Cultural Competence In Nursing: What It Is And Why It Matters

Many people go into nursing thinking that simply learning practical care techniques is all you need to succeed. As any seasoned nurse knows, there’s a lot more to it than that, and one area. You can have very good social skills for use in daily life and still struggle with the complexity of some of the challenges you will face as a nurse. In most roles, you will be treating patients from a wide range of cultural backgrounds. This article explains why cultural competence is so important, and some of the core concepts involved.

What is cultural competence?

Did you know that black women in the US face significantly higher rates of heart disease, stroke, cancer, diabetes, and maternal mortality than their white counterparts? There are multiple reasons for this, but it throws light on two crucial concerns. Firstly, work needs to be done to reduce these disparities and improve health outcomes across the board. Secondly, while these disparities exist, they need to be taken into account in the treatment of black female patients. Both these concerns fall into the area of cultural competence.

Cultural competence involves recognizing the differences between your own culture and your patient’s, and understanding that, because of this, you won’t always be able to project, based on your own experience and perceptions, so as to understand how that patient thinks or what that patient needs. Nurses must work to develop their cultural competence skills, particularly those nurses from a mainstream cultural background, who have not been exposed to the cultural nuances that come with treating minorities. Every nurse needs to work hard to develop skills in this area, but it can be particularly hard for white people from a mainstream cultural background who may have never had to make an effort to adjust like this before. Fortunately, there’s lots of help out there, and with the right education, you’ll soon be making progress.

Five components of cultural competence

Different organizations frame cultural competence in different ways, but reflecting on these five points will help you to understand and get to grips with how it works.

• Awareness – The first step in developing cultural competence involves simply being aware that your patient may not share your own cultural background, and as a result, you may experience differences of opinion, or friction when communicating.
• Knowledge – It’s important to learn as much as you can about your patient’s culture so that you can serve them to the best of your ability. Seek out online resources, read, talk to colleagues, and practice active listening.
• Attitude – Adjusting to somebody else’s culture takes effort, and you need to be willing to put that effort in without giving way to frustration or feeling resentful. An open and curious attitude is vital.
• Skill – You’ll need to develop the skills required to identify cultural differences and their potential impacts on care provision and to work around them, both generally and in specific cultural contexts.
• Empathy – Although it’s not enough on its own, empathy is a big help in developing cultural competence, enabling you to recognize that your patient has the same feelings as you, even if they manifest in different ways. 

Five barriers to cultural competence

As well as acknowledging how to best implement cultural competence, it’s also important to reflect on what might be holding you back when it comes to treating patients from different cultural backgrounds to your own. Improving in this way is a lifelong journey, and we can all find ways to do better, no matter how much effort we may have put in in the past. Some common barriers to implementing cultural competence effectively are:

• Ethnocentrism – Whenever we’re not actively paying attention to it, we all inherently see the world from the perspective of our own cultural backgrounds. This creates unconscious bias, which can affect our behavior, even when we think we’re being neutral.
• Language differences – Effective communication is crucial when it comes to patient care. It’s difficult to look after a patient properly if you don’t share a language, or if you use the same language in very different ways, while translation brings complications of its own.
• Stereotyping – It’s important to be aware of cultural stereotypes and the ways in which they may influence your decision-making, as well as strive to see beyond them and approach each patient as an individual.
• Different value systems – If you don’t share the same values as somebody from a different culture, it’s still important to be respectful of those values and adjust your approach to treatment accordingly.
• Psychological inflexibility – It’s almost impossible to make progress in understanding your patients without being willing to put yourself through psychological discomfort, It is important to care for your own psychological well-being, face difficult emotions and critically evaluate your own ways of thinking, in order to ensure you are in the best place to care for your patients.

Avoiding offense

The very minimum that any patient should be able to expect from a nurse is not being treated in a way that is actually offensive. Avoiding this, however, can be trickier than it seems. A good starting point is to recognize that what you say can still hurt someone even if you have good intentions and that although using the wrong words might seem trivial, especially if you realize what you’ve done and apologize, people from minority communities may have that experience several times a day, which isn’t trivial at all. Using the right language isn’t simply a case of avoiding obviously offensive terms. There are a lot of ways in which commonplace language can cause distress, such as talking about ‘illegal aliens’ or describing black women as ‘uppity’. It can also be very offensive to misidentify someone’s ethnicity, particularly if you confuse it with one where there is traditional conflict, such as calling a Pakistani person an Indian.

Providing the right support

Understanding your patient’s cultural background is important in ensuring that you can deliver effective care. It can make a big difference in making a patient feel comfortable when their carers are aware and open to their cultural practices. For example, for a Muslim patient who is fasting during Ramadan, it’s not helpful to suggest taking a pill three times a day before a meal. You can, however, within the rules of their religion, ask them to eat a small amount of food with a pill at three specific times. You will also need to recognize that the norms of caregiving are different in different cultures. White people often assume that the person providing care will be the patient’s partner, but in Hispanic communities, it’s more likely to be one of their teenage or adult children. In African American communities, it’s often somebody who doesn’t have a family relationship with the patient at all. Understanding this and the many other variations present in other communities means that you can make sure the right people have the information they need to do the job.

