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Reaching for cultural competence

Smith, Linda S. DSN, MS, RN, CLNC

doi: 10.1097/01.NURSE.0000429794.17073.87
Feature: CE Connection

Besides lessening the impact of healthcare disparities, culturally competent care improves outcomes, care quality, and patient satisfaction. This article brings you up to date on current guidelines, regulations, and practice standards for providing culturally appropriate care to all your patients.

Linda S. Smith is an affiliate research professor at the Institute of Rural Health at Idaho State University in Pocatello, Idaho. Dr. Smith is also a member of the Nursing2013 editorial board.

The author and planners have disclosed that they have no financial relationships related to this article.



NURSES ARE CULTURALLY UNIQUE individuals who subscribe to nursing and healthcare cultures as well as their own culturally learned assumptions and viewpoints. Likewise, their patients have cultural attitudes and preferences, which may conflict with those of the nurse or the healthcare culture. Nurses need to be aware of cultural differences in order to provide competent and compassionate patient care.

This article discusses what culturally competent nursing care means, why it's important, and how nurses can deliver it. In this article, examples will help clarify the importance of cultural competence.

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Experiencing culture shock

How would you feel in this situation?

You're traveling alone to your best friend's wedding in a foreign land. As your plane crosses the mountains of Asia, you experience an extreme health event and lose consciousness. You wake up and find yourself alone in a hospital ward, surrounded by strangers dressed in starched white clothes who speak in an unknown language and exhibit peculiar gestures and expressions.

Besides experiencing the worst pain of your life, you're terrified because you don't know what's happening to you and why. Two people with tall white hats approach you, tell you something you don't understand, transfer you to a stretcher, and whisk you out of the large ward and into a dark hallway. Looking down, you see you have an indwelling urinary catheter and your abdomen has been prepped with povidone-iodine solution. A metal boardlike apparatus that you've never seen before is next to you.

You cry out for support, begging someone to help you understand what's happening. “Please, please, won't someone try to understand me?” The two people wheeling your stretcher look at each other in bewilderment.

What would you want and need in this scenario? Contemplating what it would be like to be transported to such a strange and frightening place gives us insight into what our patients may be thinking and feeling as we, their nurses, care for them and their families. Even if they speak English, our culturally unique patients and their families may be unfamiliar with our expectations, colloquial language (including figures of speech and idioms), and healthcare and nursing cultures. Frightened and confused, our patients want, need, and deserve culturally competent nursing care. (See Understanding culture.)

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What's culturally competent care?

Cultural competence is the continuous process nurses use to work effectively and efficiently within a patient's culturally dictated world. Culturally competent nurses believe that every person and family deserve fair and equal healthcare access and opportunities.1 Asking and answering, “Where are my patients (or families) coming from? What are their ideas about wellness and illness? What are their healthcare needs and expectations?” are key, as are patient-centered care, empathy, advocacy, and very importantly, respect.2 Culturally competent nurses understand that each person is unique, and they respect the patient as well as the role culture plays in defining health and illness.

Culturally competent care includes culturally accurate assessments of a person and family based on the nurse's desire to discover (by asking questions and seeking information) the person's cultural traditions, perceptions, practices, beliefs, and values. Nursing plans of care and interventions that include and adapt to these unique cultural beliefs, perspectives, and traits improve patients' health outcomes, care quality, and care satisfaction.3

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Role of culturally competent nursing care

Within the last decade, the U.S. Hispanic population has grown by 43%; this group now comprises 16% of the total U.S. population. Overall, racial and ethnic minorities comprise 36.3% of the U.S. population and non-Hispanic Whites, 63.7%. California, Hawaii, New Mexico, Texas, and the District of Columbia have “majority minority” populations; that is, over 50% of their population belongs to a minority group (described by the U.S. Census as something other than non-Hispanic White alone).4,5 Clearly the nation is becoming more and more diverse. Members of minority groups are affected disproportionately by health burdens, called health disparities.6 (See What are the reasons for health disparities?)

