Cultural Competence Integration in Nursing Practice

Description of the Issue or Problem

Problem

Context

One of the main problems with the nursing paradigm in America is that due to being essentially euro-centric (rationale-based, positivist), it continues to prove itself ill-adjusted to the realities of today’s living in the U.S., associated with the process of American society growing increasingly multicultural. The indirect proof that this is indeed being the case can serve demographic statistics, in regards to the racial makeup of nurses, “83.2 percent of the RN workforce (in America) are white, non-Hispanic, 5.8 percent are Asian or Pacific Islander, 5.4 percent are African American, and only 3.6 percent are Hispanic” (Dudas, 2012, p. 317). There is, however, even more to it. The very conceptual premise of nursing care in the U.S. continues to be concerned with the euro-centric assumption that the main objective of healthcare is the elimination of illness-related symptoms in patients, rather than making it possible for the latter to be healed, in the holistic (concerned with body and mind) sense of this word. It is understood, of course, that such a state of affairs does undermine the effectiveness of those nursing interventions that concern ethnically diverse (non-White) patients. This simply could not be otherwise – as practice indicates, the chances of a particular patient to recover, directly relate to what happened to be his or her attitude to the received nursing care. What it means is that, as time goes on, nurses must apply ever more effort into increasing the rate of their cultural competence, defined as, “A set of skills and behaviors that enable the nurse to work effectively within the cultural context of a client (i.e., individual, family, or community)” (Waite & Calamaro, 2010, p. 74). In fact, being culturally competent now appears to be one of the main prerequisites for them to be considered professionally adequate and to qualify for working in a multicultural social environment. This paper will aim to explore some of the main challenges/opportunities, associated with the integration of cultural competence in the methodological framework of one’s professional responsibilities, as a nurse, and to provide a discursively sound initiative, as to how this can be achieved in practice.

Past interventions

The fact that nurses must work on increasing the level of their cultural competence had been acknowledged as far back, as during the 20th century’s seventies – the time when the policy of multiculturalism attained official status in the West. In its turn, this prompted many nursing schools/colleges in the U.S. (as well as in other Western countries) to encourage students to sign up for cultural awareness courses. After all, as Long (2012) noted, “Since 1986 teaching cultural competence in the delivery of nursing care is an expectation of accreditation and approval boards for schools of nursing… most nursing schools in the United States include some reference in their curriculum, to their goal” (p. 103). Among the main approaches to helping students to become culturally competent healthcare professionals, commonly used by educators in the past, can be named:

  1. Lectures ‒ nursing students are taught about the cultural specifics of how ethnically diverse patients perceive the surrounding social environment and their place in it.
  2. Group discussions – nursing students/practicing nurses are encouraged to elaborate on what they consider the professionally relevant significance of ‘cultural competence’, in front of their peers/colleagues.
  3. Experiential (live) immersions – nursing students are provided with the opportunity to study abroad for a few weeks, as the mean of bolstering their appreciation of the cultural customs/traditions that differ from those, associated with the Western way of living.
  4. Simulations – nursing students and practicing nurses are invited to practice their intercultural skills in simulated clinical settings.

Consequences

Even though healthcare workers have been consistently urged to address their professional responsibilities in a culturally sensitive manner for the duration of a few decades, the majority of today’s nurses continue to report the lack of intercultural awareness in one way or another (Ume-Nwagbo, 2012). Among the main contributing factors, in this respect, can be named:

  1. The fact that the methodological approach to endowing students/nurses with cultural competence often contradicts the discursive implications of the notion in question. That is, the emphasis is being placed on teaching cultural competence as an abstract concept, rather than as the practical tool for tackling some issues, relevant to nursing. Moreover, nursing students and nurses are being encouraged to refer to cultural competence in terms of an accomplishable objective, rather than in terms of a continual process.
  2. The presence of an unconscious biasness towards the ethnically visible patients in many practicing (and overwhelmingly White) nurses, reflected by the tendency of the latter to grow visibly/verbally irrigated with the requirement to apply extra effort, while taking care of the representatives of racial minorities.
  3. The fact that there are many good reasons for nursing students and nurses to assume that the requirement to work on increasing the level of their intercultural competence is essentially a formal one. What does not help, in this respect, is that there are no objective criteria for measuring the extent of a nurse’s cultural competence in existence.

