23.4 Becoming a Culturally Responsive Nurse

Valuing and Respecting Diversity

Valuing diversity means recognizing that everyone is unique and that diversity is a valuable aspect of society. It involves treating all individuals with respect and without discrimination and being open to learning from, and collaborating with, people from diverse backgrounds. Valuing diversity can foster a more inclusive and welcoming environment, and it can lead to better outcomes for both individuals and organizations.

What does valuing and respecting diversity look like? It begins with recognizing the unique backgrounds, experiences, and perspectives of clients and colleagues, including varied cultural health beliefs and practices. For example, a nurse serving a community that has experienced a recent influx of immigrants could follow local news stories about the new immigrant population and read books and articles about the immigrant group’s culture to develop a baseline knowledge that would become richer and more informed with each client interaction.

Nurses can engage with people from different backgrounds and cultures, both at work and socially, to get to know them and better understand their perspectives. An open mind is critical, as are effective communication and a willingness to learn from others. Nurses should advocate for diversity and inclusion in the workplace and recognize any personal biases or stereotypes that may impact their interactions with others. Self-awareness is key to both understanding one’s own perspective and challenging it. By taking these steps, nurses can show their commitment to valuing and respecting diversity, thereby fostering a more inclusive and nurturing environment for their clients, colleagues, communities, and organizations.

Developing Self-Awareness

To value and respect diversity, nurses must recognize and understand their personal biases, values, and beliefs; the ways those are influenced by their own cultural backgrounds; and the ways they influence their own perceptions and behaviors. To achieve that recognition and understanding, nurses must seek self-awareness (Foronda et al., 2018). This self-awareness can enable a nurse to identify the role their own biases, values, and beliefs play in their interactions with clients, nurse colleagues, and other health care professionals. Each nurse needs to examine their own life experiences, family background, cultural traditions, religious beliefs, health practices, and personal preferences. Because values change over time, it is helpful for nurses to consider how their biases, values, and beliefs have developed and to reflect on how they may be continuing to evolve. Nurses need to examine their own biases to ensure they are not perpetuating any stereotypes or prejudices, and they need to reflect on their own values and beliefs to identify how they may help or hinder their ability to provide culturally responsive care.

To develop self-awareness and identify hidden biases, nurses can start by reflecting on their experiences, cultural background, and stereotypes and how these may impact their ability to objectively evaluate and care for others. The Implicit Association Test (IAT), a psychological tool designed to measure bias and the impact of unconscious attitudes and beliefs on day-to-day decision-making, can help nurses identify their hidden biases (Project Implicit, 2011). Nurses can challenge their biases by engaging in open and respectful conversations with people from different backgrounds, asking questions to learn more about the experiences and perspectives of others.

Participating in activities that embrace and promote diversity can also help nurses develop self-awareness and cultural understanding. Such activities include attending cultural events, volunteering at health clinics that serve immigrant communities, and attending interfaith services. By engaging in these activities, nurses can continue to learn and grow in their understanding of individuals and groups from diverse cultural backgrounds, building the skills and knowledge necessary to provide compassionate, culturally congruent care to their clients. Managing the Dynamics of Difference describes strategies for developing cultural awareness in more detail.

The Central Vancouver Island Multicultural Society (2021) has developed a cultural competence self-assessment checklist that individuals can use to check their progress toward developing cultural competence.

Campinha-Bacote’s Process of Cultural Competence Model

Campinha-Bacote’s process of cultural competence model emphasizes that cultural competence is not a fixed attribute or trait but rather a process that health care professionals engage in to provide high-quality, effective care to clients from diverse cultural backgrounds (Campinha-Bacote, 2002). This process has five components: cultural awareness, cultural skill, cultural knowledge, cultural encounters, and cultural desire.

• Cultural awareness involves examining and exploring one’s own cultural background, beliefs, and biases and consciously avoiding them when interacting with clients from other cultures.
• Cultural skill is the ability to collect cultural data, perform culturally sensitive assessments, and consider biological and physiologic variations.
• Cultural knowledge serves as a foundation for understanding the diversity of cultural groups.
• Cultural encounters are interactions with clients from different cultural backgrounds.
• Cultural desire is the motivation to engage in the process of becoming culturally competent and to provide culturally responsive care.