Members of the Institute of Medicine review workshop, “Promotion of Health Equity and the Elimination of Health Disparities,” noted that self-reported poor or fair health was directly related to income; that is, lower income resulted in lower health status.6 The persistence of health disparities continues; minorities experience earlier and greater severity of negative health outcomes.6 For example, one study found that children of color brought to the hospital with an asthma diagnosis were far less likely than White children to receive home-care asthma medication.6

Unsafe nursing care occurs when patients feel disrespected, stereotyped, and shamed. Culturally competent care improves healthcare access and quality for all persons and decreases health disparities and poor health outcomes. With carefully implemented culturally competent nursing care, misunderstandings and poor or inappropriate care are eliminated. Patients' circumstances, feelings, emotions, values, attitudes, and beliefs should have equal or even at times greater importance for the nurse than a patient's physical signs and symptoms.7 (See Becoming familiar with current standards and guidelines.)

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Self-assessment, commitment, and education

For nurses, cultural competence isn't an end result; it's a continuous process of providing culturally sensitive, respectful, and empathetic care to all patients. Culturally competent nurses constantly reevaluate their commitment to cultural competence. This involves continually seeking new learning opportunities designed to enhance cultural competence.2

Nurses should always ask how the patients' culture, including economic, immigration, language, and social status, can be incorporated into the plan of care to improve health outcomes.8 They seek advice and guidance from their patients and colleagues. Nurses critically reflect on their own cultural beliefs, biases, prejudices, values, attitudes, and assumptions to become more aware of how their own culture impacts the care they provide. Nurses also analyze facility and unit policies and procedures to determine if these policies are fair, equal, impartial, and respectful of all patients.1

Whether or not nurses share some cultural beliefs with their patients, cultural encounters, education, and courses can help them progress from precompetency to proficiency. Cultural encounters help nurses move beyond their comfort zones to realize clear respect for all differences and world views, including the cultural context of health and illness.

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Professional medical interpreter services

About one in five people living in the United States speaks a language other than English at home.9 Culturally competent nurses ask their patients and their families what languages they use and prefer. Patients who are more comfortable with a language other than English need and deserve professional, credentialed medical interpreter services, and nurses need to inform them of this free-to-the-patient assistance. Patients with hearing impairment are also generally entitled to professional medical interpreter services.10

When using such a service, nurses listen to, watch, and face their patients rather than the interpreter. They use the first person, speak in short phrases, avoid using abstract medical slang and jargon, and routinely ask the patient to repeat the information. Instead of saying, “Ask Mr. Jones if he has any questions,” the nurse should say, “Mr. Jones, what questions do you still have about your heart medication?”11

Using medical interpreter services takes much longer than the usual patient-nurse interaction; nurses need to allow for the extra time and effort. Professionally trained medical interpreters adhere to strict confidentiality guidelines, are knowledgeable about the language of healthcare, and follow ethical and legal standards during the interpreter process.1 Because patients have the right to receive information they can understand, professional medical interpreters help patients understand healthcare and nursing cultures and expectations. They also help nurses understand a patient's world view.

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Nursing care

Nurses use their therapeutic communication skills to perform culturally competent patient assessments, which depend on recognizing, respecting, and responding to clinical cues. By understanding the cultural significance of these cues, nurses can adjust care accordingly. Specific nursing techniques include the following:1,1116