It is understood, of course, that the situation with the earlier mentioned factors continuing to undermine one’s chances to become a culturally competent nurse is hardly tolerable. The reason for this is apparent – if allowed to persist, it will result in diminishing the quality of healthcare in America, as a whole.

Stakeholders

Most-affected groups or populations

There can be only a few doubts that the most affected population, in regards to the issue at stake, consists of those ethnically diverse patients that exhibit the indications of being emotionally attached to the ethnocentric ‘traditional’ values. The reason for this is apparent – as practice indicates, it is specifically this type of patients who often end up being subjected to nursing micro-aggressions, which are “hurtful, demeaning, and dismissive words and actions committed by one individual or group against another whose characteristics and backgrounds are different” (Bellack, 2015, p. 63). The fact that the percentage of these patients in nursing care will continue to increase, naturally calls for nurses to be culturally competent.

The latter represents the second most affected group by the discussed subject matter. The rationale behind this suggestion is also quite apparent – one of the main preconditions for a particular nurse to be able to develop the skills of cultural competence is his or her willingness to reassess the validity of several different euro-centric nursing practices, such as requiring a patient to behave as prescribed by a nurse.

Finally, we can mention the relatives of ethnically diverse patients in nursing care, as the third-largest group of potentially affected stakeholders, in regards to the issue in question. The logic behind this suggestion is much too obvious to be specified additionally.

Other affected groups

Along with the directly affected shareholders, there are many of the indirectly affected ones. Probably the largest group of the latter consists of ordinary taxpayers, as those who make possible the continual functioning of the country’s healthcare system. After all, there can be only a few doubts that the integration of the ‘cultural awareness’ principle into the methodological paradigm of nursing cannot be discussed outside of what will amount to the associated costs.

America’s politicians represent yet another group of indirectly affected stakeholders. The reason for this is that in this country, healthcare-related issues have always been considered particularly acute, in the political sense of this word. By adopting one or another stance, concerning the issue of ‘cultural competence’ in nursing, they affect the public perception of themselves either favorably or unfavorably. The reason for this is that there are still many people in this country, who believe that the notion of ‘cultural competence’ is merely the by-product of political correctness – the social policy that continues to spark much public controversy.

Nurse role and responsibility

Role

The professional role of the nurse, within the context of how he or she strives to implement the provisions of ‘cultural competence’ in the nursing care settings, is concerned with making it possible for ethnically diverse patients to receive culturally sensitive treatment. In this respect, nurses are expected to be able to communicate effectively with patients, even in cases when the language barrier appears especially strong. Nurses must also be able to exhibit a friendly attitude towards patients, throughout the entirety of providing the latter with care. In its turn, the above-mentioned objects can only be achieved, if nurses do apply a conscious effort in familiarizing themselves with other cultures, on one hand, and in growing increasingly capable of recognizing cultural biasness within, on the other.

Responsibility

Many considerations support the conceptual legitimacy of the policy of providing patients with culturally sensitive care. Among the most notable of them can be named the fact that the concerned policy is largely reflective of the professional requirements, imposed on nurses by such organizations as the American Nurses Association and the National League for Nurses Accreditation Commission, throughout the recent decade. Yet, it appears that one’s varying ability to function as a culturally competent nurse has primarily to do with the concerned person’s value, as the society’s productive member. That is, it is specifically those nurses that lead a socially integrated lifestyle, while trying to become ever more professionally valuable, who have what it takes to be able to address their professional responsibilities in a culturally competent manner. In other words, cultural competence can be discussed in terms of a self-imposed professional responsibility, on the part of the majority of practicing nurses. Apparently, for a particular nurse not to experience any emotional unease with the requirement to treat patients in a culturally sensitive way, he or she must be genuinely interested in serving society.

