Cultural Diversity and Cultural Competence

Abstract

Cultural diversity is changing demographics and economics of our growing multicultural world. The long-standing disparities in the health status of people from culturally diverse backgrounds has challenged health care providers and organizations to consider cultural diversity as a priority. Cultural competency in nursing practice is the cornerstone of providing superior care for people of all cultures. It is relevant in our everyday lives, but even more so for nurses who regularly care for patients in their most vulnerable state. The process of developing cultural competence is a means of responding effectively to the huge ethnic and racial demographic shifts and changes that are confronting our country’s healthcare system. Cultural competence is a defined set of policies, behaviors, attitudes and practices that enable individuals and organizations to work effectively in cross-cultural situations. Cultural competence is the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of delivery to meet patients’ social, cultural and linguistic needs.  The purpose of this paper is to define the impact of cultural diversity and the steps that will be helpful in providing culturally competent care.  The concept of cultural competence will also be discussed.

Keywords: diversity, cultural competence, nurses, healthcare

Introduction

The term cultural competence is used to describe a set of skills, values and principles that acknowledge, respect and work towards optimal interactions between the individual and the various cultural and ethnic groups that an individual might encounter (Blanchet Garneau & Pepin, 2014). At the heart of cultural competency is effective communication that has, as its basis, a desire for mutual respect and empathy. Cultural competency is sometimes linked to the term diversity in that in encourages acknowledgement and acceptance of differences in appearance, behavior and culture. By having an in-depth understanding of how to effectively and respectfully interact with people from a wide range of cultures, nurses can maximize the chance of optimal interactions in a professional setting. This is very important in healthcare where nurses are likely to come into contact and interact with people from other cultures and backgrounds.

Diversity in the nursing field is essential because it provides opportunities to administer quality care to patients. Diversity in nursing includes all the following: gender, veteran status, race, disability, age, religion, ethnic heritage, socioeconomic status, sexual orientation, education status, national origin, and physical characteristics (Nichols, 2016). Communication with patients can be improved and patient care enhanced when healthcare providers bridge the divide between the culture of medicine and the beliefs and practices that make up a patient's value system. When the nursing workforce reflects its patient demographic, communication improves thus making the patient feel more comfortable. A nurse who has little in common with their patients cannot adequately advocate for their benefit.  

Competence/Diversity

Cultural competence is the ability to recognize the importance of race, ethnicity, and culture in the provision of behavioral health services (Cai, 2016). Specifically, it is awareness and acknowledgment that people from other cultural groups do not necessarily share the same beliefs and practices or perceive, interpret, or encounter similar experiences in the same way. Thus, cultural competence is more than speaking another language or being able to recognize the basic features of a cultural group. Cultural competence means recognizing that person, by virtue of culture, has at least some ethnocentric views that are provided by that culture and shaped by one’s individual interpretation of it. Cultural competence is rooted in respect, validation, and openness toward someone whose social and cultural background is different from one's own

Cultural competence is not acquired merely by learning a given set of facts about specific populations, changing an organization's mission statement, or attending a training on cultural competence. Becoming culturally competent is a developmental process that begins with awareness and commitment and evolves into skill building and culturally responsive behavior within organizations and among providers

Over the years, 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 (Villarruel, Washington, Lecher, & Carver, 2015). Another recent trend that has influenced nursing considerably is the consumer mandate for culturally competent care in an increasingly diverse, multicultural society. The diverse world in which one lives in is a composite of many cultures, values and ways of interacting with one another. The dimensions of diversity include gender, religious beliefs, race, marital status, ethnicity, parental status, age, education, physical and mental ability, income, sexual orientation, occupation, language, geographic location, and many more components (Villarruel et al., 2015). Understanding the dimensions of diversity and world cultures will help ensure the development of cultural competencies that will connect nurses with their patients and families they interacted with.