  • Perform a culturally based physical assessment, carefully considering biological variations in body structure, skin and hair characteristics, lab test results, and pain and discomfort. The way patients react to and demonstrate pain is often related to their culture.
  • Listen closely while paying full attention, and use patient-centered therapeutic communication techniques, giving careful attention to what isn't said (or what's minimized) and then asking the best questions. For example, if a patient denies pain but demonstrates clenched teeth, dyspnea, and distressed facial expressions, you might ask, “Mr. Jones, you're saying you have no pain, yet you look as though something isn't quite right. What's really happening?”
  • Be keenly attentive to patients' and families' nonverbal behaviors. For example, if your patient continues to deny distress, consider implementing your facility's approved pain assessment tool for nonverbal patients.
  • Use culturally appropriate eye contact and behavior. For instance, some cultural groups may consider direct eye contact to be aggressive; conversely, others might interpret someone avoiding eye contact as being shifty or deferential.
  • Refrain from interrupting, arguing, or judging. Instead, encourage patients to tell their stories.
  • From a foundation of shared power and decision making, acknowledge with the patient and family that good health is the common goal. Listen closely for the patient's perception of the health problem and continually adjust the plan of care based on this information. Explain to the patient and family any similarities and differences of their perception, building on the similarities and developing a plan of care that's mutually agreeable when conflicts arise.
  • Ask the patient and family how the patient's culture relates to health behaviors and seek information about cultural values, traditions, beliefs, and perspectives. Begin the first question with the phrase, “To help me learn more about your needs and beliefs....” (See Seeking more information.)

Patient and family advocacy occur when nurses advocate for the inclusion of a patient's (or family's) cultural beliefs, practices, and perspectives within all aspects of care. Cultural practices the healthcare team recognizes as either neutral or efficacious are honored, respected, and supported. A neutral health practice might be placing a table knife under the bed of a laboring woman to symbolically cut the pain.

A deleterious health practice might be the forced insertion of ashes into a newborn's umbilical cord. Cultural practices deemed deleterious are resolved using respectful, carefully worded explanations and culture brokers (a respected culture insider who negotiates consensus between the patient and the healthcare team). A culture broker will bridge the gap between persons of differing cultures. The culture broker, who can hold formal or informal status, has a role greater than a language interpreter and is considered by both groups to be a kind of peacemaker or middleman who navigates between differing perspectives. Your facility's ethics committee may also be called in to help resolve conflicts.

  • Use clear and specific dialogue, absent of innuendo, metaphor, slang, and ambiguity; speak in a normal volume but more slowly.
  • Pay attention to concerns about space, time, modesty, touch, and clothing, and honor preferences for male or female providers.
  • Use professional medical interpreters with all limited English proficiency patients. Even if patients are familiar with English, they may prefer to communicate in another language during health crises.
  • Use community resources and ombudsmen to help inform care. This is especially important for dealing with cultural practices the healthcare team deems hurtful and harmful.
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Cultural competence evaluation

Evaluating culturally competent care is a crucial step. Nurses striving toward cultural competence will ask themselves and the healthcare team the following:

  • How was my patient able to demonstrate understanding of the health problem and prescribed treatment?
  • How were his or her cultural needs and wishes incorporated into our plan of care?
  • How did I demonstrate respect for this patient and the family?
  • What level of treatment adherence was demonstrated?
  • What was the patient's (and family's) level of satisfaction with patient care?
  • Did the healthcare team create an open and trusting environment for this patient and family?
  • What were our care outcomes?
  • Was my patient (family) actively involved in the care and how was this demonstrated?
  • How will I improve my care, based on this patient encounter?
  • What biases or prejudices did I knowingly or unknowingly demonstrate?

Similarly, on a unit and facility level, caregivers should ask themselves these questions:

  • As a healthcare professional, how have I participated in unit and facility adherence to cultural competence regulations and standards?
  • How might our policies and procedures be more culturally sensitive?
  • Do we consistently access and use professional medical interpreters? Culture brokers? If so, how do we handle these interactions?
  • How might my colleagues and I become better care providers?
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Patient scenario #1

Sue is a postpartum nurse in a busy community-based hospital. Ms. M, who just gave birth to a healthy 7-lb (3.2-kg) boy, is her patient. Ms. M had a normal vaginal birth, her first. A Spanish speaker, she has a limited understanding of English. Her brother, Mr. J, who's in the room with her, understands, reads, and writes perfect English. While making rounds, Sue explains that she'll be back shortly to help Ms. M with her first postpartum shower. “No, no,” she protests, and with her brother's help tells Sue, “I can't bathe for 3 weeks; otherwise, my baby will be sick!” Ms. M is in tears, and Mr. J looks perplexed. What will Sue do next?