Description of the initiative

Proposed initiative

As it was mentioned earlier, the currently deployed strategies for increasing the level of intercultural awareness in nurses cannot be deemed very effective. The main reason for this is that, even though the term ‘cultural competence’ is indeed used rather frequently in the nursing-related discourses, it rarely conveys any semantically uniformed message. As a result, many nurses grow increasingly convinced that being a culturally competent healthcare worker is the same as being able to discuss the vaguely defined benefits of cultural awareness in public, without taking any practical advantage of the concept in question. Therefore, it represents a matter of crucial importance for nurses to learn how to use their knowledge of other cultures, as the practical tool of ensuring that the instrumental ends of the applied nursing care are achieved. Thus, the conceptual essence of our initiative can be formulated as follows. A special interdisciplinary (combining psychology and anthropology) course must be designed for nursing students, the taking of which, on their part, would help them to learn how to recognize the actual link between the particulars of a patient’s ethnocultural affiliation, and his or her tendency to react in one way or another to the externally applied stimuli of nursing care. The rationale behind this initiative is based upon the fact, well known to psychologists and anthropologists – just about every person in this world can be identified as someone who possesses either the ‘object-focused’ (Faustian, introverted) or ‘holistic’ (Apollonian, extroverted) mentality. ‘Faustians’ are naturally driven to profess the values of ego-centrism/individualism, because of their deep-seated unconscious belief that, “Individual’s willpower must never cease combating obstacles… and that the conflict is the essence of existence” (Greenwood, 2010, p. 53). In this regard, ‘Apollonians’ could not be more different – instead of trying to be in control of the surrounding natural/social environment, they aspire to objectivize (‘blend’) themselves within it, while thinking contextually. It is understood, of course, that the mentioned psycho-types have traditionally been associated with Westerners, on one hand, and non-Westerners, on the other. However, it is wrong to assume that the factor of race/ethnicity is the one that predetermines such a state of affairs. Rather, one’s varying degree of association with the ‘object-focused’ or ‘holistic’ values should be defined within the context of what were the societal particulars (urban or rural) of this person’s upbringing. Thus, the main purpose of the proposed initiative is to transform the actual goal of intercultural learning. Instead of being concerned with encouraging nursing students to memorize as much information about different cultures, as possible, it needs to serve the purpose of making it possible for them to gain an in-depth understanding of why people’s ethnocultural affiliation does seem to have a strong effect on their existential attitudes, in the first place. In its turn, this should prove utterly helpful for these students once they become registered nurses. The actual logic behind this suggestion is that, as a result of having learned about the qualitative characteristics of the mentioned psycho-types, nurses will be much more likely to identify the quintessence of unconscious anxieties in every particular patient, and to recognize the professional significance of such their awareness, in this respect. Consequently, this should empower nurses, in the sense of ensuring that their approach to treating ethnically diverse patients is psychologically sound, culturally sensitive, and practically effective.

Significance

There are several anticipated outcomes to the initiative in question. Probably the main of them is concerned with addressing the issue of nurses’ complaints about the fact that it often proves impossible for them to be simultaneously both: highly professional and culturally sensitive. This simply could not be otherwise – the currently deployed methodologies for teaching cultural awareness do not provide nursing students with much understanding, as to what accounts for the dialectically predetermined relationship between one’s cultural affiliation and the actual manner, in which he or she faces life challenges. As a result, nurses tend to go ‘by the book’, while engaging in intercultural communication with ethnically diverse patients – something that reduces nurses’ sensitivity to the care-related anxieties in these people (Nielsen, Noone, Voss, & Mathews, 2013). In the aftermath of the proposed initiative’s implementation, however, this will cease to remain the case. The reason for this is that, after having been taught how to recognize one’s affiliation with either of the earlier mentioned psycho-types, nurses will no longer need to apply much effort into trying to anticipate (not always successfully) this type of anxieties in patients, but to address them, as they come to influence the behavior of the latter. This, in turn, should result in increasing the overall effectiveness of nursing care.

The other expected effect of the initiative is that it should be able to eliminate the main obstacle on the way of the nursing paradigm in America becoming ever more culturally sensitive – the fact that the very discourse of ‘cultural competence in nursing continues to remain strongly euro-centric. As Southwick and Polaschek (2014) noted, “Although intended to overcome perceived limitations in transcultural nursing, cultural safety (competence), by continuing to define ethnic minority culture as other than the dominant culture, has the unintended consequence of reinforcing a discourse of binary dialectics” (p. 250). The rationale behind this suggestion is that, while prompted to regard the behavioral patterns, on the part of ethnically diverse patients, as such that have been environmentally predetermined, nurses will be able to interact with the former within the framework of the discourse of ‘cultural hybridity’. In its turn, this will make it less likely for the healthcare workers in question to be pushed to act arrogantly towards the representatives of racial minorities in nursing care. The sheer beneficence of such a would-be turn of events is obvious.

