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A tool for providing culturally competent care

Younas, Ahtisham BSN, MN, RN

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doi: 10.1097/01.NURSE.0000651628.71776.b3
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CULTURAL COMPETENCE is essential for establishing rapport with patients and for assessing patients' needs, including those arising from their cultural and social values and beliefs. This article discusses how self-awareness can help nurses provide culturally competent care to patients and their families.

Culturally competent care and its importance

Cultural competence can be defined as “the gradually developed capacity of nurses to provide safe and quality healthcare to clients with different cultural backgrounds.”1 The most significant aspects of culturally competent care are accepting and respecting racial, cultural, and religious differences and promoting social justice in healthcare settings.2 At a broader sociocultural level, cultural competence can enhance cross-cultural communication, decrease health inequalities and promote equality, improve access to healthcare services, and increase health literacy.3

A comprehensive nursing assessment that includes awareness of patients' cultural and social values helps the nurse develop and implement nursing interventions that are most relevant to the patient's needs.10 By improving communication with patients, culturally competent nursing care increases patient satisfaction and encourages patients to participate in and adhere to the treatment regimen.4

Working effectively and efficiently in today's complex healthcare environment requires nurses to be aware of different intrapersonal, interpersonal, and contextual factors that influence their interactions with patients.5Intrapersonal factors relate to the nurse personally; interpersonal factors are those that can affect the nurse's interactions with patients, their families, and other healthcare professionals. For example, if a nurse has a stressful day at work and is also caring for some challenging patients (intrapersonal factor), the nurse's interactions and relationships with other patients (interpersonal factor) may be negatively affected. Similarly, if a nurse is caring for a critically ill patient, both the patient and the family require emotional support. But if the nurse's workload prevents the nurse from being fully present to the family, overall patient care may be affected.

Contextual factors are those hidden social, cultural, political, and economic factors that influence the nurse's relationship with patients.5 For example, a patient may refuse a surgical procedure for financial or familial reasons. If the nurse is not aware of the patient's reasons, the nurse might consider the patient “nonadherent” or resistant to the treatment plan.6

Among these described factors, intrapersonal factors such as patients' and nurses' cultural and social values can significantly affect the development of effective nurse-patient relationships, ultimately affecting the quality of overall nursing care.6,7 Many nations, including the US, United Kingdom, and Canada, have multicultural populations in which nurses from various cultures care for patients who are also culturally diverse. Because culture is an intrinsic part of who a person is, cultural competence is essential for delivering quality nursing care.8-10 However, it has also been argued that to promote culturally competent care, a greater emphasis has been placed on developing a culturally diverse workforce than on modulating the individual nurse's behaviors, awareness, and characteristics.3 Developing self-awareness, the focus of this article, can help individual nurses provide more culturally competent care to patients and their families regardless of their own cultural background.

What is self-awareness?

Self-awareness is an intrapersonal and introspective process one can use to explore and recognize personal, familial, and professional nursing values, social and cultural beliefs, and life experiences in different nursing situations.7 Self-aware nurses reflect on their strengths and limitations; acknowledge their racial, cultural, and religious prejudices; and recognize negative and positive potentials to care for patients in different contexts and settings.7,11

Besides cultivating an understanding of one's own personal strengths, limitations, emotions, and feelings, nurses who are self-aware recognize environmental factors and conditions that can influence their ability to provide effective care, such as time constraints or a heavy workload.11 In short, self-awareness is foundational for developing and fostering cross-cultural therapeutic relationships.12

Points for reflection

To learn more about your patients' cultural values and beliefs and compare them with your own beliefs, incorporate the following considerations into your nursing practice.

  • What are my patient's cultural beliefs and values?
  • How are my own cultural beliefs and values different from those of my patient?
  • What are my patient's fears, hopes, expectations, and beliefs about healthcare treatments and procedures?
  • How do my patient's views and beliefs contradict or concur with my own cultural beliefs?
  • Are any recommended healthcare treatments or nursing interventions likely to be culturally unacceptable to my patient?

Nurses can seek answers to these questions through patient and family interviews and personal observations at the time of patient admission and update the information as they learn more about their patients and families. Using this awareness, nurses can explore ways to provide better nursing care while respecting patients' cultural values and differences. Reflecting on previous encounters requiring cultural competence and learning from those experiences can significantly enhance a nurse's ability to care for other patients with similar cultural values.

A recent systematic review of six experimental studies that focused on educational interventions to enhance cultural competence reported that self-awareness and reflection are necessary for developing cultural competence in nurses.13 This review reported that the most useful educational interventions were those that encouraged nurses to explore their own culture and cultural values, professional background, biases, and prejudices.

Reflecting on personal biases

A nurse's personal religious and cultural beliefs can affect the ability to care for patients in a culturally competent manner. For example, if a nurse does not believe in the effectiveness of prayer as a healing method, this personal belief may prevent the nurse from cooperating with a patient's request for clergy or a nontraditional healer, leading to a failure to fulfill the patient's needs. When you are aware of your own biases and ingrained cultural values, you can prevent yourself from projecting those biases on to patients when providing care.7

Other examples of patients and situations that require cultural sensitivity and self-awareness include a patient who refuses a blood transfusion due to religious beliefs, a male Muslim patient who is not comfortable receiving physical care from female nurses, and a patient who may not speak English and requires the services of an interpreter. In line with these examples, a recent study reported that nurses indicated that when they are more aware of their own beliefs and assumptions about folk remedies and stereotypical views of ethnic groups, their ability to provide culturally competent care is enhanced.14 Acknowledging personal biases and judgments can help nurses genuinely view a nursing situation from the patients' perspective.

Applying CULTURE to practice

Self-awareness reminds nurses not to make judgments about their patients' cultural values. The author offers the CULTURE acronym to delineate how self-awareness can be used as a tool to enhance cultural competence and provide more sensitive care.

  • Challenge your own and others' biases and prejudices that may negatively affect your caring abilities.
  • Uncover how your cultural values and sociocultural and historical beliefs may affect your interactions with patients, their families, and other healthcare professionals.
  • Listen to the viewpoints of patients and others and learn about other cultures and religions.
  • Tune in to diversity in nursing situations and situate yourself among diverse cultural groups.
  • Use your experiences caring for culturally diverse patients to discern more meaningful ways of caring for patients in other similar nursing situations.
  • Respect your own and others' cultural values.
  • Evaluate how your awareness of your own and your patients' cultural beliefs allows you to provide culturally competent care and how you can use this knowledge in the future.

Various strategies can help nurses apply the CULTURE acronym in everyday nursing situations. Elements of reflective practice include keenly observing every nursing practice situation and noticing patient-care needs; keeping a diary; developing portfolios; and seeking feedback from patients, their families, and your colleagues.7 For example, nurses can use a diary to recount and reflect upon interesting experiences with patients from various cultural and religious backgrounds, identifying positive and negative aspects of these interactions. Based on what they learn from these experiences, they may find ways to modify future actions and interventions. Reflective accounts can also be placed in a portfolio.

Self-awareness is integral to culturally competent nursing care. Nurses who recognize their cultural biases are better prepared to manage them.


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cultural competence; reflective thinking; self-awareness; transcultural nursing

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