Avoiding misunderstandings

Different cultural backgrounds, and especially different native languages (even if people also speak fluent English) can affect the way in which patients discuss their symptoms and healthcare experiences, potentially leading to serious misunderstandings. When you’re dealing with somebody from an unfamiliar cultural background, always allow extra time so that you can make sure you understand each other clearly. To ensure that your patient doesn’t feel patronized, explain that you’re concerned that you might misunderstand something and that you’re grateful for the patient making an extra effort. If the patient acknowledges that it’s difficult, try bringing in additional communication tools, such as a pen and paper, so that the patient can draw pictures to help illustrate the problem (this technique also works well when you’re struggling to understand very young patients). Encourage your patients to take away information leaflets and read them (with the help of a translator if necessary) and make sure that they know how to contact you and feel confident about doing so, if they subsequently suspect that something has been misunderstood.

Dealing with translation

In instances where you don’t speak the same language as your patient, a common solution is to have a relative or community member step in to translate. This can work if it’s clear that the problem and solution are very simple, but it’s important to be aware of the risks of misinterpretation. You should keep your language as simple as possible and try to use words that a new speaker of English is more likely to understand. Using a translation phone app can help but, again, it can sometimes get it wrong. If at all possible, you should seek the services of a qualified medical interpreter, who will not only know both languages but have a clear understanding of what you’re trying to communicate. Some such translators now work remotely, making it easier to get hold of them at short notice.

Improving communication

Communication goes beyond the words you use, and even when your patient speaks fluent English, cultural factors can interfere with how each of you understands the other. In some cultures, it’s unusual for women to be in positions of authority, so female nurses need to work carefully with first-generation immigrants to reassure them that they know that they are fully qualified and trustworthy. While it’s normal in the US to refer to patients by their first names, this is something that people from other cultures can find uncomfortable, overly familiar, and inappropriate. Touching patients can be interpreted in the same way, even if you’re just trying to reassure them. While male nurses tend to be aware that female patients can respond negatively to such contact, in some cultures, it’s also disconcerting for men to be touched by women.

Respecting family dynamics

When you’re working out treatment protocols and obtaining consent from patients from different cultural backgrounds, you will need to recognize that the ways decisions are made within their families may be very different. The age at which young people are considered capable of medical consent varies culturally, and even though the law is the same for everyone, this will affect the degree to which their parents stand back or feel it necessary to assert their concerns. In some cultures, it’s the head of the family – usually but not always a man – who makes decisions for young people or women, and, with the patient’s permission, you will need to bring that person into your confidence and ensure that they are made aware of important information. In other cases, women’s husbands will make decisions for them. If you feel uncomfortable with this, bear in mind that a patient who is used to this may feel more unsettled and vulnerable if told that it’s not acceptable, but do make sure that she understands that you care about what she thinks. As always, listening is key, and the same applies when it comes to determining whom you should inform about a diagnosis. In some cultures, illness is a very private matter.

Anticipating difficulties

When you’re aware of a patient’s cultural background, you’ll have a better idea of where you might meet with resistance to standard treatment protocols. Being aware of potential issues in advance puts you in the best position to treat the patient effectively. Knowing a patient’s cultural background, for example, might allow you to refer to cultural and religious practices that the patient is familiar with in order to make them more comfortable when undergoing treatment. Being aware of different cultural practices might also allow one to prepare for instances in which a patient refuses treatment on account of their cultural or religious practices. It is always important to respect and understand a patient’s cultural value system.

Coordinating with complementary treatments

Often a patient’s cultural background will come with beliefs about the best form of treatment for illness or injury that don’t correspond to your own. It’s important not to patronize patients in this situation. They deserve the same respect as anyone else, and furthermore, access to traditional treatments can be psychologically important. Regardless of a patient’s cultural background, they deserve respect from their healthcare providers.  If they’re told in absolute terms not to use an important traditional approach, there’s always a risk that they’ll do so in secret. It’s much safer if you know what patients are doing on their own initiative so that, as far as possible, the treatments which you are responsible for can be coordinated with them. As an example, slipper elm is commonly used by native tribes to treat gut problems. It’s a simple mutagen, so usually safe to use alongside other medicines, but taking it at the same time can potentially affect absorption. Taking the time to talk through this with patients can prevent potentially harmful complications from occurring.

When you don’t know

In some parts of the country, the population is fairly homogenous, but in places such as New York City, with multiple immigrant populations, it can be very difficult to have sufficient cultural knowledge to deal with every patient you encounter. In this situation, it’s important to be honest about the limits of your knowledge and take your cue from the patient. Practice active listening and make it clear that you’re ready to learn, but be careful not to make them feel that they’re obliged to educate you on top of dealing with what may already be a stressful situation. Check if there are other places you should be looking for help in improving your understanding.

Demographic research

Courses such as an accelerated BSN nursing program online through Elmhurst University, teach you the value of focusing on the importance of prior planning and research to improve your understanding of particular patient groups. This course gives you everything you need to prepare for the NCLEX exam, but once you qualify, you’ll need to apply what you’ve been taught to the specific patient population you’re working with. Establish its demographics and work to identify resources which can improve your understanding. Understanding your demographic is key. In addition to your studies, it could be helpful to meet with religious or community leaders, who will also be able to advise you on local issues affecting the health of the people you and they serve.

Beyond race and background

Although we tend to think of cultural competence in relation to people from different racial or national backgrounds, it also applies to other minority groups. LGBTQ+ people, for instance, often have different ways of communicating about health issues, different forms of social interdependency, and different requirements when it comes to feeling safe and respected in the context of care. Neurodivergent people can have different communication styles and ways of processing information. Improving your core cultural competence skills will help you to do a better job of caring for them, too.

Improving your cultural competence requires ongoing work, but it can make a massive difference in the health outcomes of your patients. It will also broaden your perspectives on life more generally and give you a richer appreciation of the world in which you live.