Cultural Competency in Nursing: A Concept Analysis
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Cultural Competence in Nursing: A Concept Analysis
International migration and globalization have resulted in culturally diverse populations and nurses are now faced with patients with varying cultural needs. Care provision has become more challenging as patient populations have become increasingly ethnically, racially, and culturally diverse (Alizadeh and Chavan, 2016). Language barriers, differences in held values, economic hardships, and cultural practices can present obstacles in quality care delivery and lead to disparities in all health care areas. Improving cultural competencies is a solution to the reduction of disparities. Cultural sensitivity is especially needed in emergency departments (EDs) which are often the main health care source for racial and ethnic minorities and the underserved (Enard et al., 2018). It is also an environment where acuity and high volumes of patients put nurses under demanding pressures. Yet, there is limited research on disparities and cultural competence in emergency medicine. Acquiring a solid understanding of this concept is especially important in emergency nursing due to the disproportionate use of the ED by minority and underserved populations. The Walker and Avant concept analysis method, which involves eight steps, was utilized.
The method is among the most understandable and most straightforward approaches to analyzing concepts, especially for those who have never conducted a conceptual analysis. It incorporates eight steps. The first involves selecting the concept, the second is making determinations on the purposes or aims of the analysis, and the third involves an identification of all its uses. The fourth step involves determining the attributes that define the concept. The fifth consists of constructing model cases, while the sixth consists of invented, borderline, contrary, and illegitimate cases. The seventh step consists of identifying consequences and antecedents, while the eighth and final step consists of defining the concept’s empirical references (Abdolrahimi et al., 2017).
Nursing care demands that attention is given to the patient’s culture since cultural diversities can be a significant barrier in delivering effective care. Cultural competency is now a cultural demand among all nurses in all care areas (Garrido et al., 2019). The nurses’ inadequate skills and knowledge regarding how to effective ways of dealing with clients from different cultural backgrounds impairs the relationship with them and results in care delivery inequalities. The impaired relationship leads to adverse health outcomes like losing opportunities for screening, errors in diagnosis, negative interactions of drugs, and early deaths (Young and Guo, 2020). Although cultural competencies are among the main foundations of practice, it remains ambiguous as it has not been clearly defined and analyzed in the context of the ED.
Aim of analysis
The ED is a stressful, noisy environment rife with demanding time pressure and expectations. Ethnic and racial minority populations continue to use the ED disproportionately despite serving as the safety net and frontline of the United States healthcare system (Crowe et al., 2020). A reason for this is the differences between provider and patient racial, religious, cultural and ethnic characteristics, which, when combined with the environment of the ED, leave encounters open to stereotyping, inadequate collaborations and misunderstandings. The concept was chosen for analysis to enable a thorough understanding to reduce disparities in the emergency department by promoting competent, equitable, and sensitive health care for all.
The cultural competence concept incorporates competence and culture sub-concepts. Culture is defined in the dictionary of Merriam Webster (2018) as the social forms, customary beliefs, and characteristics of a social, religious, or racial group. It also terms it as the features of existing, like ways of life that people share in specific times of places. The Oxford dictionary terms it as customs, ideas, and social behaviors of particular groups of people or society. Competence is defined in the dictionary of Merriam Webster as states or qualities of being competent, and the medical definition terms it as the states or qualities of adequate functionality. The dictionary of Oxford terms competence as involving abilities to perform things efficiently and successfully. Words like capability, ability, faculty, and capacity are synonyms for competence.
In the nursing literature, culture involves paradigms that are learned and shared within groups. It influences beliefs, values, behaviors, and rituals and is often reflected in languages, materials, food, dress, and a group’s social institutions. Nursing theorists have defined competence as acquiring desired outcomes in different real-world conditions or situations (Lor et al., 2016). Cultural competence refers to sets of appropriate attitudes, behaviors, and policies that integrate among professionals or organizations to enable working in cross-cultural scenarios. Culturally competent nursing has been termed as the sensitive, culture-based, meaningful and creative utilization of healthcare knowledge for coordination of normal living ways and needs among groups and individuals. End goals of such care involve well-being and significant health and effectively coping with issues, illness, and death. Various scholars consider cultural competence and its acquisition as an evolutionary and ongoing process (Mews et al., 2018). Healthcare practitioners make attempts of acquiring skills for working in diverse cultural environments continuously to be capable of providing adequate services in the culture of the client. Cultural competence definitions have significantly been influenced by the levels of importance placed on either of the sub-concepts. Focus on competence results in referring to attributes like attitude, knowledge, and skill, while a focus on culture involves dimensions like religion, cultural values, and health beliefs.
A fundamental aspect of concept analysis involves finding the attributes that define a concept. It consists of attributes with the most substantial association with the concept to allow improved insights and differentiating between related and similar concepts. The commonest attributes that define cultural competence include awareness, knowledge, skill, sensitivity, dynamicity and proficiency in cultural domains. Cultural awareness involves understanding how culture affects the individual and others. It helps an individual assess their prejudices and biases and forms a method of evaluating the values and beliefs of others. It can also enable identification of the differences and similarities between one’s own culture and other cultures. In the absence of cultural awareness, individuals can impose their culture’s values, beliefs, and behavior patterns on people of other cultures (Young and Guo, 2020). Cultural knowledge involves the ongoing acquisition of information about other cultures and can include learning of their theoretical and conceptual frameworks to aid in processing data. It is the basis of cultural understanding. Such knowledge enables care providers to understand how the patient behaves and thinks during illness and the essential issues that should be noticed during care decisions for patients from various ethnic groups.