The would-be effects of the initiative’s implementation on the earlier mentioned groups of shareholders are quite clear, as well. Because of being cared for by culturally competent (in the sense of being able to identify a patient’s psycho-type) nurses, patients will inevitably begin to exhibit a much higher recovery rate. Consequently, nurses will grow to regard cultural competence as a practical asset, rather than merely the intellectual byproduct of political correctness, which distracts them from paying close attention to the technical aspects of their professional responsibilities. Thus, it will be thoroughly appropriate to assume that the initiative’s implementation will have a good effect on the mentioned indirect stakeholders, as well. After all, the very discourse of post-modernity, with which we are all equally affiliated, presupposes that even a slight alteration of one of the public sphere’s integral elements (such as the healthcare system), will directly affect the rest of them. In plain words – if the currently deployed model of nursing care in the U.S. becomes not only de jure but also de facto culturally competent, it will contribute rather substantially towards reducing the acuteness of social tensions within the society.

Theoretical application

The proposed initiative appears to correlate with many conceptual provisions of the ‘transcultural’ nursing theory (by Madeline Leininger) and the nursing ‘theory of comfort’ (Katharine Kolcaba). The soundness of this suggestion can be illustrated with ease, in regard to the main ontological premise of Leininger’s theory, “Through an understanding of different cultures, nursing can better address the needs that all people share based on beliefs about common humanity” (Southwick & Polaschek, 2014, p. 249). This specific idea does sound conceptually similar to the one, articulated earlier in this paper – one’s cultural competence has the value of a practical asset. Another reason why our initiative can be considered ‘transcultural’ to an extent, is that it calls for the establishment of ‘culturally hybrid’ informational transactions between nurses and their ethnically diverse patients – something that is meant to tackle the mentioned problem of euro-centrism in nursing. At the same time, however, the proposed initiative parts away with Leininger’s assumption that the key to becoming a culturally competent nurse is the concerned person’s willingness to study the customs and traditions of foreign cultures, as the mean of addressing better the needs of such patients. Instead of doing it, nurses should simply learn how to recognize the main socio-psychological principles behind the formation of these customs and traditions.

The initiative that we came up with earlier is also consistent with the main provision of Kolcaba’s ‘comfort theory’ – while in nursing care, patients must be treated in the way that would set them on the path of a holistic betterment, as opposed to subjecting them to the symptom-eliminating therapies (the actual objective of this care, as of today). Within the theory’s methodological framework, this kind of betterment is best discussed in terms of transcendence. According to Kolcaba and DiMarco (2005), “Transcendence is the ability to “‘Rise above’ discomforts when they cannot be eradicated or avoided… Transcendence accounts for its strengthening property… The three types of comfort occur in four contexts of experience: physical, psycho-spiritual, sociocultural, and environmental” (p. 188). As our initiative implies, once nurses are in the position to understand the essence of holistic anxieties in ethnically diverse patients, this will create the objective preconditions for the establishment of the atmosphere of ‘cultural hybridity’ in the care settings, which should enable these patients to receive nursing care in the manner that they favor the most. What will come in particularly handy, in this respect, is that our initiative presupposes the possibility of intuitive/instantaneous para verbal communication between patients and nurses – something that will undoubtedly result in filling the notion of ‘cultural competence’ with concrete meaning.

Implications for nursing and healthcare

Healthcare practice

The main implication of the proposed initiative for healthcare practice is that the very approach to subjecting patients to a particular therapy should be observant of what happened to be the specifics of their ethnocultural affiliation. After all, as it was pointed out earlier, the very essence of demographic dynamics in American society presupposes that, as time goes on, the euro-centric (objectivist, physiological) paradigm of healthcare will continue falling out of favor with physicians/nurses and patients alike. Thus, it will be fully appropriate to suggest that, if adopted, our initiative will contribute towards the process of this country’s healthcare system becoming increasingly affiliated with the principle of ‘holistic healing’, as something that will eventually define the philosophy of this system’s actual functioning. The fact that this process appears to be dialectically predetermined can serve as yet additional proof of the proposed initiative’s discursive soundness.

