Cultural Competence in Nursing

Diversity based on ethnic background, religion, race, language and sexual orientation is skyrocketing each day. Multiculturalism specifically is on the rise due to globalization. This puts responsibility on the health care providers to take into consideration the diversity they face in their workplace and practice accordingly. The main aim of the health care providers, especially nurses should be to provide maximum holistic and culturally competent care to their clients. To achieve this level, we need to always keep in mind to take care of the patient as they want you to take care of them (Srivastava, 2007). If patients are considered as the centre of care by giving due respect to their values, beliefs, culture and viewpoints, nurses as well as the client will be satisfied with the care. However, sometimes a difference in values and beliefs can lead to moral and ethical conflicts between the patient, family and the nurse (Srivastava, 2007). Hence, in this paper, the focus will be laid on the emic and etic viewpoint and analyzing them through the culture care framework to overcome the varying values.

In my previous clinical experience when I was in OB, I had to care for a Muslim woman. I was with her throughout her experience of labor and then postpartum. The patient, (Mrs. AB for this paper), was also supported by her husband and in-laws. In Mrs. AB’s culture, women are expected to cover their heads and sometimes even wear a ‘veil’ or ‘hijab’ in front of their male family members. When Mrs. AB had to go outside, even as near as the breastfeeding classes on the unit, she had to wear the whole veil on top of her clothes. When I noticed her wearing the ‘hijab’, I asked if it was mandatory for her, and she replied that it was part of their culture and women are expected and sometimes forced to wear the veil. When I heard and saw this, I was pinched by this cultural practice and thought as to why she is supposed to wear the veil, which is physically inconvenient. Then I kept observing minor cultural practices which were different than mine and my values. I then talked to her about wearing a ‘veil’. She explained that some families are very strict or rather ‘conservative’ regarding these issues. It was also interesting to notice that the husband did not accompany Mrs. AB during the delivery, even though he was asked to. In their culture it is expected that a female accompany the pregnant woman; most of the time mother or mother in law. Moreover, in their culture the women or their family would consider it very disrespectful if an unknown male/doctor/nurse comes to visit the woman. Muslim women would only prefer their doctors and nurses to be female, in front of whom they could remove their ‘hijab’. Mrs. AB told me that I could measure the intensity of this strictness from the recent news that a father killed his 16 year daughter in Brampton just because she had arguments with him regarding her not wearing the ‘veil’ at school (Mitchell, & Wilkes, 2007). I was completely dumbstruck by this news. It made a deep impression on me about the importance of various cultural beliefs families have. From then, I know that I should not neglect such cultural practices but always understand the significance these practices hold for the members of that culture.

As nurses, it is crucial for us to recognize the difference in viewpoints and how the thinking of people from different background are impacted by their culture. In my culture, equal rights and equal status has to be given to women as men. Women are expected to be stronger both mentally/emotionally and physically. We are taught that the women should have the full right to express themselves; whereas the concept of the ‘veil’ or ‘hijab’ was completely against my values. To me, the ‘hijab’ was a mere obstacle in expressing oneself, their beliefs and especially their expressions. In my view, the veils give the impression of women being inferior to the men and different from everyone. I just could not understand the whole concept of the ‘hijab’. It was against my values and beliefs that even women themselves accepted the ‘marginalization’. Such opposing feelings against their attire were not going to be beneficial in the care I provided to Mrs. AB. Hence, as I went through this thought process; I saw my patient and realized that the bottom line is that all are humans and they need to be treated equally with the same respect.

On the other hand, what to me looked as an ‘alien’ and personally an unacceptable custom, it was totally normal and part of lifestyle for the Mrs AB and many other women belonging to this culture. While different cultures may perceive the meaning of ‘health’ and ‘illness’ differently and expect care that meets their requirements (Dogan, Tschudin, Hot & Ozkan, 2009), it is necessary to analyze values of our own culture and the other individuals. These two perspectives are called the emic and the etic viewpoint. “Emic knowledge comes directly from cultural informants as they know and practice care with their values and beliefs in their unique cultural contexts. Emic knowledge was the natural, local, indigenous root care values. In contrast, etic care knowledge was derived from outsider views of non-local or non-indigenous care values and beliefs such as those of professional nurses” (Leininger, 2007, p. 10). These two concepts form the pillars of the culture care framework which is based on the Madeline Leininger’s Theory of diversity and universality (Srivastava, 2007).

