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Culturally Competent Nursing Care

2004; American Association of Critical-Care Nurses; Volume: 24; Issue: 4 Linguagem: Inglês

10.4037/ccn2004.24.4.48

1940-8250

Deborah L. Flowers,

Palliative Care and End-of-Life Issues

Throughout the centuries, nursing has been a dynamic, continuously evolving entity, changing and adapting in response to a wide range of stimuli. Changes in societal norms and expectations, discoveries of new medical treatments, developments in highly sophisticated technical systems, and breakthroughs in pharmaceutical treatments have helped shape contemporary nursing practice. Another recent trend that has influenced nursing considerably is the consumer mandate for culturally competent care in an increasingly diverse, multicultural society.The ability to provide culturally competent care is especially important for critical care nurses, who function in high-acuity, high-stress healthcare environments. Critical care nurses must develop cultural competency to be effective in establishing rapport with patients, and to accurately assess, develop, and implement nursing interventions designed to meet patients' needs. As patients' advocates, critical care nurses are required to support decisions made by patients or patients' families that may reflect a cultural perspective that conflicts with mainstream healthcare practices. In today's society, culturally competent care cannot be offered to all patients unless nurses have a clear understanding of diverse cultural backgrounds.In this article, I describe current population trends in North America, discuss the need for critical care nurses to develop cultural competence, present a model for development of cultural competence, and describe common pitfalls in the delivery of culturally competent care.Demographic changes in many countries reflect an increasingly diverse population. For example, in Sweden, a society that once reflected only a single or perhaps a few ethnic groups now comprises more than 100 different ethnic groups. On the basis of their society's changing demographics, healthcare professionals in Sweden have begun to address the need for "establishing a commitment and a way of working to facilitate the development of cultural competence" in various healthcare situations.1 To this end, the executive committee of the Public Health and Medical Services in Sweden has begun to assess the need for culturally competent care and to develop training programs for healthcare workers that are designed to address this need.1The United States also has experienced a change in demographics stimulated by an influx of persons from diverse ethnic and cultural groups. If current population trends continue, it is projected that by the year 2080, the white population will become a minority group, constituting 48.9% of the total population of the United States.2 Data from the censuses of 1980 and 2000 (Table 1) illustrate a marked change in ethnic population trends among 4 ethnic groups: white, African American, Hispanic, and Native American.3The increasingly multicultural profile of the US population requires that nurses provide culturally competent nursing care.The American Nurses Association recognized the need to provide culturally competent care and stated in the association's code that nurses, in all professional relationships, should "practice with compassion and respect for the inherent dignity, worth, and uniqueness of every individual."5 The tragedy of the attack on the World Trade Center in New York City, which necessitated emergency and critical care for many persons from diverse, multicultural backgrounds, underscored the need for nurses to provide culturally competent care. Provision of such care requires that nurses recognize and understand the differences that exist among patients' cultural backgrounds.6Hospitalized patients and their families are subjected to numerous stresses. This reality is especially true in critical care units, where patients with life-threatening illnesses are treated. In these situations, the need for culturally competent care is strikingly evident, as the following anecdote illustrates.As an emergency room nurse in a small rural hospital, I was present when an elderly Native American man was brought to the emergency room by his wife, sons, and daughters. He had a history of 2 previous myocardial infarctions, and his current clinical findings suggested he was having another. During the patient's assessment, he calmly informed the emergency room staff and physician that, other than coming to the hospital, he was following the "old ways" of dying. He had "made peace with God and was ready to die" and "wanted his family with him."The emergency room physician ordered intravenous fluids, a dopamine infusion, a Foley catheter, and transfer to the intensive care unit of a regional hospital 3 hours away. The patient died 2 weeks and 2 code blues later, and was intubated and receiving mechanical ventilation for most of that time. No family members were present when he died except for his wife. The rest of his family members were unable to afford the cost of traveling to a healthcare facility that far from home. This man's cultural values and preferences in relation to dying were disregarded.Lack of cultural awareness and failure to provide culturally competent care can greatly increase the stresses experienced by critically ill patients and can result in inadequate care provided by healthcare professionals. Shi and Shu-Hsun7 compared American-Chinese and Taiwanese patients' perceptions of dyspnea and related nursing actions during the patients' admissions to the intensive care unit after cardiac surgery. Chinese patients in the study believed that physical energy was depleted during a dyspnea episode and that uninterrupted rest, sleep, and nutritional support allowed the body to recharge afterward. Lack of awareness of these concerns among the intensive care nurses resulted in several comments offered by one Chinese patient. "I wrote down 'eating, wife.' I meant I wanted my wife to prepare my favorite food for me. But American nurse didn't understand me, she suggested me to relax and sleep again. But, how can I relax? I needed the homemade food which was cooked with herbs, and only my wife knew how to make it. I didn't request it again since I was afraid they might think I was odd, and look down on me."7 This patient's level of stress could have been markedly decreased if awareness of his cultural beliefs had been incorporated into his care.Galanti8 illustrates the importance of culturally competent care with an example of a newborn Vietnamese boy too ill to be