Author: Joan Chepkemoi, BSc nursing student, Novia UAS

Supervisor: Anita Wikberg RN, RM, PhD, Senior Lecturer, Novia UAS

Abstract

Nursing is a prestigious professional service that touches the heart of society and providing holistic care is a basic responsibility of nurses. Today, nurses provide health care to culturally diverse populations in various situations and different settings. Being culturally competent and skilled in this area has become an important parameter while delivering effective treatment and care provided to clients by understanding and accepting cultural diversity.

As a result, healthcare organizations are implementing more culturally sensitive healthcare systems to gap equality and quality care that is being delivered to a culturally diverse population. Thus, leading to the need for professionals who are skilled in cultural competency. This article, therefore, talks about the components of cultural competence that is cultural awareness, skills, knowledge, encounters, and desire in nursing, its importance, and communication as one of the challenges that one can come across during the nursing process as well as how to overcome this challenge.

Introduction

Due to migration across the world over the last few decades, the world is becoming more and more culturally and ethnically diverse (Wesołowska, et al.,2018). This phenomenon has brought an increasing and important concern for healthcare organizations to enhance responsiveness to the healthcare needs of diverse clients. As a result, various countries are implementing more culturally sensitive healthcare systems to increase the equality and quality of care provided to clients as well as avoiding discrimination against populations who are from diverse cultural backgrounds. In endeavouring to meet these goals, healthcare organizations are facing the need to have healthcare professionals who are skilled in cultural competency. Over time, cultural competence has gained national attention as a way of decreasing inequalities in healthcare. To improve the quality of care and enhance client outcomes, cultural aspects must be considered. (Osmancevic, Großschädl, Stijic, & Lohrmann, 2022)

In healthcare organizations, nurses are said to have a unique position of close contact with the clients as they spend more time mainly caring for them. For this reason, nurses should be skilled in cultural competency as they can meet clients from different cultural backgrounds other than their own (WHO, 2022). They need to understand and respect their client’s cultural heritage. In other words, when nurses consider their clients' race, culture, ethnicity, and cultural background, they become sensitive to them. Being culturally sensitive enables nurses to respond in a manner that is respectful and appropriate to clients from diverse cultures in a way that they recognize and affirm their worth, without ignoring their cultural background. This leads to a meaningful approach to healthcare with more informed perspectives of health and well-being as well as coping with diseases and death with these ethnic groups (Giger & Davidhizar, 2017; Osmancevic, Großschädl, Stijic, & Lohrmann, 2022).

Cultural competence and its importance to nursing

Cultural competence is made of two concepts, culture, and competence. Culture is defined as a pattern of learned but dynamic values and beliefs that give meaning to experience and influences the thoughts and actions of individuals of an ethnic group (Wikberg, 2021). Competence, on the other hand, refers to an ongoing process where one accepts and respects different cultural beliefs while not letting one’s own beliefs influence others (Lin, et al., 2019).

Therefore, cultural competence is defined as a continuous process whereby healthcare professionals endlessly endeavour to attain the capacity to work within the cultural context of the client, their family, or community effectively. Cultural competence entails five components that are entwined, they include: (1) cultural awareness, (2) cultural knowledge, (3) cultural skills, (4) cultural encounter, and (5) cultural desire (Campinha-Bacote, 2002).

Cultural awareness

Cultural awareness is examining oneself, being aware of your own culture first, as well as your professional background. For nurses to provide quality care for clients from different cultural backgrounds, first, they must realize their own cultural beliefs and that of the nursing profession.  By understanding their own cultural beliefs and values, recognizing biases, prejudice, and assumption of other persons who are from different cultural backgrounds will be easier.

Moreover, the ability to be aware of diversity among clients and acknowledging other cultural backgrounds will increase the quality of care among people from different ethnic groups. When nurses become unaware of how their own cultural values and beliefs can influence other persons from different cultures, there is a high risk that nurses can easily impose on others. Cultural imposition is when an individual imposes their own beliefs, behavioural patterns, and values on another person from a different culture. (Campinha-Bacote, 2002)

This component, therefore, helps nurses to become aware of the needs of clients from various ethnic groups without imposing their own cultural beliefs and values (Jirwe, Gerrish, & Emami, 2006). Cultural imposition can occur in many ways, for instance, in a situation where a nurse comes across an elderly client accompanied by a family member to the hospital. The nurse started conducting interviews directly with the family member instead of the client even though he is still capable of answering the questions. Another example, where cultural imposition can be seen is when a nurse tells a mother from an African country that she should not carry her baby with a sling (large rectangular cloth) as the nurse believes the bassinet to be quite safe for the baby. In African countries, it is common that every mother to carry their baby using a sling.

