Chapter 9: Cultural Competence in Nursing Care

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Imagine this, you're working a shift, hospital's busy, and a patient you just admitted seemed okay with it suddenly says, no, not having that surgery.

Or maybe you're explaining meds to a family, they're nodding, nodding, but you just get that feeling.

It's not sinking in.

Yeah, that gut feeling.

We've all been there.

And often those aren't just small talk hiccups, are they?

No, not at all.

They can be really deep cultural things shaping how people see health, illness,

even who they trust.

And that is exactly what we are diving into today.

Cultural competence in nursing.

Super crucial stuff.

Right.

And we're pulling our insights straight from a text.

Many of you probably have on your shelf,

or digitally anyway, Fundamentals of Nursing, the 11th edition by Potter, Perry, Stockard, and Hall.

It's a cornerstone text for a reason.

Definitely.

So our mission today is to take these, you know, sometimes theoretical concepts and really show you how they work on the ground in your actual nursing practice.

Yeah, whether you're in a big hospital, a community clinic, maybe even home health.

We want to help you translate this knowledge into real skills.

We'll break down the ideas, link them to scenarios you might actually see, and keep highlighting why this is so vital for patient care.

And let's be honest, for the NCLEX too.

Absolutely.

Because understanding culture, it's not just about being like nice or politically correct.

It's fundamentally non -negotiable if you want to give safe,

effective, truly patient -centered care.

Especially now with how diverse our communities and patient populations are.

It's about making sure every patient gets care that fits them.

Exactly.

So let's start with the basics.

What do we actually mean when we say culture?

Okay, so fundamentally, culture is.

It's the learned stuff, right?

And it's shared within a group.

We're talking beliefs, values, the norms, traditions.

The things that guide how that group thinks and acts.

Precisely.

How they make decisions, how they approach life.

But here's the kicker.

It's not static.

It's not like some museum piece.

Right.

The book stresses that it's fluid.

Totally fluid.

It's always changing, you know?

Responding to the environment, social changes,

politics, biology even.

Think about your own family traditions.

They probably haven't stayed exactly the same, right?

Good point.

And tied into that is worldview.

Worldview is more personal, but heavily influenced by culture.

It's that set of assumptions we build up, usually starting way back in childhood.

And this shapes how we see everything.

Pretty much.

How we perceive other people, how we interact with reality, how we even process information.

And the analogy the book uses is brilliant.

The iceberg analogy.

Yes.

Figure 9 .3.

Love that one.

It's so effective.

So picture an iceberg.

You only see that little bit sticking out of the water.

That's like our behavior, what people see us do or say.

But the huge, massive part hidden underwater.

That's our worldview.

All the subconscious beliefs, values,

experiences.

Exactly.

Stuff we're often not even aware of.

But it massively impacts our behavior.

Okay.

So connect that to nursing.

Why is this iceberg so critical for us?

Well, think back to your opening example.

The patient refusing surgery after agreeing to admission.

The book gives a similar case.

Someone comes in for pain, agrees to be admitted, but then refuses surgery.

Why?

For deeply held religious reasons.

They believe they need to seek divine guidance before having a body part removed.

Their agreement to admission.

That's the visible tip.

But the refusal.

That's driven by the huge underwater part, their religious worldview.

You got it.

And the insight here is huge.

Conflict often pops up not because someone's being difficult, but because we as providers are looking at their tip through our iceberg, our worldview.

Instead of trying to understand what's underneath for them.

Precisely.

Which leads nicely into the idea of Emic versus Etic worldviews.

Okay.

Break it down.

Emic is the insider view.

How someone from that culture sees their world, their reality.

Etic is the outsider perspective.

That's usually us, the healthcare provider, looking in through our own lens.

Gotcha.

Like the example in the book about the Korean woman wanting seaweed soup.

Perfect example.

After childbirth, she requests seaweed soup.

From her Emic perspective, it's essential for healing, part of her cultural tradition.

But the nurse may be thinking from an Etic view, like hospital budgets or standard postpartum diets might offer something else, like kale soup.