discharged home with his mother. Nursing staff were concerned because the mother appeared unable to bond with her new infant. She provided basic care for him, such as feeding and changing his diapers, but refused to cuddle him or show any outward signs of maternal-infant bonding. Although the baby remained in the hospital nursery several days after the mother's discharge, neither parent visited the baby. By consulting a nurse who specialized in transcultural nursing care, the staff learned that many persons from rural Vietnam believe that spirits are attracted to newborns and are likely to harm the infants. Consequently, parents do everything they can to avoid attracting attention to their new infants. The seeming lack of concern and bonding in this case reflected an intense love for the infant, rather than a lack of bonding.8Campinha-Bacote and Munoz9 offered a 5-component model for developing cultural competence (Table 2). Five components of cultural competence were proposed:The first component, cultural awareness, involves self-examination and in-depth exploration of one's own cultural and professional background.9 Cultural awareness should begin with insight into one's own cultural health-care beliefs and values. Catalano2 states that "merely learning about another person's culture does not guarantee the nurse will have cultural awareness; nurses must first understand their own cultural background and explore the origins of their own prejudiced and biased views of others." The Cultural Awareness Assessment Tool (Table 3) could be used to assess a person's level of cultural awareness.2 The questions in this tool should be answered honestly; the score obtained offers insight into understanding one's own cultural healthcare beliefs and values.The second component, cultural knowledge, involves the process of seeking and obtaining an information base on different cultural and ethnic groups.9 Nurses can develop and expand their cultural knowledge base by accessing information offered though a variety of sources, including journal articles, textbooks, seminars, workshop presentations, Internet resources, and university courses. Table 4 summarizes resources for obtaining information about various cultural and ethnic groups.The third component, cultural skill, involves the ability of the nurse to collect relevant cultural data regarding the client's presenting problem and accurately perform a culturally specific physical assessment.9 The Giger and Davidhizar model10 described in Table 5 contains a framework for assessing cultural, racial, and ethnic differences between patients. This model provides a systematic method for assessing culturally and ethnically diverse persons. The elements of this model are communication, space, social organization, time, environmental control, and biological variations.10The fourth component, cultural encounter, is defined as the process that encourages nurses to directly engage in cross-cultural interactions with patients from culturally diverse backgrounds.9 Directly interacting with patients from different cultural backgrounds helps nurses increase their cultural competence. Development of cultural competence is an ongoing process that continues throughout a nurse's career and cannot be mastered.2The last component, cultural desire, refers to the motivation to become culturally aware and to seek cultural encounters.9 Inherent in cultural desire is the willingness to be open to others, to accept and respect cultural differences, and to be willing to learn from others.One common pitfall to avoid in becoming culturally competent is unintentionally stereotyping a patient into a particular culture or ethnic group on the basis of characteristics such as outward appearance, race, country of origin, or stated religious preference. Stereotyping is defined as an oversimplified conception, opinion, or belief about some aspect of an individual or group of people.4 Nurses should be aware that many subcultures and variations may exist within a cultural or an ethnic group. For example, the label Asian American is inclusive of cultures such as Chinese, Japanese, Taiwanese, Filipino, Korean, and Vietnamese. Within each of these cultures are many subcultures based on variations, including geographic region, religion, language, socioeconomic level, gender, family structure, parenthood, educational level, and degree of adherence to folk medicine.Healthcare professionals should also be careful about labeling patients. For example, citizens in the United States tend to refer to themselves as Americans. This term could also apply to persons from Central and South America, so a more accurate way of referring to a person from the United States would be "US citizen."The degree of acculturation or assimilation of the client into US society also must be determined. Acculturation is the "modification of one's culture as a result of contact with another culture."4 Assimilation refers to the "gradual adoption and incorporation of the characteristics of the prevailing culture."4 Traditionally, the United States has been considered a melting pot of world cultures, with the majority of immigrants eager to assimilate and/or acculturate into US society so they could "fit in" to their new homeland. However, since the early 1970s, the trend has been for immigrants to maintain their own unique cultural practices and traditions.2 Because of this trend, the United States now seems more of a "salad bowl" than a melting pot, with modern immigrants retaining their own unique flavors and textures.2 To provide culturally competent care, nurses working in critical care areas must determine the extent to which persons belonging to cultural or ethnic groups have assimilated or acculturated into US society.The increasingly diverse, multi-cultural population in the United States is offering new challenges in the provision of culturally competent care by critical care nurses. A direct relationship exists between a patient's culture and his or her health; of the many variables known to influence health beliefs and practices, culture is one of the most influential.9 If the provision of the best possible care for all patients is the goal, critical care nurses must have expertise and skill in the delivery of culturally appropriate and culturally competent nursing care. Each critical care nurse must take an active role in obtaining an information base upon which to develop a cultural competency. The ability to deliver nursing care that will allow effective interactions and the development of appropriate responses to persons from diverse cultures, races, and ethnic backgrounds is truly a challenge for nurses in the 21st century.