Cultural knowledge

Cultural knowledge is the process of obtaining knowledge about various diverse cultures and ethnic groups. It basically involves seeking information about the culture and beliefs of your client to better understand and interact with them. In seeking to obtain knowledge, one must focus on integrating issues such as (1) health-related beliefs and cultural values, (2) the incidence and prevalence of diseases, and (3) the efficacy of treatment. When it comes to health-related beliefs and values, it is necessary to understand the client’s worldview of things. This will help one in understanding how the client interprets illness. Incidence and prevalence of diseases involve seeking knowledge in terms of biocultural ecology, this is because incidences of diseases vary among ethnic populations. Without accurate information to help healthcare providers in terms of screening, treatments, and health education, achieving positive outcomes of healthcare provided to these populations will not be achieved. (Campinha-Bacote, 2002)

Furthermore, treatment efficacy is another issue that healthcare providers should not forget, as it seeks to address the way of obtaining cultural knowledge such as ethnic pharmacology. Ethnic pharmacology is defined as a study involving differences in drug metabolism among ethnic groups. Cultural knowledge, therefore, helps us to bear in mind that no individual is a stereotype of one’s original culture but rather a unique blend that can be seen within each culture, a life experience that is uniquely accumulated as well as a way of acculturation to other cultures. Furthermore, healthcare providers should develop their capacity to carry out cultural assessments with their clients (Campinha-Bacote, 2002). For example, in Finland, when a nurse comes by a client from regions where they practice female genital mutilation, they should have knowledge of what to expect, how to conduct the assessment as well as interviews as a means of collecting information. This is because Finland does not have this cultural practice. Another example is endemic diseases that are common in certain ethnic groups such as hypertension in the African American population (Sealey, Burnett, & Johnson, 2006).

Cultural skills

Cultural skills focus on the potentiality to collect relevant cultural information about the client’s presenting issues while performing an accurate cultural-based physical assessment. To carry out a cultural-based assessment, nurses must familiarise themselves on how to do this assessment (Campinha-Bacote, 2002). Cultural assessment is defined as a systematic examination of persons, groups, or communities based on their cultural beliefs, values, and behavioural patterns to find out the needs and interventional practices required by this group of people (Leininger, 1978, pp. 85-86). Nurses should know that when performing a cultural assessment, there are things like physical, biological, or physiological differences that the client can have which can influence their ability to do a precise as well as appropriate physical evaluation of the client. Knowing what to ask and what to look for during an examination of the client is important (Campinha-Bacote, 2002).

Communication is also another item that is important during the assessment. Due to differences in languages, an interpreter may be necessary to facilitate communication during the interview. This enhances the collection of accurate information while avoiding errors due to misunderstanding as well as inaccurate data that can cause misdiagnosis and incorrect treatment (Sealey, Burnett, & Johnson, 2006). Nurses, therefore, require the ability to understand their client’s cultural beliefs and values during the nursing process to come up with the needs that meet clients’ specific cultural needs. Culturally skilled nurses can for example organize a care plan together with their client. By doing this they form mutual goals as well as an understanding that suit them best and goes hand in hand with their cultural values and beliefs. This will enhance nurse-client trust and comfort that their care is in good hands. This concept is then important that nurses are skilled in this area otherwise they might not be able to accommodate the client’s perspective when making healthcare and lifestyle recommendations (Jirwe, Gerrish, & Emami, 2006).

For example, a female client from a Muslim religion with a wound injury on her head needs a physical examination. As a nurse, for you to do an assessment of the wound, it is important to have a female nurse. This is because according to the Muslim religion, no other male person should see them without a hijab unless it is their husband.  Another example is having a client with different skin color, without adequate skills, one can easily ignore or might not notice injuries or bruises. Leading to inaccurate physical examination which can affect diagnosis as well as treatment.