Though tempted to continue to use Mr. J as an interpreter, Sue knows that using family members in this process violates her patient's right to confidential, safe care. It also places Mr. J in an uncomfortable and difficult position and prevents him from fully engaging with his sister and new nephew.

Sue faces her patient, thanks her for talking with her, and promises to return shortly with a professional medical interpreter. Two hours later, Sue, Ms. M, and the professional medical interpreter work together to negotiate a bathing schedule that won't compromise Ms. M's cultural practices and beliefs or Sue's commitment to her patient for a safe, healthy, well-informed postpartum experience. At the end of her stay, Ms. M reports great satisfaction with her care and especially with Sue's commitment to her as a person and new mother.

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Patient scenario #2

Barry is charge nurse at a same-day surgery center. Mr. C, age 60, arrives for his scheduled right knee arthroscopy. As Barry begins preparations, Mr. C tells him that, before he “goes under the knife,” he needs his shaman to perform several “healing” procedures on him. When questioned, Mr. C explains that these procedures involve chanting, praying, and placing a small hankie of bones, ashes, and tea leaves on the bed next to him. This will take about 10 minutes, Mr. C states, and his shaman is in the waiting room, ready to begin. After consulting with the healthcare team members who decide these procedures aren't harmful, Barry moves Mr. C to a more private pre-op waiting area. Placing screens around his patient and his shaman, Barry waits patiently for the shaman to finish and exit before competently, and with cultural sensitivity, continuing with Mr. C's pre-op care.

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Building trust

Now recall the story in the beginning of this article. Consider how you'd feel if you were in such an unfamiliar setting, with nurses who looked upon you with bewilderment rather than empathy. Like all of our patients, you'd need and expect culturally competent communication and care. When these are provided, the fear and anxiety experienced by a person in an unfamiliar environment can be replaced with trust and confidence.

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Understanding culture

Culture involves much more than race, ethnic background, and language. A person's culture is the dynamic and ever-changing totality of that person's physiologic and psychological perceptions and experiences. Besides gender identity and sexual orientation beliefs and practices, culture includes the following characteristics:

  • biological—such as body structure and disease susceptibility
  • physical—including physiochemical responses related to age and gender
  • social—such as learned and transmitted norms, values, beliefs, and world views
  • spiritual
  • environmental
  • economic
  • psychological
  • political.8,15,16

Our own cultural identity is shaped by much more than our genetic inheritance. This identity contributes to the enormous diversity among ourselves, our colleagues, and our patients. Knowing about a specific cultural group's practices helps inform our patient and family assessments, but this general information never predicts our nursing care. Each person is treated as a culturally unique individual.

Healthcare and nursing cultures also have their own norms, values, beliefs, and practices. For example, many healthcare facility and nursing policies are imbedded with assumptions unique to these systemwide cultures. These include the importance of patients' right to information, patient autonomy, self-care, self-decision-making, and self-determination. These culturally linked assumptions may conflict with our patients' cultural beliefs and values. In some cultures, for example, family and group wishes and decisions rank well above those of the individual.7

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What are the reasons for health disparities?

Health disparities experienced by minorities may be related to these patient characteristics:

  • income
  • age
  • comorbidities
  • insurance coverage
  • lack of primary healthcare access
  • socioeconomic status
  • racism
  • stressful life conditions
  • low health literacy
  • language barriers
  • how, when, and why patients express symptoms and seek care.6,8,13
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Becoming familiar with current standards and guidelines

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color, or national origin. The U.S. Department of Health and Human Services (USDHHS) regulations prohibit patient exclusion from government programs or services (for example, Medicare and Medicaid) based on these traits.17 Any healthcare practice that negatively impacts a person based on these criteria is considered discrimination and is prohibited. Care, service, and access for non-English or limited English proficient (LEP) speakers must be equal.17

To aid compliance with these rules, the Office of Minority Health (OMH) within the USDHHS developed 14 national standards for culturally and linguistically appropriate services (CLAS) in healthcare. These three themes were identified: culturally competent care, language access services, and organizational supports for cultural competence.18 Culturally competent healthcare is central to all 14 CLAS standards, including the provision that all patients receive care that's effective, understandable, and respectful, and that considers their unique cultural beliefs, practices, and language.18 Four mandated CLAS standards relate to the patient's right to have qualified professional medical interpreters when needed. Hence, the use of family, friends, or even lay interpreters for LEP patients is considered discrimination (as well as a confidentiality violation) under these provisions. Unqualified interpreters make mistakes and family members serving as interpreters can't focus on their own response to their loved one's illness.

