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Psychiatric-Mental Health Nursing

8.3 Cultural Practice in Nursing

Psychiatric-Mental Health Nursing8.3 Cultural Practice in Nursing

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 and transcultural nursing
  • Recognize factors that can affect diversity and inclusion in nursing

Cultural competence enables a nurse to provide the best quality client-centered care possible. Establishing a culturally sensitive environment is the first step in providing culturally responsive care to clients. An accurate and thorough cultural assessment allows for the gathering of client-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 clients and their family members with these suggestions:

  • Set the stage by introducing oneself by name and role when meeting the client and their family for the first time. Address the client formally by using their title and last name. Ask the client how they want to be addressed and record this in the client’s chart. Respectfully acknowledge any family members and visitors at the client’s bedside.
  • Begin by standing or sitting at least arm’s length from the client.
  • Observe the client 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 client prefers to use, and record this in the client’s chart. If English is not the client’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 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 client’s cultural beliefs, values, and practices. It is possible not to agree with a client’s cultural expressions, but it is imperative that the client’s rights be upheld. As long as the expressions are not unsafe for the client or others, the nurse should attempt to integrate them into their care.
  • Assure the client 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 clients. There are many assessment guides used for client interviews that are adaptable to a variety of health-care settings and are designed to facilitate understanding and communication.

One such model is the 4C’s of Culture, a mnemonic developed by Slavin et al. (2019) to prompt health-care providers with culturally sensitive inquiries more likely to present the client’s point of view. This model asks questions about what the client 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 to begin the cultural assessment:

  • What do you think is wrong? What is worrying you? (In other words, discover what the client Considers to be the problem and what they call it.) Example: A client 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 client 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 client 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 client views the illness as being “God’s will” and states, “It’s in God’s hands.”

Psychosocial Considerations

How to Perform a Brief Cultural Assessment

Scenario: The nurse enters the client’s room to perform a cultural assessment. The client is a female from China in the area visiting family whose preferred language is Mandarin. The nurse sets up the video translator to begin the conversation and allows the translator to introduce themselves to the client.

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?

Client: Mei Wang, January 2, 1947.

Nurse: What would you like for me to call you?

Client: 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?

Client: Yes, that is fine.

Nurse: What do you think is wrong? What is worrying you?

Client: 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?

Client: 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 with what I’m used to.

Nurse: Have you been trying things at home to make yourself feel better? How have you been coping?

Client: I’ve been making some special food. A lot of soup, and other foods with ginger, onion, and garlic to help with the phlegm.

Nurse: How serious is this problem for you? How concerned are you?

Client: 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?

Client: 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 (Spector, 2017):

  • Where were you born? Where were your parents born?
  • What pronouns 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?

Cultural Knowledge

Another important step toward becoming a culturally competent nurse is acquiring cultural knowledge, which involves seeking information about a culture’s health beliefs, history, customs, and values to understand clients’ 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 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 clients 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. Table 8.4 lists the twelve standards and an example of each:

Standard Example
1. Social justice: Nurses must promote and advocate for social justice for all. Nurses advocate for equitable access to mental health services, ensuring that all individuals, regardless of socioeconomic status, can receive necessary care.
2. Critical reflection: Nurses must engage in ongoing, personal, critical reflection of how their cultural beliefs and practices affect their nursing care. A nurse regularly examines how their cultural beliefs and implicit biases impact interactions with clients and adjusts their approach to respect diverse perspectives.
3. Knowledge of cultures: Nurses must understand diverse cultures and factors that affect health and well-being. A nurse understands the dietary restrictions of a Hindu client and ensures their meal choices align with their cultural beliefs.
4. Culturally competent practice: Nurses must use cross-cultural knowledge and skills in implementing culturally competent nursing care. A nurse uses language interpreters to communicate effectively with non-English-speaking clients, recognizing the importance of linguistic competence in care.
5. Cultural competence in health-care systems and organizations: Health-care institutions must provide the structure and resources necessary to meet the needs of their culturally diverse clients. A health-care institution in a diverse urban area offers culturally tailored health education materials and services for its diverse client population.
6. Client advocacy and empowerment: Nurses must empower their clients to navigate the health-care system and advocate for inclusion of the client’s cultural beliefs in their health care. A nurse helps a Muslim client navigate the health-care system, ensuring their religious practices are respected during treatment.
7. Multicultural workforce: Nurses must actively work toward having a multicultural workforce in health-care settings. A nurse actively recruits health-care professionals from diverse backgrounds to create a more culturally inclusive health-care team.
8. 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. A nursing school incorporates cultural competency training into its curriculum to prepare students to provide culturally congruent care.
9. Cross-cultural communication: Nurses must use culturally competent communication skills when providing client care. A nurse uses visual aids and gestures to communicate effectively with a client who speaks a different language, recognizing the importance of nonverbal communication.
10. Cross-cultural leadership: Nurses must strive to influence others to achieve culturally competent care for diverse groups. A nurse leads a cultural competence training session for colleagues, sharing best practices in providing care to diverse client populations.
11. Policy development: Nurses must work to establish policies and standards for culturally competent care. Nurses collaborate with hospital administrators to develop and implement a comprehensive policy that mandates cultural competency training for all health-care staff, ensuring that all client interactions are culturally sensitive and respectful.
12. Evidence-based practice and research: Nurses use current research to ensure policies and standards are effective for culturally diverse clients, or when evidence is lacking, they do their own investigation and testing. A nurse establishes a committee for an evidence-based review of cultural best practices for improving client care of a diverse population.
Table 8.4 Standards of Practice for Culturally Competent Nursing Care (Douglas, 2011)

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, n.d.-a). Conventional (Western) therapies are much more common than alternative therapies in the United States. Examples of complementary therapies include the use of guided imagery and meditation for insomnia, or acupuncture for muscle pain. It is important for the nurse to perform a thorough medication reconciliation to understand use of complementary or alternative therapies. Clients may not consider alternative supplements to be “medicines” or “drugs.”

