Developing cultural competence in nursing is important for two reasons:

• The nation’s health care needs are becoming as diverse as its population.
• Overall health for most Americans has improved, but health disparities related to race, ethnicity, and socioeconomic status continue to exist.

In general, minorities are receiving a disproportionately low quality of care that is evidenced by the range of health disparities found among racial and ethnic minority groups.

Patient Outcomes (Illness and Death)

• Rates of death from heart disease are 29% higher among African American adults than among White adults, and African American adults are 50% more likely to die from a stroke than White adults.
• Hispanics have higher incidence rates of cervical and stomach cancer than Whites.
• Mexican Americans, the largest Hispanic subgroup, are more than twice as likely as Whites to have diabetes.
• Of all the racial and ethnic minority groups in the U.S., American Indian/Alaskan Native populations have the highest rates of depression and suicide.

As nurses, we interact with a multitude of patients from diverse cultural backgrounds. As the frontline provider of patient care, nurses need to take a proactive approach to expanding the perception of what is means to provide “patient-centered care.” A holistic approach to patient care that includes cultural safety is an essential factor in eliminating healthcare disparities. When nurses fail to meet the cultural needs of patients, the patient may feel demeaned, disempowered and disrespected. These negative feelings can contribute to patients deciding not to access healthcare. This is where healthcare disparity often enters into the caring process.

Cultural Competence and Health Disparities

The Institute of Medicine reported: Minorities receive lower quality of health care even when socioeconomic and access related factors were controlled. Bias, stereotyping, prejudice, and clinical uncertainty may contribute to racial and ethnic disparities in health care.

Nurses should also be familiar with the following terms to help facilitate their understanding of cultural competency:

• Bias: An inclination or preference that interferes with impartial judgment
• Stereotype: An oversimplified conception, opinion, or belief about some aspect of an individual or group of people
• Prejudice: Irrational intolerance of or hostility toward members of a certain race, religion, or group
• Race: A local geographic or global human population distinguished as a more or less distinct group by genetically transmitted physical characteristics. A group of people united or classified together on the basis of common history, nationality, or geographic distribution
• Ethnicity: The characteristic of a group of people that share a common and distinctive racial, national, linguistic, or cultural heritage
• Assumption: Something taken for granted or accepted as true without proof
• Discrimination: Treatment or consideration based on class or category rather than individual merit, partiality or prejudice that results in unfair treatment

The Institute of Medicine recommends that health care providers "adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability and to improve the health and functioning of the people of the United States"

To reach this goal, nurses should aim to provide health care that is:

Safe Avoiding injuries to patients from the care that is intended to help them.
Effective Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
Patient-centered Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient Avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

Reducing Health Care Disparities

Nurses need to learn the facts about diverse population groups and examine and continually enhance their awareness, knowledge, and skills related to cultural differences. In doing so, it helps nurses ensure the delivery of effective, understandable, and respectful care for all patients.

Factors That May Affect Culturally Competent Care

Awareness of one's own values and those of the health care system is the foundation of culturally competent nursing. Ethnocentrism, essentialism, and power differences - for which beliefs and approaches may be conscious on unconscious - may affect a nurse's ability to provide culturally sensitive care.

Ethnocentrism is a belief that one’s way of life and view of the world are inherently superior to others and more desirable. Ethnocentrism in nursing may prevent nurses from working effectively with a patient whose beliefs or culture does not match their own ethnocentric worldview. Unaddressed ethnocentrism can compromise nurse–patient relationships and lead to misdiagnosis, mistreatment, and insufficient treatment.

Essentialism defines groups as “essentially” different, with characteristics “natural” to a group. Essentialism does not take into account variation within a culture. Essentialism can lead nurses to stereotype their patients. As such, their clinical practice focuses on beliefs about groups instead of individuals.

Power differences reflect the power imbalance in patient–provider relationships. Some ethnic and racial groups may feel powerless when faced with institutionalized racism and other forms of privilege enjoyed by the dominant group. Without knowing about power differences and their effects, nurses can perpetuate health disparities. Specifically, learning about a patient’s “truth” formed by culture, language, experience, history, alternative sources of care, and power differentials is an integral component in the delivery of culturally competent care.