Cultural encounter

Cultural encounter encourages healthcare professionals to directly engage and interact with clients from various cultural backgrounds. By doing this, one’s existing belief about another culture can be modified hence preventing stereotyping that can occur when caring for the clients. Nevertheless, meeting a few people of a specific ethnic group does not mean that you are an expert when it comes to this ethnic group. This is because there is a chance that these few people you have met may or may not represent the beliefs, values, or behavioural patterns of the encountered cultural group which is referred to as intra-ethnic variation (Campinha-Bacote, 2002). Encounters also increase the provider’s response to verbal and non-verbal communication. In situations where verbal communication is not possible due to differences in language non-verbal communication can be used. As a nurse and when using non-verbal communication, it is important to know what it means to different ethnic groups (Sealey, Burnett, & Johnson, 2006).

Cultural encounters occur more often at the hospital whether with nurse-client or with the client’s loved ones. For example, a thumbs-up sign which seems to be easily understood by many could be offensive to other ethnic groups for whom they have a totally different meaning to it while to others it is not (Sealey, Burnett, & Johnson, 2006). Another situation occurs when a nurse comes across a client from an African country, and during their conversation, the client barely keeps eye contact. Keeping eye contact during a conversation in other cultures symbolizes attentiveness, honesty, and trust. Nurses found out by asking the client that in most African cultures when communicating with a person who is older than you, keeping direct eye contact is considered impolite. From this situation, therefore, nurses have encountered new cultural behaviour and learned its practices.

Cultural desire

According to Campinha-Bacote, (2002), cultural desire is the willingness of healthcare professionals to ‘want to’ engage in the process of cultural competence. She maintains that for nurses or healthcare providers to be truly culturally competent, while having had cultural encounters, knowledge, and skill as well as being culturally aware and being familiar with cultural encounters, they must truly want to care for culturally diverse clients. Since cultural desire involves being caring, ‘‘it has been said that people don’t care how much you know until they first know how much you care’’ (Campinha-Bacote, 2002, p. 183). Hence, respecting the client’s beliefs and values or following what the literature says is not enough, what is of grave importance is the nurse’s real desire to deliver care that is culturally relevant and responsive.

Therefore, for providers to provide culturally relevant care and good healthcare, they should not only be motivated by what the literature says to be correct, but their actions must go hand in hand with their feelings. It should be a genuine passion to be open as well as being flexible with whom they encounter, learn to accept differences, and come up with similarities. This process will not only show nurses’ desire but also humility.

This way, nurses maintain cultural competence that is relevant and that is challenged from day to day to learn new cultures in preparation for their next encounter rather than avoiding it (Campinha-Bacote, 2002; Sealey, Burnett, & Johnson, 2006). Cultural desire involves a situation where a maternity care nurse comes across a client who would like to have female relatives as support during birth rather than their husband which is common in African cultures. From this situation, nurses are motivated to learn about new experiences rather than being prejudiced.

Challenges of intercultural caring in nursing

There are various challenges nurses encountered from day to day when they come across clients from a different cultural background other than their own. The language barrier has appeared to pose more difficulty compared to other challenges, this is because, without an effective way to interact with clients, caring becomes difficult. Coming up with a caring plan that is suitable and comfortable to the cultural beliefs of the client might not be achieved.

Communication and Language barriers

Communication plays a major role in nursing, as clients share information that is vital to delivering quality care. When nurses come across clients from different cultural backgrounds, there is usually a barrier between them. In situations where they do not speak a common language or the style and patterns of communication differ, clients may feel neglected, helpless, and frustrated. When clients do not understand what is happening to them or feel that they have been misunderstood they can appear angry, non-compliant, or withdraw even if their health issues pose a negative consequence to their well-being. Therefore, communication and language barrier affect the nurse-client relationship which can cause conflicts between them. Leading to a lack of trust or even suspending their treatment completely (Campinha-Bacote, 2002; Giger & Davidhizar, 2017). There are several studies that show language barriers as a negative consequence when collecting, planning, and implementing quality care.  Some of these studies are as follows:

