Cultural Competency: Current Practice

The purpose of this course is to prepare healthcare professionals to use their understanding of the influence of culture on clients and to apply appropriate standards of care.

Upon completion of this course the learner will be able to:

1. Define cultural competence in health care

2. Identify cultural disparity in health care

3. Identify Three Cultural Competence Models of Care

4. Discuss current standards and guidelines

5. Apply culturally competent care in healthcare practice

You are driving down a beautiful country road in Germany. You have always wanted to see this country and are enjoying the time with your family. Suddenly, you are upside down in the car. You hear sirens and strange voices. As you become more alert, you realize you have been in an accident. You frantically start looking for your family only to realize you cannot move. You try to call out, but your voice is very weak. The voices are louder now outside the car. They are talking in German. You can catch a few words here and there but are not sure what they are saying. As the paramedics reach you, you start asking about your family. However, they can’t understand you, and you can’t understand what they are saying. Imagine yourself in this scenario. How frightened are you? What are you thinking as this is all going on? How will you communicate your needs with the paramedics? This situation may seem unreal, but there are patients who feel just like this. What can be done to help this family? Who can they turn to?

Today’s health care system is a literal melting pot of individuals from various races, cultures, and ethnic backgrounds. It is estimated that by 2060, 57% of the US population will be composed of minorities.(12) Currently, one is five people speak a second language or use a primary language other than English.(23) Each culture has been own set of characteristics and issues about health care access called disparities. In order to provide competent and equal care to this diverse population, healthcare facilities need to develop cultural care programs. Nurses are in a unique position to provide care to a diverse population in many settings and on many levels of care.

Health care organizations such as The Institute of Medicine, The Robert Wood Johnson Foundation, the National League for Nursing and the American Nurses Association have identified a need for culturally competent care in nursing to reduce disparities in healthcare. Furthermore, Healthy People 2020 focuses on eliminating health disparities and providing equal care to all who need healthcare services. The ANA, in particular, created the American Academy of Nursing in 1973 for the sole purpose of advancing health care policy and practice. Within this organization is an expert panel on cultural competence. This panel developed the core guidelines for culturally competent nursing care based on the theory of social justice and the human rights framework which emphasizes that all people are entitled to health care and equal rights in the health care system. Equality in health care means that every patient regardless of race or ethnicity is given the same quality of care (3). This is a very important aspect of providing culturally competent care.

To understand culturally competent care, it is first important to define culture. Culture is not one variable or characteristic but rather a conglomerate of variables and characteristics. Although there are many definitions, culture can be broadly stated as behavioral patterns, values, beliefs, family life, and a way of living for a particular population (17). These characteristics guide worldviews and influence how decisions are made including health care decisions. Nurses who are aware of how these characteristics influence health care are in a much better position to provide care that is culturally acceptable. The outcome will improve quality of care and patient satisfaction (19). However, culture is more than just beliefs. It also includes biology, spiritual view, economics, as well as psychological and political situations. By recognizing these variables, nurses can help patients achieve improved health care outcomes.

Cultural awareness is the appreciation of this diversity and cultural sensitivity is respecting the diversity of the culture. Cultural competence then is an ongoing process in nursing. It is the understanding and ability to work effectively within the patient’s cultural needs (17, 19). However, understanding these concepts is only part of practicing cultural competence. Different cultures have different issues or health disparities. Typically health disparities are related to the patient’s characteristics and have a significant impact on health and health care practices (6).  Health disparities include income, age, comorbidities, insurance, lack of health care access, socioeconomics, racism, stress, health literacy, language, symptom expression, healthcare expectations and when to seek care (6).  The Institute of Medicine has linked healthcare disparities with poorer health outcomes (1). Knowledge of cultural competence by healthcare workers is a suggested strategy to reduce health care disparities mainly in the area of patient-nurse communication (3).

There are also legal standpoints of equality and discrimination that have migrated into healthcare. Title VI Civil Rights Act of 1964 does not allow federally funded programs to discriminate based on race, color or nationality (11). Therefore, federally funded health care programs must provide equal care to all patients. Furthermore, Title VI mandates equal care for patients with limited English speaking skills. The Title also requires language assistance for anyone who is part of a federally funded program including a health care program (11). This would include Medicare, Medicaid and state children’s health programs.