As nurses, it is crucial for us to recognize the difference in viewpoints and how ones thinking is impacted by their culture. In my culture, it is tried that equal rights and status be given to women. Women are expected to be stronger both mentally/emotionally and physically. We are taught that women should have the full right to express themselves; whereas the concept of the ‘veil’ or ‘hijab’ was completely against my values. To me, the ‘hijab’ was a mere obstacle in expressing oneself, their beliefs and expressions. In my view, the veils give the impression of women being inferior to the men and different from everyone. I just could not understand the whole concept of the ‘hijab’ and why would someone go through this trouble of getting ready. It was against my values and beliefs that even women themselves accepted the ‘marginalization’. Such opposing feelings against their attire were not going to be beneficial in the care I provided to Mrs. AB. Hence, as I went through this thought process; I saw my patient and realized that the bottom line is that all are humans.

The term ‘Cultural competence’ is used to refer to the “multi-cultural knowledge base that nurses need, together with the ability to apply such knowledge in practice” (Jirwe, Gerrish, & Emami, 2006, p. 6). To provide cultural competent care, nurses should utilize the culture care framework that provides a guide for health care providers and reach to enlightenment of one’s own culture, other’s culture and how it influences the perception and solution of an issue. The first element that comprises the framework is, ‘cultural sensitivity’. It includes the concept of cultural awareness by being appreciative and sensitive to different beliefs, values and problem solving strategies (Srivastava, 2007). It includes both getting to know the other’s and our own culture. It is evident that we as nurses would certainly not be able to know and understand the culture in-depth; however a brief idea should exist about the prevailing difference. For example, in the scenario provided earlier, the reflection from the emic and etic viewpoint is our awareness of ourselves and also my patient’s culture. As health care providers, we are expected to respect the choices our patients make, but we are not obliged to leave our own beliefs and follow someone else’s culture. In addition, the aim of being culturally sensitive is also that we recognize our biases and assumptions against a specific culture, but we cannot label or stereotype all the individuals in that culture, as each person is unique (Srivastava, 2007).

The second element of the framework is cultural knowledge. Cultural knowledge is to gain as much information about what individuals in that culture believe in. Hence, the culture’s lifestyle, communication, family involvement, personal space and diet should be not be forgotten (Srivastava, 2007). In the scenario, communication with Mrs. AB should be non-judgmental, we should not provide advice or even not doubt what they believe in. It should also be kept in consideration that not just one or two, but many family members would arrive to meet the patient and may even bring gifts for the patient’s wellbeing (Wehbe-Alamah, 2008). Nurses with a welcoming nature should give adequate time to the patient and family to bond. Muslim women would also expect that they have their ‘hijab’ when any other male member comes to visit her. Women may also resist accepting ‘pericare’ or would hesitate to change in front of someone else. Moreover, taking care of their diet is an important aspect, because they usually like ‘halal’ meat which means, slaughtered meat (Wehbe-Alamah, 2008). While caring for patients, bringing into light all the minute cultural practices, respecting and giving the opportunity to practice their cultural beliefs shows our acceptance and nurturance of their culture.

The third element of the framework is ‘cultural resources’. To gain more knowledge about the culture and have answers to all the needs of the patients, extra resources need to be employed. Individual level resources are by seeking information, reflecting on experiences and developing diverse connections. Whereas, organization resources include the use of interpreter, multi-religious and spiritual services (Srivastava, 2007). For example, in the scenario, I and Mrs. AB knew the same language, so it was easy for her to communicate her needs. Therefore, patients who belong to specific culture or religion could be paired up with the nurse or physician of the same culture. This will help the care to be provided smoothly as all the patient’s needs will be understood and addressed. Also, reflecting on experiences and building learning upon them, gaining information from colleagues or books or internet about the culture would be helpful. However, the most reliable source can also be the client and his/her family. So just showing the enthusiasm to learn and apply in our practice is one step towards providing culturally competent care to patients.

There are a myriad of cultures present in our society and this culture care framework allows us to view them with respect. It allows us analyze one’s own beliefs and that of the patient and be educated about the varying viewpoints. As nurses, we are then responsible to integrate that teaching regarding cultures in our practice while caring for diverse clients and families. In doing so, we will be considered more trustworthy by our patients which eventually will lead to satisfied patients, satisfied nurses by their contribution to the care and positive patient outcomes. The relationship between a patient and nurse acquires increased stability and stronger bond if we treat them as person and understand that every person has a culture and they hold a great importance for the patient (CNO, 2009).