Right.

And suddenly there's a disconnect.

Trust can be damaged.

The patient feels misunderstood.

It highlights the need to uncover the patient's Emic view, not just impose our Etic one.

That curiosity, asking why, seems so important.

Because let's face it, we all have biases, it's just human.

Absolutely.

And the text digs into two types we really need to be aware of in nursing.

First, there's unconscious bias.

The stuff we don't even know is there.

Exactly.

Those automatic snap judgments.

They're shaped by our background, our experiences, and we're totally unaware of them.

They happen outside our control.

Okay.

And the other type?

Implicit bias.

Now, with implicit bias, the key difference is we are aware it exists, maybe as a tendency or a feeling.

We might not like it, but we know it's there.

And because we're aware.

We're responsible for it.

As nurses, we have to acknowledge that implicit bias and actively work to stop it from affecting our care.

It's the shift from, I had no idea, to, okay, I recognize this tendency, I need to manage it.

That vigilance is crucial.

Because if bias,

whether it's about ethnicity, race, gender, religion,

social class, whatever, isn't checked.

It makes truly patient -centered, transcultural care incredibly difficult.

The goal isn't necessarily to eliminate all bias overnight, that might be impossible, but to recognize it and consciously prevent it from coloring our judgment or how we interact with patients.

And that ties into stereotypes too, right?

Making assumptions about whole groups.

Definitely.

A stereotype is just that an assumed belief about a group.

And the book warns us it's really easy to read about general cultural values and then accidentally apply them as stereotypes to individuals.

So we read about hot and cold foods and assume every Hispanic patient believes it.

Exactly.

Which is dangerous.

We have to avoid those generalizations.

The key is always approaching each person as an individual, ask questions, understand their unique perspective, their needs.

Because stereotyping can happen unconsciously.

Yeah.

There are two phases, apparently.

Activation, where the belief pops into your head automatically.

And then use, where you might unconsciously apply it.

We need to catch it before the use phase impacts care.

Okay.

This brings us to a really heavy but critical topic.

Health disparities.

And the social determinants of health or SDOH.

Let's define disparity first.

A health disparity is basically a health difference that's tied closely to some kind of disadvantage social, economic, or environmental.

And the really important part.

They are often preventable.

That's the tragedy in the called action.

You see examples everywhere.

The book lists quite a few in Box 9 .1.

Like higher rates of cognitive decline in American Indian and Alaska Native adults.

Or increased risk of cardiovascular disease linked to low food security.

That's a big one.

And African Americans facing higher rates of heart disease and high blood pressure, often at much younger ages than other groups.

These aren't random.

Not at all.

They're patterns.

And they point to those deeper issues of social determinants of health.

SDOH.

Everyone's talking about these now.

As they should be.

The World Health Organization defines SDOH simply as the conditions where people are born, grow, live, work, and age.

So everything outside the hospital walls basically.

Pretty much.

Healthy People 2030 gives us five main categories to think about.

Economic stability, education access and quality, health care access and quality, neighborhood and built environment and social and community context.

Can you give some examples?

Sure.

Think about someone's age, their race or ethnicity, income, education level, whether they have access to nutritious food, safe housing, reliable transportation, clean water.

It's a huge range.

And the crucial link for us as nurses is realizing these factors can drive health outcomes more than just individual choices.

Absolutely.

It's easy to focus on telling a patient to eat better.

But if they live in a food desert with no car, understanding their SDOH changes the whole conversation.

It shifts the focus from blaming the patient to understanding their context.

And certain groups feel this more acutely.

The book mentions marginalized groups.

Right.

Groups like LGBTQ plus folks, people of color, individuals with disabilities, those without higher education.

They often face a higher burden of poor health outcomes.

And it's not just one thing, is it?

It's complex.

Super complex.

It's the interplay between behaviors, environment, policies, clinical care.

And sometimes, unfortunately, the health care system itself can contribute.

Also.

Through things like inadequate resources in certain communities, poor communication, maybe a lack of culturally competent care, not enough language services.

