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Population Health for Nurses

25.1 Strategies to Promote Culturally Responsive Nursing

Population Health for Nurses25.1 Strategies to Promote Culturally Responsive Nursing

Learning Outcomes

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

  • 25.1.1 Describe strategies to integrate cultural humility into the five components of cultural competence.
  • 25.1.2 Utilize the mnemonic A-S-K-E-D to promote cultural competemility.
  • 25.1.3 Differentiate between conscious impermeability and unconscious impermeability.
  • 25.1.4 Describe the process of advancing from a state of unawareness to a heightened state of mindfulness.
  • 25.1.5 Identify actions that promote cultural humility in providing client-centered care.
  • 25.1.6 Differentiate between cultural sensitivity and cultural humility.

Culturally and Linguistically Responsive Nursing Care discusses the importance of cultural responsiveness, particularly the attributes of cultural awareness, knowledge, skills, encounters, and humility. These concepts are essential in establishing positive client relationships. This chapter builds on this foundation to address strategies to promote culturally responsive nursing.

Integrating Cultural Humility

As discussed in Culturally and Linguistically Responsive Nursing Care, cultural humility is a lifelong process of self-awareness, self-reflection, and a willingness to learn from and engage with individuals from different cultural backgrounds that promotes effective health care interactions (Tervalon & Murray-García, 1998). Cultural humility goes beyond competency, emphasizing a continuous process of self-reflection and self-awareness. Nurses who practice cultural humility approach each interaction as an opportunity to learn, appreciating that they may not always have the answers but can seek better to comprehend the nuances of another person’s cultural background.

The framework for cultural humility is based on two models: The Process of Cultural Competence in Healthcare (Campinha-Bacote, 2002) and A Biblically Based Model of Cultural Competence (Campinha-Bacote, 2013). These models form the foundation for cultural competemility, “the synergistic process between cultural humility and cultural competence in which cultural humility permeates each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters” (Figure 25.2) (Campinha-Bacote, 2018). Conscious permeability emerges when individuals actively apply cultural humility in their daily lives and interactions. It involves acknowledging that cultural competence is a continuous journey rather than a destination. Conscious permeability enables individuals to be flexible and adapt their behavior, communication style, and decision making in response to different cultural contexts.

A diagram shows the five components of cultural competence infused with cultural humility.
Figure 25.2 This image depicts the infusion of cultural humility into each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Campinha-Bacote (2019) contends that for nurses to enhance their journey toward cultural competemility, they must humbly consider, “Have I ASKED myself the right questions?” The A-S-K-E-D mnemonic represents self-examination questions regarding one’s cultural awareness, skill, knowledge, encounters, and desire. The components of the mnemonic include:

  • Awareness: Am I aware of my prejudices and biases and the presence of racism and other “isms”?
  • Skill: Do I know how to conduct a culturally specific history, physical, mental health, medication, and spiritual assessment in a culturally sensitive manner?
  • Knowledge: Do I have knowledge regarding different cultures’ worldview, the field of biocultural ecology, and the importance of addressing social determinants of health?
  • Encounters: Do I have sacred and unremitting encounters with people from cultures different from mine, and am I committed to resolving cross-cultural conflicts?
  • Desire: Do I really “want to” engage in the process of competemility?

Cultural sensitivity in nursing care refers to the awareness, understanding, and consideration of clients and their families’ diverse cultural backgrounds, beliefs, practices, and preferences. It involves providing health care services that respect and accommodate cultural differences, ensuring clients receive care tailored to their needs that maintains their cultural dignity and values (Leininger, 2002). Cultural sensitivity and cultural humility are closely related concepts that work in tandem to promote cultural competency in health care. Both emphasize the importance of recognizing and respecting clients’ diverse cultural backgrounds, beliefs, and practices. Cultural sensitivity serves as a foundation for cultural humility, allowing health care professionals to recognize and appreciate cultural differences. Cultural humility goes further, requiring individuals to question their assumptions, engage in self-examination, and strive for a deeper understanding of other cultures (Tervalon & Murray-García, 1998). Cultural humility builds on cultural sensitivity to promote curiosity, respect, and a willingness to be corrected or educated by clients about their cultural beliefs. It encourages health care professionals to collaborate with clients, share power, and foster more effective partnerships in care.

Moving from a State of Becoming Aware to a State of Being Aware

The process of fully integrating cultural humility occurs across a continuum from impermeability to permeability (Campinha-Bacote, 2018). As nurses progress toward competency, they move through stages from being unaware of cultural humility to being mindful and spontaneously engaging in it during cultural encounters. Unconscious impermeability refers to a lack of recognition that cultural humility is necessary to become culturally competent. At this stage, the nurse may not be aware of power imbalances that influence care (Campinha-Bacote, 2019). Power imbalances, which arise due to various factors, including social status, language fluency, health system familiarity, and previous discrimination, can impede culturally sensitive care delivery.

At the stage of conscious impermeability, a nurse recognizes the importance of cultural humility but struggles to demonstrate it in practice (Campinha-Bacote, 2018). In contrast, conscious permeability is the mindful act of learning to become culturally humble and use a cultural lens throughout the entire client encounter (Campinha-Bacote, 2018). Finally, in unconscious permeability, the nurse can spontaneously operate from a place of cultural humility. These stages represent the process of moving from a state of becoming aware to a state of being aware. Integrating cultural humility into all aspects of cultural awareness, knowledge, skills, encounters, and desire can lead to unconscious permeability, as shown in Table 25.1.

Attribute Actions to Promote the Integration of Cultural Humility
Cultural Desire
  • Develop cultural competence out of genuine desire, not obligation
  • Commit to understanding and appreciating diverse cultures with sincere curiosity and eagerness to engage
Cultural Awareness
  • Develop deep understanding of how cultural factors impact human interactions, relationships, and communication
  • Be open-minded and receptive to learning about different cultures and be willing to examine one’s cultural biases and assumptions
  • Reflect on one’s cultural background, experiences, and beliefs in relation to those of others
Cultural Knowledge
  • Acquire solid educational background in diverse groups to provide culturally sensitive care
  • Learn from the community’s lived experiences and stay curious about other cultures
  • Ask questions, read diverse texts, watch films, learn another language, attend classes and workshops, and participating in cultural events
Cultural Skill
  • Effectively and sensitively integrate one’s cultural awareness and knowledge into practical actions and interactions
  • Assess clients with open-ended interviews, cultural competence tools, or questionnaires while respecting their autonomy and preserving confidentiality
  • Be mindful that each client is unique and avoid cultural generalizations while remaining aware of biases
Cultural Encounters
  • Seek cultural encounters in various forms, from community events to immersive travel experiences, to interact with people from different cultural backgrounds, fostering mutual respect and enhancing cultural competence
  • Learn to navigate diverse and globalized environments effectively
  • Recognize the limits of one’s understanding and be willing to learn from others
  • Acknowledge that each person’s experiences are unique and cannot be fully understood without active engagement
Table 25.1 Actions to Promote the Integration of Cultural Humility into the Five Components of Cultural Competence (See Campinha-Bacote 2011, 2018.)
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