Becoming Culturally Competent

Cultural competence is about one’s will and actions to build understanding between people, to be respectful and open to different cultural perspectives, strengthen cultural security and work towards equality in opportunity. Relationship building is fundamental to cultural competence and is based on the foundations of understanding each other’s expectations and attitudes, and subsequently building on the strength of each other’s knowledge, using a wide range of community members and resources to build on their understandings ("Cultural Competence in Nursing”, 2014). Cultural sensitivity is not limited to one group but applies to all cultures. All healthcare providers must avoid using their own group as the standard by which to assess appropriate behavior in others. In addition, greater differences may exist within the same cultural group than between different cultural groups, and nurses need to be intra-culturally sensitive as well as multi-culturally sensitive. Underlying cultural competence are the principles of trust, respect for diversity, equity, fairness, and social justice.

Culture is the fundamental building block of cultural identity and the development of a strong cultural lifestyle (Dreachslin, Gilbert, & Malone, 2013). Cultural identity is essential to an individual’s healthy sense of who they are and where they belong. Culture is defined as the attitudes, habits, norms, beliefs, behaviors, customs, rituals, styles and artifacts that express a group’s adaptation to its environment; that is, ways that are shared by group members and passed on over time. Culture can represent external and internal dimensions. Most obvious are the external expressions reflected in customs, rituals, and styles. Internal dimensions, which are the focus of service providers, include awareness of the attitudes, habits, norms, and both spoken and unspoken rules within a culture. Cultural competency includes healthcare providers’ awareness of their own culture and the working to understanding the culture of others. Cultural competency is more than being aware of cultural differences and is more than knowledge of the customs and values of those different from one’s own. It transcends being respectful of the cultures represented in the service or even the community. Explanations of culturally competent nursing care focus on recognizing a patient’s individual needs, including language, customs, beliefs and perspectives. Cultural sensitivity is foundational to all nurses because nurses must practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Transcultural Nursing

Transcultural nursing is an essential aspect of healthcare today. The ever-increasing multicultural population in the United States poses a significant challenge to nurses providing individualized and holistic care to their patients. This requires nurses to recognize and appreciate cultural differences in healthcare values, beliefs, and customs. Nurses must acquire the necessary knowledge and skills in cultural competency. Culturally competent nursing care helps ensure patient satisfaction and positive outcomes (Darnell & Hickson, 2015). The need for transcultural nursing will continue to be an important aspect in healthcare.

Transcultural nursing is both a specialty and a general practice area. It focuses on worldwide cultures and comparative cultural caring, health, and nursing phenomena. Established as a formal area of inquiry and practice more than forty years ago, transcultural nursing's goal is to provide culturally congruent care. Transcultural nursing's goal is to provide culture specific and universal nursing care practices for the health and well-being of people or to help them face unfavorable human conditions, illness or death in culturally meaningful ways (Blanchet Garneau & Pepin, 2014). Transcultural nursing draws on a large field of information, stretching beyond nursing to use research from many health sciences disciplines.

Sensitivity to cultural needs, beliefs, and values, including in communication, is essential for nursing interventions to be effective. Communication is the central factor in providing transcultural care. One of the most obvious challenges occurs when a nurse and a patient do not speak the same language. Non-native English-speaking patients or nurses may have to process English conversation in their native tongue interpreting word for word, thinking in their native tongue, and then trying to make sense of their thoughts before expressing them (Darnell & Hickson, 2015). In the meantime, there may be an uncomfortable silence and a delay in response, which the patient may misinterpret.

When caring for a patient from a culture different from one’s own, one needs to be aware of and respect cultural preferences and beliefs; otherwise, a patient may consider the nurse insensitive and indifferent, possibly even incompetent. But beware of assuming that all members of any one culture act and behave in the same way; in other words, do not stereotype people. The best way to avoid stereotyping is to view each patient as an individual and to find out his/her cultural preferences. 

Minority/Majority Status

The nursing profession has long emphasized its commitment to social justice and health equity. Nurses are known for advocating policies and regulations that are inclusive and lead to positive patient outcomes ("Promoting cultural competence," 2018). However, an essential component of promoting health equity is acknowledging our individual unconscious biases and understanding how they may impact the care that we provide. Unconscious bias (also known as implicit bias) refers to the beliefs and prejudices one holds that reside outside of one’s awareness. Acknowledging and unpacking one’s own unconscious biases can be troubling, especially when these unconscious biases do not align with one’s conscious value systems.