It's why organizations like the Joint Commission are really pushing for improvements.

Let's make this concrete with the case study.

Mrs.

Millman.

Okay, yeah.

Mrs.

Millman.

27 African -American, new type 2 diabetes diagnosis needs insulin.

But she's lost her job, lost her insurance, she's homeless, living in a shelter.

And keeps ending up in the ER with high blood sugar.

Hannah, the nursing student, is trying to educate her.

Mrs.

Millman nods, seems agreeable, but Hannah feels like she's not really getting it.

Mrs.

Millman just says, no questions when asked.

So applying the SDOH lens here.

It's critical.

Look at her determinants.

Homelessness.

Unstable housing.

Job loss.

No economic stability.

No insurance.

Barrier to healthcare access.

Relying on the ED for primary care.

Plus, Hannah suspects a health literacy issue.

And being African -American puts her in a group known to face disparities in diabetes care.

Exactly.

All these factors are intertwined.

Hannah can't just focus on the diabetes teaching.

She has to see Mrs.

Millman's whole situation, driven by these social determinants, to create a plan that might actually work for her.

That leads perfectly into the concept of intersectionality.

How do all these different parts of someone's identity combine?

Mm -hmm.

Intersectionality is a framework, a way to study that complexity.

It looks at how different identities, race, gender, class, sexual orientation, disability status, et cetera, overlap and intersect.

And how that affects their experiences.

Yes.

Particularly focusing on power, privilege, and oppression.

How being marginalized in multiple ways shapes health and access to care.

Just so for Mrs.

Millman, it's not just being homeless or just being African -American or just having diabetes.

It's the intersection of all those things.

Young, black, female, homeless, newly diagnosed, maybe low -health literacy.

Each layer adds complexity and potential barriers.

Understanding intersectionality helps us see that whole complex person.

The book also mentions figure 9 .2, the ladders of oppression and cultural competence.

Right.

That visual helps understand how these systems of oppression work and how recognizing them is part of developing cultural competence.

It connects the societal structures to our individual practice.

Okay.

So we see the need, we understand the context.

How do we actually build cultural competence?

This seems huge.

It is.

But thankfully, we have models.

Campina -Bacota's model is a really practical one highlighted in the text.

It has five core constructs.

And the key thing to remember is...

It's a journey, not a destination.

Campina -Bacota emphasizes that.

It's lifelong learning and growth, not a checklist you finish.

Okay.

What's the first construct?

Cultural awareness.

This starts with you.

It's about self -examination.

Really looking honestly at your own biases, your own assumptions about other cultures.

And exploring our own cultural background, too.

Absolutely.

And your professional background.

What are the cultural norms of nursing itself?

It also means being aware of documented isms in healthcare, like ageism affecting how pain is treated in older adults.

You have to understand your own starting point.

The book uses eye contact as an example here.

Yeah, it's a simple but powerful one.

In some Western cultures, direct eye contact means honesty, engagement,

lack of it might feel disrespectful.

But in other cultures?

It can be the exact opposite.

Avoiding direct eye contact, especially with an authority figure like a nurse, can be a sign of deep respect.

If you aren't aware of that difference in your own reaction, you can easily misinterpret the interaction.

Okay.

Self -awareness first.

What's next?

Cultural knowledge.

This is the more active learning part.

Seeking out and building a solid educational base about diverse cultural groups.

What kind of knowledge?

The text points to three key areas.

Health -related beliefs and values, specific care practices common in a culture, and also disease, incidence, and prevalence, knowing which groups might be at higher risk for certain conditions.

Like the hot and cold concept in Box 9 .2.

Exactly.

That's a classic example of a health -related belief found in many Hispanic, Asian, African -American, and Arab cultures.

It's not about temperature, but about balancing perceived intrinsic properties of foods, drinks, herbs, and medicines to maintain health or treat illness.

Like yin and yang in Chinese culture.

Similar concept.

Yeah.

Understanding this means you don't dismiss a patient wanting hot foods for a cold illness as superstition.