Since 2000, the National Institute of Medicine has identified culturally competent healthcare as a national priority. According to the Institute of Medicine workshop participants, culturally competent care is very important.6 Patients must feel valued and respected as well as able to discuss issues with healthcare providers; culturally competent care improves patient outcomes.

The Patient Protection and Affordable Care Act of 2010 also includes provisions designed to improve minority health, including the upgraded status of the OMH to an institute within the National Institutes of Health.19

Individual states and organizations are implementing requirements for mandated cultural competence training for healthcare professionals, including nurses.17 Additionally, the new Joint Commission safety standards for patient-centered communication include specific inpatient and outpatient treatment requirements for patient access to professional medical interpreters at no charge to them, as well as healthcare information presented in a language and manner understandable to them.20

In addition to national, state, and organizational requirements, professional standards specific to cultural competence within nursing are firmly in place. The American Nurses Association Code of Ethics explains that within all professional relationships, the nurse practices with respect for the uniqueness, dignity, and worth of every person, regardless of their attributes or health concerns.21 Building on this respect and the belief that every person and group deserves fair and equal healthcare participation and opportunity are the 12 standards of practice for culturally competent nursing care.21 These standards, developed by transcultural nursing experts from the American Academy of Nursing and the Transcultural Nursing Society, include provisions for social justice, critical reflection, transcultural nursing knowledge, cross-cultural practice, healthcare systems and organization, patient advocacy and empowerment, multicultural workforce, education and training, cross-cultural communication and leadership, policy development, and evidence-based practice and research.

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Seeking more information

Obtain cultural information relative to the patient's specific health needs and problems with questions like these:

  • What's happening to you because of this health problem? Why?
  • What are your greatest fears and concerns about this problem? Why?
  • What do you call it?
  • When did it first begin? Why?
  • How serious is it? Why?
  • When do you think it will end? Why?
  • What will fix your problem? Why?
  • What do you most need and expect from your nurses? From your healthcare team?
  • What remedies have you tried or will you try, and what happened or will happen?
  • What foods or fluids will help (or not help) this problem?
  • What tests or procedures are prohibited?
  • What else do we need to know about you that will help us to best serve your health needs?
  • How will we know if you don't understand us or have questions about your care?

Here are some general questions to consider asking your patients:

  • What's your preferred language? (Assess the patient's ability to read, write, and calculate, and determine whether the patient is competent with apothecary or metric measurements and in which language or languages. A nurse could learn this information by showing patients a ruler with both inches and centimeters and asking for a simple measurement, such as the size of a tissue box. Or patients could be handed a medication cup labeled with both systems, while asking them to measure out their liquid medication.)
  • When face-to-face, how do you prefer to communicate important information with friends, strangers, and healthcare professionals? How far away should they be when you speak with them?
  • What are your spiritual needs, concerns, and practices?
  • When things are really difficult, what and who helps most? What or who is least helpful?
  • What does health and illness mean to you? Or more simply, what does it mean to be healthy? Sick?
  • In the past, how have you stayed healthy?
  • What past experiences have you had with doctors, nurses, and hospitals? Did they help you and your family? How?
  • How much control do you have over your future health and illness?
  • What or who is most (or least) important to you right now and why?
  • How do you want to be addressed and touched?
  • How are important healthcare decisions made in your family and why?
  • What financial concerns do you have?
  • What's a good time to arrive for a 10:00 a.m. clinic appointment?
  • How do you prepare for emergencies?
  • What do you like or need to eat and when?
  • How do you spend a typical day?
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