Nutritional/Supplemental Therapies

The most popular complementary therapy among Americans is dietary supplements, such as fish oil. This category also includes special diets, herbs, vitamins, minerals, and probiotics. Because these products can interact with drugs, it is important to get a comprehensive list from the client 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 SSRIs, 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, and qigong. Cupping, coining, yoga, art, music, and dance also fall into this category. Acupuncture and cupping are two of the more popular alternative 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 (Figure 8.4).

An individual’s back showing raised, circular red marks after a cupping session.
Figure 8.4 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, Traditional Chinese Medicine, naturopathy, and homeopathy. Naturopathic medicine is derived from eighteenth- and nineteenth-century European natural healing systems and involves a combination of therapies, including herbal medicine, diet, acupuncture, and psychotherapy (U.S. Department of Health and Human Services, 2017). Another complementary therapy is homeopathy, the belief that the body can heal itself with natural substances. It uses natural products in extremely diluted doses to treat illness. Examples include Chestal Honey cough syrup used for coughs, 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 client’s chart (U.S. Department of Health and Human Services, n.d.-c).

Cultural Competency and Transcultural Nursing

All people have the freedom to express their cultural beliefs. 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 competency is the skill of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of clients to produce improved client outcomes.

Culturally competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their clients’ cultural beliefs. It takes motivation, time, and practice to develop cultural competence, and it will evolve throughout a nursing career. Nurses who accept and uphold the cultural values and beliefs of their clients are more likely to develop supportive and trusting relationships with their clients. In turn, this opens the way for optimal disease and injury prevention and leads toward positive health outcomes for all clients.

The roots of providing culturally competent care are based on a concept developed by nurse and anthropologist, Dr. Madeleine Leininger, called transcultural nursing, which incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way. It forms the foundation of all culturally competent care. Dr. 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). Dr. Leininger states that health-care providers cannot offer effective care without considering the client’s cultural background. The theory emphasizes the importance of understanding the cultural values, beliefs, and practices of clients in order to provide appropriate care. According to Leininger, as cited in McFarland & Wehbe-Alamah (2019), culture is a fundamental component of human life and influences an individual’s perception of health, illness, and health care. Therefore, health-care providers must approach each client with cultural sensitivity and strive to deliver care that is respectful and tailored to the client’s cultural needs.

The culture care theory is an important framework for promoting culturally competent care and achieving health equity for all individuals. Using the culture care theory 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, Equity, and Inclusion in Nursing

The American Nurses Association recognizes specific factors that negatively affect diversity, equity, 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 health-care providers and clients, and between health-care team members, as well as outcomes (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 themselves is their cultural self-awareness. Understanding oneself is a crucial step in forming a broader understanding and acceptance of other cultures (Lu & Wan, 2018). It is important to note that cultural awareness is not a one-time activity, but an ongoing process that requires continuous learning and adaptation. Cultural self-awareness can help nurses understand what shapes their own values and beliefs and recognize their place in a larger multicultural society.

The belief that one’s culture (or race, ethnicity, or country) is better than and preferable to another’s is called ethnocentrism. An example would be a nurse telling a client 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 client’s culture is one way to avoid ethnocentrism. Other ways to avoid ethnocentrism include avoiding making generalizations or stereotypes about other cultures. Deal with cultural differences with an open mind and a willingness to learn and understand. Always try to approach each client interaction with a sense of cultural humility and practice 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 developed as a way for nurses to assess and provide care for culturally diverse clients. 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 health-care provider. Communication styles can vary across cultures and can influence the effectiveness of health-care interactions.
  • Personal space: All communication occurs in the context of space. There are four distinct zones of interpersonal space: intimate, personal, social and consultative, and public (Figure 8.5) (Hall, 1966). This includes the physical and emotional distance between the individual and the health-care provider. Cultural norms around personal space and touch can vary across cultures.
  • Social organization: This includes the individual’s cultural values and beliefs related to family, community, and social roles. Cultural expectations around family involvement in health-care 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.
Image showing a person standing at the center of the four concentric zones of interpersonal space: Intimate, Personal, Social, and Public.
Figure 8.5 There are four zones of interpersonal space, and cultural norms around how much space is acceptable varies across cultures. (modification of work from Fundamentals of Nursing. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Cultural Context

Clients, Personal Space, and Touch

The amount of space that a person surrounds themselves 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 appropriate when conversing with another. There are times when a nurse must enter a client’s personal space, which can cause emotional distress for some clients. The nurse should always ask for permission before entering a client’s personal space and explain why and what is about to happen.

Clients may also be concerned about their modesty or being exposed. A client 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 client 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 client and vice versa. In some cultures, it is also considered rude to touch a person’s head without permission.


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