Tim J. Bristol, PhD, RN, CNE
Cultural and Spiritual Awareness
[10 People, 10 Colors]
—JAPANESE PROVERB
Thanks to the previous author of this chapter—Valerie Eschiti, PhD, RN, CHTP, AHN-BC.
After completing this chapter, you should be able to:
• List practice issues related to cultural competence.
• Identify challenges in defining spirituality.
• Determine cultural and spiritual beliefs of patients in the health care setting.
• Assess spiritual needs of patients in the health care setting.
Culture and Spirituality
What Is Meant by Cultural Competence?
In today’s global society, cultural competence is necessary for excellence in nursing care. People can travel like never before. Nurses are connecting to patients through the Internet. Medical “tourism” is now a reality. These factors demonstrate the need for nurses to understand cultural and spiritual differences in themselves and others.
The American Nurses Association (ANA) asserts that the necessity of the nurse being sensitive to individual needs in the Code of Ethics: “The need for health care is universal, transcending all individual differences. The nurse establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice. An individual’s lifestyle, values system, and religious beliefs should be considered in planning health care with and for each patient” (ANA, 2005).
Dr. Margaret Leininger, considered a top authority on culture care diversity, proposes that cultural understanding would allow for peaceful relations among people groups (Leininger, 2007). This philosophy was considered so important by some, that Dr. Leininger was nominated for the Nobel Peace Prize. Cultural competence is essential for nurses.
But what exactly is cultural competence? It is defined as “developing an awareness of one’s own existence, sensations, thoughts, and environment without letting it have an undue influence on those from other backgrounds; demonstrating knowledge and understanding of the patient’s culture; accepting and respecting cultural differences; adapting care to be congruent with the patient’s culture” (Purnell & Paulanka, 2008, p 6).
“Inattention to cultural competence in patient care leads, at best, to sub-optimal patient outcomes and, at worst, to active harm,” says Carla Serlin, PhD, RN, director of ANA’s Ethnic/Racial Minority Fellowship Programs. “When we fail to address issues of difference such as language, ethnicity and race, our patients will have lower levels of compliance with care instructions and longer hospital stays” (as cited in Stewart, 1998, p 1).
A mnemonic, CULTURE, developed by Zerwekh and Claborn (2006) can be helpful for nurses to assess and improve their level of cultural competence (Box 21-1). In addition, nurses need to use effective cultural interviewing questions, which are best if left semistructured and open-ended. Spector (2000) has identified nine suggestions for enhancing communication when gathering cultural data (Box 21-2).
What Practice Issues Are Related to Cultural Competence?
Barriers to Cultural Competence.
Two categories of barriers to cultural competence exist: provider barriers and systems barriers (Mazanec & Tyler, 2003). Provider barriers are those such as a nurse may have, including lack of information about a culture’s customs regarding end-of-life care. Systems barriers are those that exist in an agency, because the agency’s structure and policies are not designed to support cultural diversity (Mazanec & Tyler, 2003).
For instance, an American Indian family may wish to spend the night in the intensive care unit room with a critically ill family member. However, the room does not have a cot on which to sleep, and the waiting room is not large enough to accommodate all the family and extended family members who are present to support the patient. The community in which the hospital is located has a large American Indian population. The nurse, as an advocate for patients and their families, can intervene through activities such as joining a hospital committee focused on hospital redesign. The nurse can point out the need for space for family members to stay the night near their loved ones. In this way the nurse supports the needs of the cultural diversity in her community.
Many organizations are involved in improving cultural competency in the health care industry. One governmental organization (Office of Minority Health) provides extensive continuing education for health care professionals (AHRQ, 2009). Through a web resource (www.thinkculturalhealth.org) and other offerings, they assist providers in delivering respectful, understandable, and effective care to patients of all ethnicities. Education like this is crucial because of the increasing diversity of the American population.
Health and Health Care Disparities.
One of the goals of Healthy People 2020 is to eliminate health disparities (Healthy People 2020, 2010). Health disparities are inequalities in disease morbidity and mortality in segments of the population. These disparities may be due to differences in race or ethnicity. They are believed to be the result of the interaction among genetic variations, environmental factors, and health behaviors. For instance, the infant death rate among blacks is more than double that of whites. American Indians and Alaska Natives have an infant death rate almost double that for whites. Also, their rate of diabetes is more than twice that for whites. Hispanics are almost twice as likely to die of diabetes than are non-Hispanic whites. New cases of hepatitis and tuberculosis also are higher in Asians and Pacific Islanders than in whites (Healthy People 2010, 2000).
Inequalities in income and education are at the root of many health disparities. In general, those populations who have the worst health status are those that have the highest poverty rates and the least education. Low income and low education levels are associated with differences in rates of illness and death, including heart disease, diabetes, obesity, and low birth weight. Higher incomes allow better access to medical care, enable people to afford better housing and live in safer neighborhoods, and increase the opportunity to engage in health-promoting behaviors. Recent initiatives are even focusing on increasing the minority representation amongst workers in the health care industry (Healthy People 2020, 2010).
According to the Institute of Medicine (IOM) report Unequal Treatment, conscious and unconscious bias from health care professionals affects quality of care and hence leads to health disparities (Smedley et al, 2003; White-Means et al, 2009). Some of the causes of health care disparities include provider variables and patient variables. Provider variables are provider/patient relationships, lack of minority providers, as well as provider bias and discrimination. Studies have clearly demonstrated that providers will often make different plans for different patients when the only difference is culture or skin tone. Patient variables are mistrust of the health care system and refusal of treatment (Baldwin, 2003). Often this mistrust comes from barriers in communication.
The solutions to challenges of health and health care disparities are complex and still being discovered (Critical Thinking Box 21-1). Some solutions are increasing the diversity of health care providers; ensuring that all people have access to affordable, basic health care; promoting wellness and a healthy lifestyle; strengthening provider/patient relationships; increasing cultural competency of health care providers; and conducting research to determine why certain diseases affect minorities so greatly and to discover effective intervention strategies (Baldwin, 2003).
Culturally Diverse Work Force.
In order to meet the health care needs of an increasingly diverse society, it would be beneficial to have such diversity represented in the nursing profession. Unfortunately, the diversity of the nursing workforce does not mirror that of the U.S. population (AACN, 2009). For instance, in 2007 the U.S. Census Bureau reported that 34% of the American population was from a minority background. However, in 2004 the National Sample Survey of Registered Nurses showed that minorities accounted for 10.7% of registered nurses. It is also important to have minority faculty to mentor nursing students. In 2008, 10.7% of nursing faculty listed a minority for their ethnicity.
The American Hospital Association (2002) recommends that exposure to health careers begin early in the education of minority populations, as well as males, in order to reach out to those who are currently underrepresented in nursing and who will account for an increasing share of the labor pool. The AHA states, “Improving diversity will not only help solve the workforce crisis, but also enhance the cultural competencies of hospitals, making them more responsive to their communities’ health care needs” (p 47). See Evidence-Based Practice Box 21-1 for information about culturally diverse nurse-patient interactions.
BOX 21-1
Evidence-Based Practice
Cultural Diversity
Practice Issue
With the increasing diversity of patients, relationships between nurses and patients may become strained if there is lack of cultural awareness between them. It is vital to maintain positive nurse-patient interactions, in order for patients to achieve the highest level of health and well-being.
Implications for Nursing Practice
Three themes emerged from this study—shared tension, perceived differences, and held awareness.
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