The studies carried out by Antón-Solanas et al., (2022) where nurses mentioned language barrier as a major obstacle they encountered when caring for clients from diverse cultures. Which was mainly reflected in the nurse-client relationship and the quality of care provided to them. Therefore, planning care that is effective, comfortable, and culturally appropriate for the clients was a challenge to the nurses and this led to low-quality care for clients from different cultural backgrounds. Hendson et al., (2015) also reported on communication issues that healthcare professionals encountered in neonatal intensive care units with immigrant families who had their infants admitted. This interfered with the interaction between families and the healthcare providers leading to stereotyping behaviours as well as lack of intuitive perceptions that nurses can use in needs required by the families. Also, during a crisis, language barrier was identified as having negatively affected the process of decision-making due to beliefs and values that weren’t communicated by the families causing poor relationships between nurses and these families. Families felt unsatisfied or misunderstood which in turn affected their experience in the neonatal intensive care unit.

Overcoming communication and language barrier

To gap issues related to communication and language barriers in hospitals, a professional interpreter can be used to ease communication. This will enable nurses and other healthcare professionals to feel safer and reduce misunderstandings or misinformation that can result from communication (Besey & Sibel, 2021). I have come across a situation where a family member who speaks a common language with the nurses is used as an interpreter for their families. This has also been described by Antón-Solanas et al., (2022) where children who spoke good Spanish were used in translating for their parents. Campinha-Bacote, (2002) continues to mention that using untrained professionals such as family or even friends can cause issues related to a lack of knowledge in terms of medical terminologies and what diseases entail leading to faulty and inaccurate information that is collected. In other situation, the client can withhold information that could be crucial for his/her treatment because they do not want their family members to know. As a nurse, therefore, it is important to evaluate whether or not to use the family members as an interpreter and if it is satisfactory for the client that another member of the family is aware of their medical issues (Giger & Davidhizar, 2017).

Another way of overcoming this issue is introducing cultures that have high patient admission to nurses and supporting and encouraging them to learn different languages. Learning a new language can be used as a means of reducing language barriers. This approach also helps in reducing the tedious work involved in booking time with an interpreter and when it comes to an emergency situation, one can act effectively (Besey & Sibel, 2021; Giger & Davidhizar, 2017). Professional interpreters are usually the golden standard and best option for mitigating language barriers in healthcare settings, their services can sometimes be unavailable and costly. Through the widespread use of mobile phones with application translators in today’s technological world, translation between various languages has become a convenient means that are readily available and inexpensive compared to professional interpreters. This can be seen as a way of improving clinical communication among healthcare professionals and their clients (Chang, Thyer, Hayne & Katz, 2014).

In studies carried out by Panayiotou et al., (2019) where the evaluation of 15 translation apps with iPad compatibility was done. Only 2 apps were rated to be suitable for usage in healthcare settings for everyday communication as both apps had easy as well as appropriate health phrases. These 2 apps are culturally and linguistically diverse Assist and Talk To Me. Nevertheless, caution should be considered while using these apps as it needs accuracy and capability to affirm that the client understands the conversation as it can result in miscommunication.  It is important to keep in mind that the use of these types of technology is accompanied by ethical issues and it affects the confidentiality and privacy of clients’ information. Furthermore, as a nurse, you should remember that professional interpreters should not be replaced by mobile phone application translators since these apps have neither been developed nor validated for their usage in the healthcare context.

Conclusion

Cultural competence has become a necessity in our today’s society and nursing. To be able to work harmoniously, being culturally sensitive as well as being culturally humble, openness to learning and encountering different cultures is necessary. This way you as a nurse become culturally competent, by understanding your worldviews and those of your clients. Furthermore, avoiding stereotyping and misapplication of scientific knowledge will enhance the quality and equality of care that nurses provide to clients. In the process of providing culturally based care to diverse cultural clients, challenges can be encountered, and nurses should be motivated to learn ways of overcoming these challenges rather than avoiding them. This is because nurses who are not culturally competent might act according to their own beliefs, values, and behavioural patterns leading to negative consequences such as cultural imposition, stereotyping, and prejudice as well as ethnocentrism.  Moreover, seeking and obtaining cultural information and then applying that knowledge will impact positively to clients’ healthcare outcomes when we come across them in the future. Therefore, nurses should have a consistent way of acquiring knowledge of cultural information during their nursing journey.

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