In the context of health care, unconscious bias can lead to health disparities such as the under treatment of conditions like pain, cardiovascular disease, asthma, mental health, etc. in racial and ethnic minorities. One of the things that accounts for health disparities is unconscious bias in health care providers. Not only does unconscious bias contribute to under-treatment, but studies have shown that providers with more implicit biases are more likely to have negative interactions with patients (Darnell & Hickson, 2015). This impacts trust and the likelihood that patients will seek health care. An implicit bias is not only harmful because it is undeserved, but it can also lead to disparities in care. Even if one is unaware of how one is feeling, one’s body language, one’s focused attention, and one’s level of care can be impacted directly by the way one is feeling. Each patient deserves their nurses care, so understanding what might trigger one to act differently will make that person a better nurse.

Institutionalized bias is practices, scripts, or procedures that work to systematically give advantage to certain groups or agendas over others. Institutionalized bias is built into the fabric of institutions. Organizations that conform to accepted practices and structures are thought to increase their ability to obtain valuable resources and to enhance their survival prospects because conforming produces legitimacy. When organizations structure themselves in institutionally illegitimate ways, the result is negative performance and negative legitimacy.

Cultural bias is the phenomenon of interpreting and judging phenomena by standards inherent to one's own culture. The phenomenon is sometimes considered a problem central to social and human sciences, such as economics, psychology, anthropology, and sociology.  Numerous such biases exist, concerning cultural norms for color, location of body parts, mate selection, concepts of justice, linguistic and logical validity, acceptability of evidence, and taboos. Cultural bias extends on many more fields in the globalizing world. Ordinary people may tend to imagine other people as basically the same, not significantly more or less valuable, probably attached emotionally to different groups and different land.

Organizational Behavior

Organizational behavior is the study of interactions between people and organizations, people within organizations, and organizations themselves. In other words, its how organizations interact with people and other organizations. In healthcare, organizational behavior can be used to understand what sorts of people are going to thrive in healthcare and what sorts are going to suffer. Organizational behavior deals with the study of human behavior within groups or organizations and how this behavior can be modeled through analysis to impact the organizations in a positive way. An organization in itself is composed of a group of people working individually or often within teams. The disposition of people towards each other in an organization remains the contributing factor towards shaping the organization (Snyder, Frogner, & Skillman, 2018). Organizational behavior is an interdisciplinary field, in that it draws greatly from other subjects such as psychology, sociology, anthropology, political science and economics, to mention a few.

The success of a healthcare organization is largely dependent on effective management of its employees. Behavior of people within a healthcare organization is governed by their ideas, feelings and activities. For effective management of employees, it is crucial to perceive their requirements. However, since human behavior can differ with everyone, it becomes almost impossible to come with a unique solution to the organizational problems. The behavior of individuals within an organization can either defile the organization or aid in its overall improvement. For instance, certain employees may be compassionate and helpful towards their co-workers which helps to create a supportive work culture. This selfless attitude can be a result of the employee’s faith in the management and their satisfaction and commitment towards the organization.

Best Practices

The trend of today’s healthcare leans toward being more inclusive of personal and cultural preferences. This demands a knowledgeable and open response from caregivers. What can nurses do to facilitate this trend toward honoring individual choices and beliefs? That question is not easily answered.

One of the most important elements emphasized in pursuit of competent cultural care is identifying one’s own beliefs and culture before caring for others (Snyder et al., 2018). Caregivers are expected to be aware of their own cultural identifications in order to control their personal biases that interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the client’s culture. Developing self-awareness can bring into view the caregiver’s biases or culturally-imposed beliefs. It can also shed light on oppression, racism, discrimination, and stereotyping and how these affect nurses personally and their work (Darnell & Hickson, 2015). How can patients love and accept themselves in ways that promote healing if nurses are not willing to offer them acceptance in their myriad of problems and complexities? Through the simple act of acceptance, nurses can become an agent of healing, whether or not they are aware of it. 