Health care providers may have stereotypes about people from countries they are unfamiliar with and about second-language patients. Others may impose beliefs in their health system that contradict the culture of their patients. Ways of speaking may transmit biased attitudes more visibly than the spoken message, such as speaking louder or slower to folks in exaggerated ways.

Principles of Cultural Competence: Implications for Nurses

Patients benefit when nurses learn more and become confident in their ability to care for diverse cultural groups. Specifically, patients may be more satisfied with their health care interactions and may increase treatment compliance. Nurses have many ways to intervene with patients in a culturally appropriate way. However, nurses must be aware of the factors that affect their ability to provide culturally competent care, especially because their biases may be unconscious.

Culture shapes our language, behaviors, values, and institutions. Understanding culture can help us develop knowledge of how to interact with other groups and avoid prejudice, stereotypes, and biases. To be culturally competent means being able to understand how your patients present themselves based on their culture. Being culturally competent also means being able to manage your own cultural beliefs and those of your patients. Cultural competence can thus help you ensure the delivery of effective, understandable, and respectful care for all patients.

Factors that negatively impact cultural competence and delivery of culturally competent care include ethnocentrism (the belief in superiority of one’s ethnic group), essentialism (viewing other groups as essentially different), and power differences (the power imbalance in the patient-provider relationship). As a nurse, you must be aware of these factors, especially because your biases can be unconscious.

The First Step: The Need for Self-Awareness in Culturally Competent Nursing

Nursing continues to reflect the most common values of the majority culture, and nurses may project their own culturally based values and expectations onto patients whose beliefs about illness and health may be different from their own. Nurses and other health care providers have been socialized into a “provider culture” that may conflict with patients who have differing cultural beliefs. Furthermore, the background of minority patients may include discrimination, lack of quality health care, successful treatment with nontraditional medical approaches, or any number of other experiences that their nurses may not share.

Cultural Competence Self-Assessment Tools

A key component of cultural competence is to examine one’s own beliefs in terms of culture and identify and understand the different cultures in the communities served.

Self-assessment tools can help nurses learn about their own assumptions, biases, and stereotypes. As the previous situations with the health care provider and teens depicted, individual assumptions, biases, and stereotypes have an impact on how providers treat their patients. Awareness of one’s own beliefs and attitudes is a first step to ensuring that you are not providing differential care to patients based on assumptions, biases, and stereotypes. Nurses need to be aware of the many different beliefs and desires of their patients and not make assumptions based on their own beliefs or training.

To be culturally competent, it is very important to be aware of your own stereotypes and biases. These stereotypes and biases are not isolated facts; they are closely related to the socialization into your own social group and the provider culture and are acquired during this process. To effectively communicate with your patients across cultural lines, you need to critically examine your own beliefs and assumptions and continually monitor them.

It is important to treat the patients based on your knowledge of their culture and direct experience with them rather than on what you have heard about them. In other words, self-awareness of your assumptions and stereotypical beliefs can help you alleviate differential treatment of your patients. This is the first step toward cultural competence.

Developing Self-Awareness: Implications for Nurses

It is important for nurses to examine individual beliefs and behaviors, because they can lead to differential care of patients based on bias or stereotypes. There are many self-assessment tools available to assist nurses in assessing their own beliefs. Nurses should continually consider and monitor how their beliefs and assumptions might influence their interactions with patients.

A Self-Assessment Checklist: Promoting Cultural Diversity and Cultural Competencehas been provided as an exercise. Please take a few minutes to complete by choosing A, B, or C for each item. This is a self assessment tool and will remain confidential. This exercise is for your benefit to assess the level of bias or belief in stereotypes that you possess. With this information, you can affect changes in your behaviors toward your clients and others in personal situations. To make a difference it is important to reflect on the answers and to adjust your behaviors in such a way to meet the needs of your clients to provide better health care outcomes for them.

For more information on cultural competence for nurses and 9 free CEU’s, go to:
www.thinkculturalhealth.org

Sponsored by The U.S. Department of Health and Human Services Office of Minority Health