In 2000, the Clinton administration expanded upon the ideas of equal access to those with language barriers by requiring all federally assisted agencies to create a plan to help their clients who have language barriers (11). In 2007, the Joint Commission reported that hospitals lack the resources to provide language services. Furthermore, the report stated that demographic data was inconsistent, and few hospitals used the data to improve services (21). As a result, standards and methods to evaluate cultural care were created and include respecting the values and beliefs of others, provide adequate communication services, provide informed consent, provide culturally appropriate end of life care, and to ensure the equality of health care as part of standards of care (22).

Culturally competent nurses see all patients as being unique, and they can respect the patient’s health care beliefs. Asking the patient what their beliefs are in regards to health care is appropriate and will help determine care. Care includes assessment of the patient and the family’s cultural traditions, practices and values (6).

Communication is an essential skill in the assessment as well as in ongoing care. Nurses should perform a culturally based assessment that includes biological variations as well as reactions. Some reactions to look for are non-verbal such as looking to a family member and eye contact. Assess the patient’s perception of health and wellness. What traditions does the culture prescribe to? Are there any metaphors or slang language the nurse needs to be aware of? How does the patient respond to touch, space and time? (6). Answering these questions can help the nurse provide quality care. There are several assessment tools to help in understanding the patient and their perspective of health and wellness.

Most tools are based on Madeleine Leininger’s theory of Cultural Care. Leininger’s theory is founded on the idea that cultural heritage and customs are important to each group. It is imperative that nurses understand these customs and be able to care for each patient individually to preserve the cultural atmosphere. This translated in transcultural nursing care and several models of care were developed including Giger and Davidhizar, Purnell, and Camponha-Bacote.

Leininger’s Cultural Care Diversity and Universality Theory and the Sunrise model, which arose from the theory, started the revolution of defining cultural care and the use of cultural care concepts in the nursing assessment process. The Sunrise model uses components of Leininger’s Culture Care Diversity and Universality Theory that focuses on nursing care in a global environment and is multifaceted to include the culture’s characteristics in an interdependent relationship (12).  When used in conjunction with the theory, nurses have a powerful tool for practice.

Leininger used ideas from anthropology as well as her own experiences to develop a model of care that is universal and holistic in nature to assess how cultural components influence health perceptions of the patient as well as how nurses care for patients (18). The Sunrise Model has been used as the basis for several other models including Giger and Davidhizar’s Transcultural Assessment Model, Purnell’s Model for Cultural Competence and Campinha-Bacote’s Process of Cultural Concept Model.

Giger and Davidhizar’s Transcultural Assessment Model is based on six data collection areas (9). The model centers on the idea that although cultures are different in characteristics, they share basic factors.

• Communication- what language is spoken? How is silence used? Notice pronunciation of words, what non-verbal forms of communication are used?

• Space- what is personal space?, Notice body movements during conversations

• Social Orientation- Note what is the culture, race, ethnicity, family role and function, religion, work.

• Time- How is time used, how important is time, is there more focus on past, present or future?

• Environmental controls- What are current health practice? What is the definition of health and illness?

• Biological variations- physical dimensions, genetic susceptibility to disease, nutritional preferences, social support, coping structure

• Cultural uniqueness-Place of birth, race, length of time in this country

The Purnell Model for Cultural Competence is an assessment tool that can be used in primary, secondary and tertiary care. The model has its roots in several disciplines including biology, anthropology, sociology, economics, geography, political science, pharmacology, nutrition, communication, family development and social support (15, 18). Concepts from each discipline are reflected in the domains used in the model. It is conceptualized as a circle with society being the outer ring, community the second ring, family the third ring and inner ring is the person. There are 12 domains in the Purnell Model that are used as guides in the assessment. These are:

• Heritage- origin, residence, economics, topography, politics, education, occupation

• Communication- language, dialects, time, names, touch, facial expression, body language, spatial distancing, volume, tone, eye contact

