Cultural Competence in Nursing
Updated November 29, 2022
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Health disparity refers to health differences linked to economic, environmental, and social disadvantages that result in groups of people experiencing greater obstacles to health. Health equity seeks to reduce and eventually eliminate health disparities by allocating resources based on need.
Cultural awareness, diversity, and inclusivity in nursing strive to combat differences in healthcare that lead to worse health outcomes for disadvantaged racial and ethnic groups.
In some American regions, for example, the average life expectancy can vary by decades from one neighborhood to another. Dr. Jamil Norman, a registered nurse and nursing instructor, has found in her research that Black mothers in the U.S. are 3-4 times more likely to die in childbirth compared to white mothers.
"These health disparities for childbearing Black women have persisted despite overall improvements in pregnancy-related outcomes," Norman says.
This guide discusses cultural competence and how it relates to health equity in the U.S., and includes insights from nursing professionals on how both nurses and their patients can benefit from culturally competent care.
What is Cultural Competence in Nursing?
The word "culture" refers to integrated patterns of human behaviors, including norms, traditions, and values that affect the thinking and behavior of members of particular groups. Cultural competence describes the ability to effectively interact with people belonging to different cultures.
The importance of cultural competence in nursing focuses on health equity through patient-centered care, which requires seeing each patient as a unique person.
As Dr. Gregory Knapik, DNP and assistant professor of nursing, explains, "Nurses must be able to understand and appreciate different cultural backgrounds in order to do their job effectively and with the highest degree of care."
Norman specifies that "cultural competence is the willingness to understand and interact with people of different cultures, race, ethnicity, gender, and sexuality."
This approach allows nurse professionals to successfully treat patients even when patients' beliefs, practices, and values directly conflict with conventional medical and nursing guidelines. Nurses can develop the ability to tailor and explain treatment plans according to patients' needs, which may be influenced by cultural practices that don't fall within the parameters of conventional medicine.
"Utilizing cultural competence appropriately will allow for deeper connections with patients," says Knapik. "You will gain the trust of the patient by being empathetic to their differences and unique needs.”
Components of Culturally Competent Care
Culturally competent care consists of four components: awareness of one's cultural worldview, attitudes toward cultural differences, knowledge of different cultural practices and worldviews, and cross-cultural skills. Together, these components contribute to a high degree of cultural competency, and nurses can integrate them into the care of their patients.
- Awareness
- Nurses can pay close attention to their own biases and how they react to people whose backgrounds and cultural experiences differ from their own. For example, a person who becomes conscious that they think of immigrants as illegal aliens achieves cultural awareness of that particular bias.
- Attitude
- Once nurses tap into awareness, they can actively analyze their increased awareness and internal belief systems. Using the above example, the person can examine their background, beliefs, and values to understand their cultural bias regarding immigrants.
- Knowledge
- Often, individual beliefs and values do not correspond to their behavior and actions. Nurses can work to acknowledge that this disconnect exists and view knowledge as an important element of developing cultural competence. Research has shown that people who score low on prejudice tests may still use labels such as "illegal alien."
- Skills
- Nurses put their awareness, attitude, and knowledge into practice by repeating culturally competent behaviors until they become integrated into their daily interactions. These behaviors include effective and respectful communication and body language. Among various cultures, nonverbal communication methods, such as gestures, can mean very different things.
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Benefits of Culturally Competent Care
Research shows significant benefits resulting from culturally competent nursing care. Social benefits include fostering mutual respect, understanding, and trust; promoting inclusion and patient and family responsibilities for their health; and increasing community participation and involvement in health issues.
Health benefits include improved data collection, preventative care, cost savings, patient compliance, and patient outcomes. Cultural competence can also reduce healthcare disparities and missed medical visits. Healthcare businesses benefit from fewer barriers and costs, increased efficiency, higher legal and regulatory compliance, and access to different ideas, perspectives, and strategies in decision making.