You can work with that belief, maybe adjusting dietary recommendations to fit their framework where possible.

Makes sense.

Awareness, knowledge, then comes skill.

Right.

Cultural skill.

This is where you put the awareness and knowledge into practice.

It's the ability to actually do a cultural assessment and a culturally -based physical assessment.

How do we do that?

It starts with how you gather information.

The cultural nursing history.

Box 9 .4 gives great guidance.

Be mindful.

Don't make assumptions.

Listen actively.

Validate what you hear.

And use those open -ended questions we talked about earlier.

Yes.

Questions like, what do you call your problem?

What do you think caused it?

What kind of treatment do you think you should receive?

What do you fear most about your sickness?

These get you much richer, more useful information than a checklist.

Like Hannah going back to Mrs.

Millman and asking questions like that about her diet instead of just lecturing.

Exactly.

Finding out Mrs.

Millman's understanding, her challenges at the shelter, her own ideas about healthy eating within her constraints.

The book also mentions storytelling here in Box 9 .3.

Storytelling as an evidence -based practice.

Allowing patients to share their narrative, their experience in their own words.

It helps us understand their perspective and it can empower them, enhance self -management.

So creating a safe space for them to just talk.

Yes.

Be present.

Listen without judgment.

Let them lead.

It builds incredible rapport and understanding.

Okay.

Another key skill.

Assessing health literacy.

Super important.

Health literacy is just the ability to get, process, and understand basic health info to make good decisions.

And the stats are kind of shocking.

Millions of U .S.

adults have limited health literacy, plus language barriers.

How can we tell if someone might be struggling?

Look for clues.

Maybe they have trouble filling out forms, they miss appointments frequently, they ask very few questions, or give vague yes answers when you ask if they understand.

Are there tools for this?

Yeah, the book mentions a couple like the Realm SF and SHL, S &E, short assessment tools you can use.

But often it's about being observant and using clear communication strategies.

And if language is the barrier, that requires working with interpreters.

Absolutely.

And doing it properly.

The national CLS standards, culturally and linguistically appropriate services, are the benchmark here.

What are the key takeaways for nurses from CLAS?

Offer free language assistance, qualified interpreters, translated materials, tell patients these services are available, and critically, ensure the interpreters are competent.

Meaning, not just anyone who speaks the language.

Right.

No untrained staff, and never use family members or minors if you can avoid it.

They might filter information, lack medical terminology, or have their own biases.

You need a professional.

And when you're using an interpreter.

Speak in the first person.

Like, I need you to take this, not tell us you need to take this.

Look at the patient, not the interpreter.

Use short sentences.

Avoid jargon, slang jokes, pause often.

And always check for understanding with the patient afterwards.

Thank both.

Okay, cultural skill also includes the physical assessment itself.

Yes, the culturally based physical assessment.

Your cultural knowledge guides what you look for and how you interpret findings.

Like knowing about Mongolian spots.

Exactly.

Knowing those bluish marks common on infants of color are birthmarks, not bruises.

Or recognizing marks from coining or cupping traditional practices in some Asian cultures aren't signs of abuse, but healing methods.

So we need to ask about home remedies.

Always.

And consider conditions more prevalent in certain groups, like sickle cell anemia and those of African descent.

Knowledge prevents misdiagnosis or unnecessary interventions.

And the final big skill area.

Communication,

teach back, and plain language.

Crucial.

Plain language first.

Just using clear, simple, easy to understand language.

Avoid jargon.

Use active voice.

Break things down.

The federal plain language guidelines are a great resource.

And then teach back.

This seems like a game changer.

It really is.

Figure 9 .4 illustrates it well.

It's an ongoing process.

Instead of asking, do you understand?

Which usually gets a yes, regardless.

You ask the patient to explain it back in their own words.

Or demonstrate it.

Or demonstrate it, yeah.

Show me how you'll use this inhaler.

Explain to me what side effects you'll watch for.

And the key is, it's not a test to the patient.

No.

It's a check on our teaching.

Did I explain it clearly enough?