• Family role and organization- structure, gender, roles, childrearing, social status, roles of child and elderly

• Workforce- language barriers, autonomy, dominant culture, secondary culture

• Biocultural ecology- biological and physical characteristics

• High-risk behaviors – safety, alcohol and drug

• Nutrition – common foods, rituals, limitations, health promotion

• Pregnancy and childrearing -fertility practices, view on pregnancy and child rearing, birthing, postpartum

• Death- rituals, bereavement

• Spirituality – religion, meaning of life, prayer, spirituality

• Health care practices -traditions, responsibility for health, self-medication, rehabilitation, beliefs, barriers

• Health care practitioner – perceptions, folk practices, gender health care status (16,18)

The model is based on the assumption that all health care providers need the same information and that the assessment is based on for factors of how the person functions in each factor of global society, family, personal practice, and health practices. Further, it is assumed that all cultures have similar core components but each culture has specific variations that can change over time. The model also assumes that health care providers understand the importance of culture in the assessment and care of each patient. 

Posted with permission by Dr. Larry Purnell (personal email communication, September 11, 2015

Campinha-Bacote’s Process of Cultural Concept Model views cultural care as a continuing process for the nurse and health care providers (4, 14). The model uses a combination of cultural desire, cultural awareness, cultural knowledge, cultural skill and cultural encounter. These constructs are designed to work together to aid the nurse in gaining perspective on cultural needs and care of the patient. Ideally, these constructs should also work together with an intersection where true cultural competence is achieved.

Inherent in the model is a self-awareness component for nurses to examine his or her own cultural practices and, therefore, be more sensitive to the cultural needs of others (14).

Another aspect of this model assumes that there is significant differentiation in each ethnic group, which Campinha-Bocate calls intra-ethnic variation (4). The model also relies on the belief that the nurse’s knowledge is directly related to providing culturally appropriate care. Furthermore, the model can be applied in any area of practice including research, administration, policy and education (4).

The models of cultural care have several similar constructs and foundations for culturally competent care. Each model of care can be used to aid the nurse becoming more culturally competent by being aware of the patient’s cultural background and expectation of health care. Furthermore, the nurse can ask specific questions about the patient’s healthcare beliefs and background in healthcare. However, being aware of the patient’s heritage and ideas on health is not enough. Becoming culturally competent and culturally sensitive means that the nurse must also reflect upon his or her own beliefs, values, and cultural background.

Self-awareness is the first step toward culturally competent care. This starts with knowing one’s own personal values and beliefs as well as nursing values and beliefs. This is helpful knowledge when assessing and understanding the cultural beliefs of patients. Being aware of your own biases and attitudes allows you to become more appreciative and sensitive to the needs of patients (7, 4). This means that the nurse must engage in introspection and reflection of his or her own attitudes toward different ethnic backgrounds and how those beliefs may impede care when working with different cultures. This is only one component, however. Nurses must be able to develop skills in delivering culturally competent care.

Knowledge is another step in gaining cultural competence. Knowledge is not just learning about different cultures. There is a need to understand the worldview of the patient as it pertains to their culture. Purnell (2008) defines worldview as how the individual sees the world based on their values and beliefs, which are part of their culture. Understanding the patient’s worldview will aid the nurse in understanding behaviors and beliefs that will directly impact care (7). Knowledge also entails learning about biological characteristics and variations as well as cultural practices (7).  This knowledge will also aid in assessment skills and communication. 

Communication is of vital importance in cultural competence. Communication within a cultural is socially constructed and often complex. It entails the variation of the culture, which can often be misconstrued. Misunderstandings can lead to incorrect assumptions, stereotyping, prejudice, and issues with cultural boundaries (10).  When communicating with patients from different cultures, it is important to keep in mind the norms of the culture. The differences that exist when two cultures communicate can impact the messages that are sent and how the messages are interpreted. This is defined as intercultural communication (2). In nursing practice this is often termed cross-cultural communication (5).