Cultural competence in nursing can be observed through the following examples:
- Using language and terms patients understand
- Make sure a medical interpreter is present if the patient speaks another language, asking a family member to translate may not be enough
- Respecting patients' cultural and religious beliefs that conflict with treatment plans
- Recruiting health professionals from underserved, diverse, and LGBTQ+ communities
- Analyzing the ethnic composition demographics of patients currently served
- Identifying patients in underserved populations and communities
- Forming a committee of diverse nursing staff members to promote and coordinate cultural awareness measures, such as signage and forms in different languages and community outreach
Taking Steps to Improve Cultural Competence
Beginning in the mid-1980s, health officials began developing resources and guidelines to improve culturally competent nursing care:
- The Heckler Report, also called the Report on Black and Minority Health, was released in 1985 to mobilize elimination of health disparities.
- The federal Office of Minority Health was established in 1986 to implement the Heckler Report.
- The Healthy People 2010 agenda, which includes the goal of eliminating health disparities, released in 2000 with an update in 2010.
- National CLAS Standards, a 2000 federal report outlining culturally and linguistically appropriate services (CLAS) in health care, was updated in 2013.
- LEP Guidance, issued in 2000 and in 2003, addresses working with people with limited English proficiency (LEP).
- Think Cultural Health launched in 2004 as a clearinghouse of resources where healthcare professionals can find culturally and linguistically appropriate services.
- The National Partnership for Action to End Health Disparities is a community-driven approach to achieving health equity.
- MedlinePlus offers health information in multiple languages.
While nursing education curriculums do focus on health disparities prevalent in specific cultures and the importance of culturally competent care, Norman believes that further steps can be taken.
"Although I believe that the profession of nursing is doing a lot, there is still more that needs to be done," says Norman. "Until all health care disparities are eradicated, there is always more that can be done."
Tips for Nurses to Improve Cultural Competence
Cultural competence in nursing helps build trust more effectively, which leads to better patient outcomes. This guide describes how to build cultural competence in your own work and your team's.
1. Change your practitioner/patient perspective
Cultural competence in nursing means understanding differences in perspective. For example, in some Asian and Hispanic cultures, family members may not want the older adults in their family to find out how sick they are when they are diagnosed with a disease. Family members fear this knowledge will make their older family members give up.
Additionally, calling everyone by their first name immediately after meeting them is a friendly gesture in many parts of the United States. However, it may seem disrespectful to somebody from a culture where young people refer to elders as "Mr." or "Ms."
Showing respect is a fundamental part of how to build cultural competence. "Work from a place of humble partnership instead of from an imbalanced hierarchical notion of caregiver/care-recipient," says nursing faculty member Caroline Ortiz.
2. Share Something About Your Own Culture That May be Similar to Your Patient's Culture
Establishing common ground is another vital part of cultural competence in nursing. Sharing from your own experiences is often part of cultural competency training. Norman points out "This is just a great way to build rapport with your patient, and helps to break down preconceived barriers."
For example, if you are advising a patient about healthy eating, they might mention a favorite dish from their background, a dish that is not very healthy. Rather than saying not to eat it or eat less of it, share about a dish from your background that you might not want to give up, but that you now serve as a side dish rather than an entree, or you substituted ingredients to make it healthier.
3. Learn From Your Coworkers and Colleagues
"Working in a place that has people with different cultures, beliefs, genders, race, and ethnicity helps to foster an environment of belonging," Norman says. The more that an organization recognizes and treats diversity as an asset, the easier it is to learn cultural competence.
If people feel encouraged to bring their whole selves to work, staff can develop cultural competence during all their interactions. Informal learning and employee-led initiatives can augment formal cultural competency training. "Inquire about a cultural competency department or task force," Dr. Gregory Knapik, DNP and assistant professor of nursing, recommends.
Be sure that, as a supervisor, you respect the time and effort to learn or to teach. Avoid making people feel as though they have to be spokespeople for an entire group. For example, ask for "a Hindu perspective" from a Hindu staff member rather than "the Hindu perspective."
Sometimes, you need to respect that your staff member is not up for being a spokesperson at all, that they currently cannot undertake the emotional effort of educating. And that's okay.
4. Learn a New Language
Learning a new language can help to address many of the language gaps in healthcare. Language barriers have a negative impact on healthcare outcomes and on the satisfaction of both patients and providers.
While only qualified medical interpreters should provide interpretation for patients with limited English proficiency, learning medical vocabulary or common expressions creates a welcoming atmosphere and increases trust.
