Imagine you become ill while traveling in a country where almost no one speaks English. When you’re able to establish rudimentary communication with someone, you ask about medical care and available medicines. With a sigh of relief, you follow the directions you’re given, only to find yourself at a street market where herbs are for sale. At that moment, you’d probably feel a bit lost because of the cultural disconnect. And depending on the seriousness of your illness, you might feel downright scared.

This scenario may give you a glimpse into what many people living in—not just traveling through—America experience when they seek health care. These people may or may not speak a language that American healthcare providers understand. And their concept of appropriate care probably isn’t in sync with our evidence-based approach. But these people are ill, and they do need understanding and care. That’s why healthcare providers, especially community health nurses, need to develop the skills to provide appropriate care for patients from diverse backgrounds. (See Understanding ourselves, understanding others.)

Becoming culturally competent

Culturally competent care means providing care within the context of a patient’s culture and beliefs. To provide this care as a community health nurse, you need to continually acquire knowledge, refine skills, and assess yourself. Becoming culturally competent is an ongoing process.

Nurses can develop cultural competence in different ways, but the key elements are experiences with patients from other cultures, an open-minded awareness of these experiences, and a respect for cultural differences. As part of the development process, community-health nurses should assess their cultural competence. (See Assessing your cultural competence.)

Performing a cultural assessment

A cultural nursing assessment is a systematic way to identify the beliefs, values, meanings, and behaviors of people while considering their history, life experiences, and social and physical environments. In a brief cultural assessment, you should ask about ethnic background, religious preference, family patterns, food preferences, eating patterns, and health practices.

Before the assessment, know the key topics to address and know how to address them without offending the patient and family. Determine if you’ll need an interpreter, and identify a patient confidante who may help bridge the cultural gap. Also, interview other providers who know the patient to obtain relevant information. Select a strategy for gathering data, such as a formal interview, an informal conversation, or observation.

During the assessment, be aware of the environment. Look around. Assess verbal and nonverbal communications.

The brief cultural assessment helps determine the need for an in-depth cultural assessment, which can be conducted over the course of the nurse-patient relationship, as trust builds. Questions may include:

• What do you think caused your health problem?
• What do you think made it start when it did?
• What does your sickness do to you?
• How severe is your sickness?
• How long do you expect it to last?
• What problems has your sickness caused?
• What do you fear about your sickness?
• What kind of treatment do you think you should receive?
• What results do you hope to receive from your treatment?

After making your nursing diagnoses, review patient and family responses regarding cultural beliefs and Western medical goals, so you can identify cultural factors that may influence the effectiveness of interventions.

Overcoming cultural dissonance

As a community health nurse, you may experience cultural dissonance, a sense of discomfort brought on by patient beliefs that are difficult to negotiate. Remember, every patient is unique, yet all have the same basic needs. The LEARN model can help:

• Listen with sympathy and understanding to the patient’s perception of the problem, using a nonjudgmental manner that encourages dialogue.
• Explain your perception of the problem.
• Acknowledge and discuss the differences and similarities between the two perceptions and build on the similarities.
• Recommend treatment from a cultural perspective.
• Negotiate an agreement regarding treatment that incorporates cultural aspects.

Ultimately, cultivating trust, understanding, and respect will promote the best outcomes.

You can use three approaches to facilitate the delivery of culturally competent care: cultural preservation, cultural accommodation, and cultural repatterning.

A nurse using cultural preservation supports the use of scientifically sound cultural practices, such as acupuncture for managing pain in a Chinese patient, and interventions from the biomedical healthcare system, such as using lower doses of opioid analgesics. A nurse using cultural accommodation supports and facilitates the use of cultural practices that have not been proven harmful—for instance, placing a key, coin, or other metal object on the umbilicus of a Mexican newborn, which is believed to promote healing. A nurse using cultural repatterning works with a patient to help him or her change cultural practices that are harmful. If, for example, a patient comes from a culture that values the use of herbs, a nurse needs to negotiate abstinence from particular herbs that can cause adverse effects.

Accommodating valued traditions usually produces the desired outcome, but the accommodation must be based on knowledge of the culture. A nurse can gain this knowledge from conversations, direct assessment, and other resources.

A failure to provide culturally competent care may result from a lack of understanding, organizational pressure regarding productivity, or peer influence. Stereotyping, prejudice, racism, ethnocentrism, cultural blindness, cultural imposition of one’s values on others, and cultural conflict arising from misunderstood expectations all can diminish or destroy a patient-nurse relationship.

Rules and responsibilities

Because of the overwhelming evidence regarding the relationship of culturally competent care and health outcomes, the federal government, professional organizations, accrediting bodies, and the private healthcare industry now place greater attention on cultural competence. The American Nurses Association, the National League for Nursing, and the American Association of Colleges of Nursing have standards for increasing the cultural competence of healthcare providers.

In 2000, the U.S. Department of Health and Human Services’ Office of Minority Health released national standards for culturally and linguistically appropriate services. These standards ensure that community-based organizations offer appropriate cultural care for patients, strive for diversity in staffing, provide education in culturally diverse care, provide language assistance services and translators, and supply the Patients’ Bill of Rights in the patients’ language. Organizations also must maintain an up-to-date cultural assessment of their services and develop partnerships to facilitate community involvement.

Role of nurses

Community health nurses must be active in efforts to deliver appropriate care to diverse populations. If patients can participate in their care and have a choice in their health-related goals, plans, and interventions, both patient compliance and outcomes will improve. As a community health nurse, you should constantly strive to provide the best possible care, while continuing to learn about others and about yourself.

Selected references

Campinha-Bacote J. Many faces: addressing diversity in health care. OJIN. 2003;8(1). www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Volume82003/No1Jan2003/
AddressingDiversityinHealthCare.aspx. Accessed March 12, 2009.

Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13(3):181-184.

Leininger M, McFarland M. Culture Care Diversity and Universality: A Worldwide Nursing Theory. 2nd ed. Sudbury, MA: Jones and Bartlett; 2006.

Purnell L, Paulanka B. Guide to Culturally Competent Health Care. Philadelphia, PA: F.A. Davis; 2005.

Stanhope M, Lancaster J. Foundations of Nursing in the Community: Community-Oriented Practice. 2nd ed. St. Louis, MO: Mosby; 2006.

Lauren M. Huber is head of staff development and nursing education for the Hebrew Hospital Home Care Community-Based Programs in Bronx, New York.