and mental health services. Nurses are responding to this need by advocating for culturally adapted, locally based interventions. For example, the Native Alaskan Yup’ik community-initiated alcohol abuse prevention program Qungasavik was developed as a toolbox for building on Native community strengths (Rasmus et al., 2014). Similarly, work by the Native Transformations Project identified the importance of family, community, and spirituality as protective factors against substance abuse (Rasmus et al., 2016).
Case Reflection
A Culturally Responsive Approach to Working with a New Client
Read the scenario, and then respond to the questions that follow.
Cory, the community health nurse introduced at the start of this chapter, is meeting another new client in the clinic today. Faiza is a married 28-year-old woman who is trying to establish primary and obstetric care. Cory is scheduled to meet with Faiza to assist her in arranging for appropriate and timely care and to assess whether she needs other health-related resources. When Cory goes to the waiting room and calls Faiza’s name, a man rises from his seat, and only then does the young woman seated beside him move her head and stand. The woman, who is wearing a hijab head covering, walks behind the man to the front of the room where Cory is waiting. The man says, “She is Faiza.” Faiza does not look directly at Cory. Cory reaches his hand out to Faiza and says, “Hi, my name is Cory, and I’m the nurse you’re seeing today; nice to meet you.” Faiza does not look up and does not take Cory’s hand. She says nothing and takes a small step backward. The man, who appears to be upset, says, “She needs a woman nurse. And she does not speak English, but I always translate for her.”
- Why do you think the man with Faiza requests a woman nurse?
- Does anything about this scenario make you uncomfortable? If so, consider why.
- What additional information should Cory obtain before proceeding?
- How should Cory respond to the statements “She needs a woman nurse . . . she does not speak English . . . I always translate for her”?
- What does the client’s nonverbal communication (no eye contact, no handshaking, backward step) signify?
- If the clinic cannot provide this client with a woman nurse, how should Cory proceed?
- Do you think Cory should have done anything differently from the beginning?
(See Attum et al., 2022.)