Cross-cultural communication includes all the elements of therapeutic communication including respect and appreciation for another language, the ability to observe and communicate without judgment, recognize cultural barriers, encourage expression, speak slowly and clearly without slang, show empathy and the ability to intervene when misunderstandings are noticed (5). Therapeutic communication skills, however, are more than language. Other strategies include active listening, paying attention to non-verbal cues, paying attention to perceptions of time, space, touch, expressions, and silence( 8). This also involves being able to understand how the patient perceives the situation and health treatments.

If an interpreter is needed the nurse should understand that cultural values can still impact the communication process with the interpreter (16). Family members should not be used as an interpreter as this can interfere with privacy and lead to bias in the assessment process (7). Once communication barriers are understood and overcome, therapeutic communication skills can enhance the conversation and assessment process. Using the patient’s own language and terms shows respect and caring (7).

The nurse-patient relationship is the core of nursing care. It must be understood that each situation is different. Nurses should make every attempt at communication and stay committed to advocating for patient care. The nurse-patient relationship will only be enhanced and will impact patient outcomes.

Skills in assessment and interventions are also important in the care of culturally diverse patients. The nurse should evaluate cultural information that is relevant to the care of the patient. (7) This includes asking open-ended questions and allowing for expression of the situation. Asking the patient what they think about the illness or injury and how will impact their life can reveal information about cultural perceptions (7). The nurse can alleviate fears and form a partnership with the patient, which will enhance the outcome.

Interventions in caring for a diverse population should rely on evidence-based approaches and the best available data (7). There is a significant amount of qualitative data on cultural variations; there is little on culturally competent interventions. Nevertheless, current studies used in practice can reduce disparities in health care.

Guidelines developed by the American Academy Expert Panel on Cultural Competence for culturally competent nursing care serve as a resource for nurses (Adopted from: Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., & Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing)..

1. Knowledge of Culture- Nurses need understanding of cultural norms, traditions and other variables to achieve health and wellness
2. Education and Training – Training in cultural variations and skills will be included in formal education and continuing education.
3. Critical Reflection – Nurses need to reflect on their own values, beliefs and heritage.  There should be awareness of how these factors can influence care giving to patients.
4. Cross-Cultural Communications – Use appropriate verbal and non –verbal communication skills to assess values, needs, beliefs, health practices and beliefs.
5. Culturally Competent Practice – Use knowledge and culturally sensitive skills to provide nursing care.
6. Cultural Competence in Health Care Systems and Organizations – Organizations should provide resources to meet the needs of a diverse population.
7. Patient Advocacy and Empowerment – Nurses need to recognize the impact of policy, procedure on patient care and advocate for cultural needs of patients.
8. Multicultural Workforce – Focus recruitment and retention on gaining a multicultural workforce.
9. Cross-Cultural Leadership - Nurses should have the influence to impact culturally competent care across the health system continuum.
10. Evidence Based Practice and Research – Interventions should be tested and shown to be effective for the diverse population. If there is a lack of evidence, nurses should conduct research to reduce disparities.

In conclusion, our Nation is a vessel for many ethnic nationalities each with its own subculture and ideas on health care. The nurse is a unique caregiver that has a responsibility to care for a variety of individuals with different ethnic backgrounds and cultural beliefs. Cultural competence is important in nursing care and is an ongoing process of learning, advocating, and understanding. The journey begins with self-reflection of ideas on different cultures as well as one’s personal and nursing culture. Conflicts need to be identified and an awareness of how one’s own ideas can impact care. Education on communication and assessment skills are of utmost importance. Nurses should seek out resources to be better able to understand how to care for a diverse patient population. Furthermore, nurses should rely on therapeutic communication techniques and use an interpreter is warranted. Finally, nurses need to use the best evidence-based resources and data available. Where there is a gap in the knowledge base, it is important that research is conducted to continue to reduce healthcare disparities.

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22. The Joint Commission. (2007b). The Joint Commission 2007 Requirements Related to the Provision of Culturally and Linguistically Appropriate Health Care

23. U.S. Census Bureau. Table 1. Detailed languages spoken at home and ability to speak English for the population 5 years and over for the United States: 2006-2008. 2010 (Visit Source).