Knowing medical and healthcare vocabulary in another language also helps you understand patients or family members who might speak conversational English fluently, but be less familiar with healthcare terms.
Being multilingual is an asset for any healthcare job, especially if you speak a language widely spoken in the community, but less common among healthcare workers.
5. Complete Continuing Nursing Education Courses
Many organizations offer cultural competency training for healthcare workers. These include the following:
- The Office of Minority Health's free online cultural competency training, including the Cultural Competent Nursing Care course, is designed for online learning. Once you have completed the course, you can lead in-person facilitated sessions.
- Georgetown University's National Center for Cultural Competence provides online courses in how to build cultural competence with specific audiences.
The National LGTB Cancer Network offers cultural competency training for oncology professionals.
6. Reach Out to Clergy to Understand Different Faiths in Your Community
Clergy can provide valuable insights into faith communities and how different faiths perceive issues related to health. These perceptions may affect treatment plans or delivery.
For example, imams (Muslim clergy) can provide guidance on how to work with patients who wish to fast for Ramadan, but should not because of health considerations.
Similarly, understanding the Amish belief that the heart is the "soul of the body" can help healthcare workers communicate about heart health to Amish communities. Being able to speak about a faith with knowledge and respect will strengthen communication with patients.
7. Seek Out Opportunities to Work With Local Community Leaders or Organizations
Partnerships with local community leaders and organizations can help build your cultural competence in nursing and establish relationships that lead to stronger relationships. For example, your organization might invite leaders of community organizations to give a talk at your workplace about a particular group and its perceptions and needs.
This lecture series can lead to building partnerships for health education and health promotion, encouraging speakers of a language to become medical interpreters, or other ways to enhance trust and empathy.
Cultural competence in nursing builds a virtuous cycle of improved reputation and trust, leading to better health outcomes.
Sources
- Cultural competency training (n.d.) https://cancer-network.org/cultural-competency-training/
- Distance learning (n.d.) https://nccc.georgetown.edu/resources/distance.php
- Education. (n.d.). https://thinkculturalhealth.hhs.gov/education
- Karliner, Leah S. (2018). When patients and providers speak different languages. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
- Shamsi, Hilal Al et al. (2020). Implications of language barriers for healthcare: a systematic review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201401/
Meet Our Contributors
Jamil Norman, Ph.D., RN, CNE
Jamil Norman, Ph.D., RN, CNE, and academic coordinator for Walden University’s RN-to-BSN program, has more than 16 years of experience as a registered nurse and 12 years in higher education. Her areas of expertise include nursing research and women’s health nursing. At Walden, Dr. Norman teaches foundations of nursing research and topics in clinical nursing.
Caroline Ortiz, MSN, MPH, RN, NC-BC
Caroline Ortiz (MSN, MPH, RN, NC-BC) has 24+ years of nursing experience, combining holistic health approaches with conventional medical care. She is on the faculty of Pacific College of Health and Science's Holistic Nursing Program and is a Ph.D. candidate investigating the traditional healing practices of Mexican-American women.
Dr. Gregory Knapik, PMHCNS-BC, ANP-PC
Dr. Gregory Knapik is an assistant professor of nursing at Notre Dame College (NDC) in South Euclid, Ohio. He has been in healthcare for over 30 years and received his Ph.D. in nursing from Kent State University. He holds a doctor of nursing (ND) from Case Western Reserve University as well as two advanced certifications in PMHCNS-BC and ANP-PC. Prior to joining NDC, Knapik taught nursing courses at Kent State University, the University of Akron, and Walsh University. Currently, he teaches community health, mental health nursing, holistic nursing, and global nursing at NDC. Over his teaching career, he has traveled to Central America many times with his students to learn cultural competency in a deep, immersive way.
Reviewed By:
Karen Luu, MSN, PMHNP-BC
Karen Luu is a board-certified psychiatric mental health nurse practitioner. Luu holds a master of science degree in nursing from Azusa Pacific University as well as an undergraduate degree in public health science. She has seven years of nursing experience, which includes working at the Level II Trauma Center, community hospitals, mental health urgent care, and private practice. Luu is currently working at a private practice which specializes in bipolar disorder, schizophrenia, depression, anxiety, and PTSD. She emphasizes the importance of incorporating the recovery-based model in her everyday practice.
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