If they can't teach it back, the assumption is I need to explain it differently.

So like with Hannah and Mrs.

Millman in Box 9 .6.

Yeah.

Hannah would use plain language, maybe visuals, talk about food choices at the shelter.

And then ask teach back questions.

Okay.

Tell me two healthy snacks you could get at the corner store near the shelter.

Or show me on this plate picture what a balanced meal would look like.

It's about chunking the info, checking understanding, clarifying, checking again.

Exactly.

Shame -free environment.

Making it okay not to understand the first time.

It puts the responsibility for clear communication squarely on us, the providers.

Okay.

That covers cultural skill.

What's the fourth construct in Campini -Baccotti's model?

Cultural encounter.

This is about the actual interaction.

Having direct contact with patients from diverse backgrounds.

Just talking to people?

Pretty much.

But with intention.

The goals are two -fold.

One, learn to communicate effectively verbally and non -verbally in different cultural contexts.

Two, use these encounters to continuously refine your understanding.

So interacting helps validate or challenge the cultural knowledge you learn.

Prevents stereotyping.

Precisely.

Every encounter is a chance to learn and adjust your perspective based on real people, not just textbook descriptions.

And the final construct.

The fifth one.

This one is cultural desire.

Campini -Baccotti calls it the pivotal construct.

The key.

Desire.

As in wanting to do it.

Exactly.

It's the motivation.

The genuine want to engage in cultural competence.

Not because you have to check a box, but because you have a passion for it.

Being open, flexible, humble, willing to learn from patients as cultural informants.

Accepting differences.

Building on similarities.

Yes.

That intrinsic drive is what fuels the whole process.

And the LEARN model is a great tool to help guide that desire in practice.

Okay, LEARN.

What does that stand for?

It's a mnemonic.

Actively listen to the patient's perception of their problem, non -judgmentally.

Okay.

Explain.

Clearly explain your perception of the problem.

You got it.

Acknowledge.

Acknowledge and discuss the differences and similarities between your two perspectives.

Respectfully.

Recommend.

Recommend treatment options, but make sure the patient is involved in the recommendations.

Patient -centered.

Negotiate.

Negotiate a treatment plan that is mutually agreeable, incorporating the patient's cultural preferences whenever possible and beneficial.

That sounds like a really practical framework for difficult conversations.

It is.

Think about the scenario with Mrs.

Adelman.

39 weeks pregnant, needs an emergency c -section,

but refuses until her husband arrives because of her Muslim faith.

How would LEARN help there?

Well, cultural desire means you want to understand and respect her.

So you'd listen to her reasons, her fears.

Explain the medical urgency clearly, but respectfully.

Acknowledge the conflict between the medical need and her religious requirement.

Recommend options.

Maybe exploring if her husband can be reached quickly, or if there's another trusted person who could consent according to her faith.

And negotiate a plan, maybe preparing for surgery while efforts are made to contact him.

Ensuring safety while honoring her beliefs as much as possible.

Instead of just overriding her or getting frustrated.

Exactly.

It guides you toward a respectful collaborative solution.

Wow.

Okay.

So wrapping this all up, what's the big picture takeaway from this deep dive?

I think it's that cultural competence isn't a task.

It's an ongoing process, a dynamic way of being as a nurse.

It empowers us to give that truly patient -centered care, right?

And to actually do something about those health disparities we talked about.

Absolutely.

It's fundamentally about seeing and respecting each patient's unique worldview, their iceberg, and moving beyond just procedures and protocols.

So maybe a final thought for everyone listening.

As you go forward, think not just about the tasks of cultural competence, but the how.

How can understanding your own worldview,

your own biases, your own cultural journey, continually deepen your empathy?

And help you make that genuine connection with every single unique patient you meet.

That's the heart of it.

Well, thank you so much for joining us for this deep dive today.

Your commitment to learning this stuff is really what makes nursing stronger.

Yeah.

Thanks for being part of our learning community.

We really hope you take these insights, reflect on them, and find ways to bring them into your practice every day.

It makes a difference.