Recently, Campinha-Bacote refined her model to include cultural competemility, the combination of cultural competence and cultural humility in the delivery of health care services (Campinha-Bacote, 2018), to encourage health care professionals to be culturally humble throughout the process of cultural competence.

Because Campinha-Bacote’s model specifically examines the process of cultural competence, it is easy to use in clinical situations. For example, a nurse who is motivated to engage in the process of cultural competence expresses a desire to provide culturally responsive care for a client from a religious background that observes dietary restrictions. Through cultural awareness, the nurse recognizes that the client’s beliefs and traditions may impact which foods they can eat. Therefore, the nurse clarifies these preferences during their assessment and continues to use cultural assessment skills to seek knowledge about the client’s dietary practices.

The Giger and Davidhizar Transcultural Assessment Model

Giger and Davidhizar’s transcultural assessment model (Giger & Haddad, 2020) is used to evaluate a client’s cultural values and perspectives of health and disease behaviors. According to this model, every individual is culturally unique and should be assessed according to six phenomena: communication, space, social organization, time orientation, environmental control, and biological variations.

• Communication, both verbal and nonverbal, transmits cultural norms and expectations, thereby conveying meaning and forming identity.
• Space refers to the distance between individuals when they interact; different cultural groups have different behaviors concerning personal distance and physical interaction.
• Social organization refers to how a cultural group is organized and includes factors such as family structure, religious values, and role assignments.
• Time orientation, which is the perspective and value placed on the past, present, or future, can vary based on culture.
• Environmental control refers to the belief in one’s ability to control and plan for factors in the environment.
• Biological variations are differences between individuals in developmental patterns, disease prevalence, and genetic variations.

Nurses may use Giger and Davidhizar’s transcultural model to evaluate how different individuals and groups perceive and approach illness to develop tailored plans of care. For example, some cultures place a greater emphasis on the present and less value on planning for the future. This can affect the way group members approach health care, such as their willingness to adhere to long-term treatment plans or to obtain preventive care. On the other hand, cultures that have a more future-oriented perspective place greater emphasis on planning and preparing for the future, including taking steps to prevent illness and maintain good health.

Another example of this model’s application is to consider how, in some cultures, illness may be viewed as a natural part of life, with more emphasis on the social and spiritual aspects of disease than on physiologic or biological manifestations. Individuals from these cultural backgrounds may prefer to seek care from traditional healers or practitioners instead of, or in addition to, Western medical care. In contrast, Western culture emphasizes biomedical explanations for illness and tends to prioritize evidence-based interventions. When differences arise, it is critical for the nurse to remain nonjudgmental and respectful of the client’s preferences. For example, if a client expresses a desire to receive acupuncture, the nurse should work with the client and healer to develop a culturally congruent care plan (Figure 23.3). This care plan should be communicated to all members of the care team and tailored to the individual’s needs.

Figure 23.3 Some clients may seek care from traditional healers or other practitioners of complementary and alternative medicine. A nurse would incorporate these practices into a culturally congruent care plan. (credit: “Curandera-Traditional Healers” by Larry Lamsa/Flickr, CC BY 2.0)

The Purnell Model for Cultural Competence

The Purnell model for cultural competence (Purnell, 2019) promotes cultural awareness and appreciation in the context of health care. Consisting of 12 domains of cultural knowledge, the model covers a wide range of concepts and skills related to cultural competence. Each domain includes a range of topics related to cultural differences and their impact on health care. For example, the death rituals domain identifies a client’s beliefs and practices related to death, dying, and bereavement. Pregnancy and childbearing practices vary widely around the world; this domain covers cultural beliefs and practices related to fertility, birth control, pregnancy, childbirth, and postpartum care. See Transcultural Nursing for more about the Purnell model.

Nurses can implement Purnell’s model throughout the nursing process, using their clinical judgment and collaborating with the client to select and emphasize the components that are most relevant to the individual client’s care (Purnell & Fenkl, 2021). For instance, using Purnell’s model, a nurse caring for a Native American client who follows traditional spiritual practices would elicit the client’s views and preferences about incorporating care from a tribal healer and then work to facilitate that collaboration if the client desires.