Trends/Future

As the demographics of the nation’s population change over the next several decades, nurses will find an equally diverse patient population seeking treatment. Patients are becoming more racially and ethnically diverse, prompting the need for nurses who not only provide culturally competent care but reflect the characteristics of the patients they serve. Diversity in nursing can help bridge existing gaps in care and promote better outcomes and satisfaction among patients. To evaluate the movement of nursing’s cultural diversity intention, the attitudes and beliefs about cultural diversity should be examined for its impact on behavior and actions that have resulted in the operational definition and actualization of cultural diversity. In process, reflection, and practice, nursing science should embody characteristics of cultural diversity; in that way, the science would serve as a process for understanding all aspects of cultural diversity.

Nursing as a profession and discipline can conceptualize cultural diversity as more than just an awareness of diverse cultures through basic nursing curricula. Members within a cultural group must be seen as individuals experiencing human dimensions of health and illness.  The ability to use diversity in a competent manner will become second nature for each nurse. Future nurses need to be taught how to apply culture and diversity in the clinical setting (Villarruel et al., 2015). This will begin when nursing faculty are prepared in the cultural diversity dimension and are fully passionate about the cause. Increasing the diversity among nursing faculty within nursing’s educational programs is needed so that students have diverse role models (Repo, Salminen, & Leino-Kilpi, 2017). Diversity among nursing faculty can also help to disseminate and interpret cultural knowledge and needs of diverse nursing students.

Nursing as a culture transmits its survival through education that continues to use a mainstream Anglo-culture-based curriculum. This often creates great demands on culturally diverse students. More curricular time and integration of cultural diversity concepts and content need to be considered.  

Conclusion

Diversity and cultural competence are the combination of different cultures, ideas, and perspectives that brings forth greater collaboration, creativity, and innovation, which leads to better patient care and satisfaction. This is the direction in which healthcare needs to go in order to better the health of our current and future demographics. Culture is an important dimension of group diversity that influences communication. Culture is the integrated system of beliefs, values, behaviors and communication patterns that are shared by those socialized within the same social group. Cultural diversity is the mixture of societies or cultures in a specific region. It is also referred to multiculturalism within an organization. Obvious cultural differences exist between people, such as language, attitudes, traditions, clothing or dress. There are also significant variations in the way culture or society organizes itself, in its shared morality conception, and in the behavior, they interact with their environment. Cultural diversity continues to impact day to day life making diversity in the workplace more common. Diversity refers to the qualities that are different from one’s own. Accepting and understanding the differences of any culture, and embracing diversity can reduce conflict and help team work in healthcare. 

References

Blanchet Garneau, A., & Pepin, J. (2014, July 17). Cultural competence: A constructivist definition. Journal of Transcultural Nursing, 26(1), 9-15. http://dx.doi.org/10.1177/1043659614541294

Cai, D. (2016). A concept analysis of cultural competence. International Journal of Nursing Science, 3(3), 268-273. http://dx.doi.org/10.1016/j.ijnss.2016.08.002

Check it out! Cultural competence in nursing. (2014). Nevada RNformation, 23(2), 7. (Original work published). Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=103929006&scope=site

Darnell, L. K., & Hickson, S. V. (2015). Cultural competent patient-centered nursing care. Nursing Clinics, 50(1), 99-108. http://dx.doi.org/10.1016/j.cnur.2014.10.008

Dreachslin, J. L., Gilbert, M. J., & Malone, B. (2013). Diversity and Cultural Competence in Health Care (First ed.). San Francisco, CA: Jossey-Bass.

Nichols, J. (2016). Becoming culturally competent in the face of diversity. Caring for the ages, 17(1), 4. http://dx.doi.org/10.1016/j.carage.2015.12.004

Promoting cultural competence in nursing. (2018). Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=130205947&scope=site

Repo, H., Salminen, L., & Leino-Kilpi, H. (2017). The cultural competence of graduating nursing students. Journal of Transcultural Nursing, 28(1), 98-107. http://dx.doi.org/10.1177/1043659616632046

Snyder, C., Frogner, B., & Skillman, S. (2018). Facilitating racial and ethnic diversity in the health workforce. Journal of Allied Health, 47(1), 58-65. http://dx.doi.org/2018571775?accountid=62703

Villarruel, Washington, D., Lecher,. T., & Carver, N. A. (2015). A more diverse nursing workforce. American Journal of Nursing, 115(5), 57-62. Retrieved from https://search.ebscohost.com/login.aspx/A%20More%20Diverse%20Nursing%20Workforce.pdf

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