Our communities need culturally competent nursing care.
After completing this chapter, you should be able to:
• Define cultural competence.
• List practice issues related to cultural competence.
• Identify challenges in defining spirituality.
• Determine the cultural and spiritual beliefs of patients in the health care setting.
• Assess the 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. Individualizing the care nurses provide to patients is dependent on a thorough understanding of a person’s cultural identification. These factors demonstrate the need for nurses to understand cultural and spiritual differences among themselves and others.
The American Nurses Association (ANA) affirms in the Code of Ethics the necessity for the nurse to be sensitive to individual needs: “The need for and right to health care is universal, transcending all individual differences. Nurses consider the needs and respect the values of each person in every professional relationships and setting …” (ANA, 2015).
Dr. Margaret Leininger, considered a top authority on culture care diversity, proposed that cultural understanding would allow for peaceful relations among groups of people (Leininger, 2007). Some considered this philosophy so important 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 suboptimal 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). Culturally competent nurses are accountable for assessing and recognizing not only the differences but also the variation of being the same.
The mnemonic CULTURE, developed by Zerwekh (2016), can help 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 system barriers (Mazanec & Tyler, 2003). Provider barriers are those that a nurse may have, including lack of information about a culture’s customs regarding health care. System barriers are those that exist in an agency, because the agency’s structure and policies are not designed to support cultural diversity (McGibbon et al., 2008).
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 all 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 (U.S. Department of Health and Human Services, 2016). Through a web resource (https://www.thinkculturalhealth.hhs.gov/) and other offerings, this organization assists providers in delivering respectful, understandable, and effective care to patients of all ethnicities. This sort of education is crucial because of the increasing diversity of the American population.
Another barrier to cultural competence in the nursing profession is the need for a more diverse culture among nurses. Nursing programs have a difficult time recruiting diverse students and in some instances diversities such as English as a second language interfere with success in courses and on the NCLEX. It only makes sense that the more diverse the nursing profession, the more diverse the delivery of care, resulting in improved patient outcomes.
Health and Health Care Disparities
One of the goals of Healthy People 2020 is to eliminate health disparities (Healthy People 2020, 2016a). Health disparities are inequalities in disease morbidity and mortality in segments of the population. These disparities may be a result of 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 as are non-Hispanic whites. New cases of hepatitis and tuberculosis also are higher in Asians and Pacific Islanders than in whites (Healthy People 2020, 2016b). Visit the website: https://www.thinkculturalhealth.hhs.gov/.
Office of Minority Health and Disaster Preparedness
Office of Minority Health (OMH) is a part of the Department of Health and Human Services (DHHS). In 2009, OMH launched an initiative to help first responders better manage disasters and crises in diverse populations. Some of the issues addressed include
▪ Using interpreters
▪ Using bilingual materials
▪ Managing cultural variation
▪ Implementing culturally based standards
Inequalities in income and education are at the root of many health disparities. In general, those populations that 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 focusing on genomics, sleep, social and environmental factors that promote optimal health, as well as addressing the health needs of the lesbian, gay, bisexual, and transgender (LGBT) populations (Healthy People 2020, 2016b).
According to the Institute of Medicine (IOM) report Unequal Treatment, conscious bias and unconscious bias from health care professionals affect quality of care and hence lead 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. For example, what types of interviewing questions would you include during an initial nursing history of a transgender patient? When obtaining a patient’s sexual history, how would you address these questions to the lesbian, gay, bisexual, transgender, and queer and/or questioning (LGBTQ) community? Ignatavicius and Workman (2016) offer several interviewing questions about gender identity and sexual activity that nurses can use in their practice (Box 21.3).
The solutions to challenges of health and health care disparities are complex and are still being discovered (Critical Thinking Box 21.1). Some solutions involve increasing the diversity of health care providers; ensuring that all people have access to affordable, quality 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
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, 2015). For instance, in 2010 the U.S. Census Bureau reported that just over one-third of the American population was from a minority background (U.S. Census Bureau, 2011). However, in 2008 the National Sample Survey of Registered Nurses showed that minorities accounted for 16.8% of registered nurses. It is also important for minority faculty to mentor nursing students. In 2010, 12.6% of nursing faculty reported their ethnicity as one that falls under a minority category.
CRITICAL THINKING BOX 21.1Can you think of ways to decrease disparities in health and health care in your community? What projects could you do as a nursing student to make a positive impact? Could you devise a project as part of a class assignment or a Student Nurses Association activity?
The American Hospital Association (AHA) (2012) recommends that exposure to health careers begin early in the education of minority populations, as well as of males, 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, “In addition to training all staff on cultural competency, look for opportunities to employ bicultural clinical and administrative staff to improve education, care delivery, and ultimately, outcomes” (p. 12). See Box 21.1 for information about culturally diverse nurse–patient interactions, and see the end of this chapter for additional relevant websites and online resources.
What Is the Meaning of Spirituality?
One of the challenges for the nurse in providing spiritual care to patients is that there is not yet a clear definition of spirituality (Gijsberts et al., 2011). Health care professionals recognize the important relationship between patient well-being and spirituality, but many feel underprepared to assist patients in incorporating this aspect of their life into the health care setting (Blaber, Jones, & Willis, 2015). Many people confuse religion with spirituality, when in fact, they can be separate entities. Pesut et al. (2008) contend that current trends in health care tend to define religion as a set of institutionalized beliefs and rituals, whereas spirituality can be defined “as an individualized journey characterized by experiential descriptors such as meaning, purpose, transcendence, connectedness and energy” (p. 2804).
McSherry (2006) presents several components of spirituality with relevance to nursing, which is a helpful framework for understanding the spirituality concept (Box 21.4). At times, a spiritual advisor or chaplain may be called on for a patient’s or family’s spiritual needs. But there are times when these spiritual needs may be met most appropriately by the nurse (Bokinskie & Evanson, 2009).
A definition of spiritual nursing care is “an intuitive, interpersonal, altruistic, and integrative expression that is contingent upon the nurse’s awareness of the transcendent dimension of life but that reflects the patient’s reality” (Sawatzky & Pesut, 2005, p. 23). Spiritual distress is a NANDA-approved nursing diagnosis (Ackley & Ladwig, 2014). It is essential to include the subjective spiritual assessment of patients’ spiritual needs to assure there is a plan for providing ongoing interventions and evaluation of effectiveness. Examples of spiritual nursing interventions include prayer, presence, scripture reading, peaceful environment, meditation, music, pastoral care, inspiring hope, active listening, validation of patients’ thoughts and feelings, values clarification, sensitive responses to patient beliefs, and developing a trusting relationship (Callister et al., 2004). To that end, nurses have many resources available to them to improve the spiritual care of their patients so that the benefits of this important aspect of patient care can be realized.
• Spirituality is a universal concept relevant to all individuals.
• The uniqueness of the individual is paramount.
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