Cultural sensitivity involves valuing, respecting, and admiring cultural diversities. Cultural sensitivity characteristics include attention, knowledge, respect, understanding, and optimizing treatments and interventions according to the patient’s cultural needs. It has been described as an attempt to understand others’ worlds without being blurred by racism. It helps nurses understand how the viewpoint and attitude of the patient affect their care-seeking patterns and behavior. The cultural skill involves establishing effective communications with people from other cultural backgrounds (Mews et al., 2018). Such abilities include considering the different values, beliefs, and methods during care planning and provision. Dynamicity involves a nurses’ acquisition of cultural competence through frequently encountering different patients.
Model cases involve examples of the concepts used where all defining attributes are demonstrated and enable a better articulation of the concept’s meaning. Mr. A, an ED nurse, was tasked with caring for a diabetic woman referred to the ED with her husband due to chest pain and dyspnea. At the initial communication, Mr. A notices that the couple is Arabic and cannot speak English. While reflecting on previous encounters, Mr. A remembers that Arabs place high value on getting cared for by providers of similar genders. He coordinates with the charge nurse, and delegates care delivery responsibilities to a nurse who is female. He also asks for an Arabic colleague to be referred to the ED for the establishment of adequate communication with the clients and to acquire more information on her beliefs, culture and values.
In this case, Mr. A displays various attributes of cultural competencies in the relationship with the client who has a different culture and language. Awareness to the patients’ culture id evident he was also sensitive to a female nurse’s need based on cultural skill and sensitivity in delivering care. He also called for the Arabic colleague to obtain more information, thereby improving cultural knowledge. Mr. A attempted to provide care that was culturally congruent, which reflects his competency in culture. The process of care displayed also shows dynamicity in the interaction and the process through which it was developed.
Borderline cases contain most of the defining attributes of a concept. Mrs. B was tasked with admitting and caring for a young woman referred to the ED with her spouse due to abdominal pain complaints. As they were waiting for the doctor, restlessness and discomfort increased even further after noticing that the doctor was male. The husband requested a female doctor, and Mrs. B became aware of the patients’ and husbands’ sensitivity to gender in medical visits. After taking vital signs and a brief history, Mrs. B went to the doctors. After returning, she respectfully informed them that their sensitivity in understood and respected, but there was no female doctor available in the ED. Sadly, the husband told Mrs. B that he could not allow a male doctor to attend to his wife and exited the ED.
The case shows that Mrs. B became aware of the culture of the patient through the interaction and the respect displayed to their values denotes cultural sensitivity as she attempted to find a female physician. She also did not try to convince or coerce the clients to accepting service provision from the male doctor.
Related cases show scenarios with similarities to concepts, but all the attributes that define it are not present. Mrs. C, an ED nurse, was charged with delivering care to a client and her husband referred to the ED due to increasing back pain. The patient and her husband only spoke Spanish. Mrs. C, who only speaks English, made attempts at communicating with them. Due to the inability of understanding Spanish, Mrs. C only responded to the patients and husbands words with smiles and nodding while using body language to explain. She continuously made responses to questions with smiles and admitted a lack of understanding. Eventually, the client stopped communicating.
Although the nurse made attempts of treating the patient respectfully and providing care, she failed in establishing communication that was effective and providing care that was culturally congruent due to the barrier in language. She had inadequate knowledge of the culture of the patient, and no efforts were made at communicating with her. Such practice shows limited cultural sensitivity and skill.
Mrs. D was tasked with admitting and caring for a diabetic woman with dyspnea and chest pain. During the initial encounter, the nurse noted that the patient’s language and culture differed from her own and opted to avoid communicating with the patient since she did not understand the language or culture. She admitted the patient, provided routine care, and informed the charge nurse of the barriers in communication caused by language differences. This case shows an absence of cultural competencies in the nurse. None of the characteristics of the concepts defining attributes are present and it resulted in inabilities of providing care to clients from different cultural backgrounds.
Antecedents refer to events that take place before the intended concept. The antecedents involved in the cultural competence concept include cultural diversities, cultural interaction and encounters, cultural desires, humility to culture, competencies that are humanistic, preparation through education, and organization supports.
Concept consequences refer to events that occur due to the presence of the concept. One consequence is the reduction of health inequalities. Culturally competent providers can plan activities related to care like diagnosis or treatment according to the client’s culture, which paves the way for holistic care delivery. As a result, patient trust in the healthcare system is increased, adherence is improved, and satisfaction with care service is achieved together with improved quality of life. Cultural competence also facilitates successful interactions and mutual relationships between the nurse, the patient, and their family members (Mews et al., 2018). It gives nurses feelings of empowerment and respect, while developing professional and personal values, performance, and relationships. Ethnic and cultural discrimination in care and the likelihood of malpractice is also reduced while improvements are obtained in care effectiveness, public health, and mortality and morbidity rates.
Empirical references clarify the concept further and provide a way of measuring it. Various tools have been developed for measuring cultural competence based on their defining attributes. They include Perng and Watson’s Nurse Cultural Competence Scale and the Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals (Wall-Basset et al., 2018).
From the analysis undertaken, cultural; competence can be defined as an evolutionary and dynamic process of acquiring abilities for providing safe, effective, and quality care to individuals from different cultural backgrounds. It also involves giving due consideration to the different aspects of an individual’s culture during care provision.
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