Nursing education

The implementation of the earlier outlined initiative should have a positive effect on nursing education, as well, in the sense of addressing its main shortcoming – the fact that the currently deployed educational approach to teaching nurses places more emphasis on memorization, rather than on understanding. As a result, many graduated nurses lack the skill of taking practical advantage of their theoretical knowledge. If adopted, our initiative will help to enlighten nurses that ‘cultural competence’ is not merely a buzz-term (with the associated professional requirements being integrated into the nursing curriculum due to the considerations of political correctness), but the crucial indication of one’s factual worth, as a nurse. The concerned initiative will also help students to acquire yet another analytical skill, relevant to nursing – the ability to recognize what accounts for the dialectical relationship between causes and effects. Given the fact that, while on the line of addressing their professional responsibilities, nurses are often required to make quick executive decisions, there can be very little doubt that this initiative will contribute towards increasing the quality of nursing education, as a whole.

Nursing leadership

The proposed initiative is likely to result in the further legitimization of the specifically Transformational theory of leadership in nursing, as such that is based upon the essentially holistic assumption that the truly effective leading process presupposes the absence of any clearly defined difference between leaders and followers (Franco & Almeida, 2011). The reason for this is that, as was mentioned earlier, our initiative stands in opposition to the discourse of subtle euro-centrism in nursing.

Conclusion

The paper’s main discursive propositions are as follows:

  1. There are many objective reasons to believe that the notion of ‘cultural competence’ will continue becoming increasingly integrated within the functional paradigm of nursing in the U.S.
  2. The currently deployed strategies to endowing nurses with cultural competence are implicitly euro-centric, which in turn explains why they exhibit the lack of practical effectiveness.
  3. The teaching of cultural competence in nursing schools and colleges should be concerned with helping students to identify the environmental causes that prompt ethnically diverse patients to be more predisposed towards holistic care-therapies.
  4. The adoption of the proposed initiative will help the U.S. healthcare system to be transformed from being nothing short of a profitable industry (operated by this country’s pharmaceutical companies), into the social institution that is there to provide people with the opportunity to receive holistic healing, rather than to be merely prescribed to swallow some pills.
  5. After having been enacted, the proposition in question will contribute towards making the system of nursing education in this country to be more effective, in the sense of encouraging students to expand their intellectual horizons – hence, bolstering their ability to react properly to the externally applied stimuli in the nursing care-settings.
  6. The initiative should also result in boosting nurses’ interest towards the Transformational model of leadership, as such that correlates with the discourse of post-modernity in nursing more than any other theory does.

References

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Dudas, K. (2012). Cultural competence: An evolutionary concept analysis. Nursing Education Perspectives, 33(5), 317-321.

Franco, M., & Almeida, J. (2011). Organisational learning and leadership styles in healthcare organizations. Leadership & Organization Development Journal, 32(8), 782-806.

Greenwood, S. (2010). Anthropology of magic. Oxford: Berg Publishers.

Kolcaba, K., & DiMarco, M. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursing, 31(3), 187-194.

Long, T. (2012). Overview of teaching strategies for cultural competence in nursing students. Journal of Cultural Diversity, 19(3), 102-108.

Nielsen, A., Noone, J., Voss, H., & Mathews, L. R. (2013). Preparing nursing students for the future: An innovative approach to clinical education. Nurse Education in Practice, 13(4), 301-309.

Southwick, M., & Polaschek, N. (2014). Reconstructing marginality: A new model of cultural diversity in nursing. Journal of Nursing Education, 53(5), 249-255.

Waite, R., & Calamaro, C. (2010). Cultural competence: A systemic challenge to nursing education, knowledge exchange, and the knowledge development process. Perspectives in Psychiatric Care, 46(1), 74-80.

Ume-Nwagbo, P. (2012). Implications of nursing faculties’ cultural competence. Journal of Nursing Education, 51(5), 262-268.