May 04, 2018
Do you value difference and embrace diversity as a strength?
We must pursue cultural competence if we are to eliminate historical disparities and inequities in the health status of people of diverse racial, ethnic and cultural backgrounds
All nurses will eventually have an illuminating experience that readjusts their career trajectory. In my case, it happened when I had to perform CPR on my mother and then help my family navigate through the health-care system to ensure her physical and cultural safety. Despite warning the nurses that she would be extremely confused when she woke up, we were barred from her bedside and had to wait anxiously down the hall. Hearing a commotion, I rushed in to find the nurses trying to restrain her as she called for me to come to her aid. Though she had been proficient in English, her seizure and subsequent arrest robbed her of that skill and she could only communicate in her mother tongue — compounding the cultural barrier. She was terrified when she woke up in a strange place to complete strangers and shamed by their attempts to attend to her personal needs. She needed her family to provide that intimate care, a simple cultural need that, had the nurses respectfully and humbly assessed for, would have been easily addressed.
That experience was the first of many that have shaped the last 20 plus years of my career and pushed me onto the soapbox of advocating, researching, teaching and writing about cultural competence.
Although nurses — the first to recognize culture as the missing dimension of care — established the field of transcultural nursing, we have also contributed to much of the confusion about those concepts. We have blurred the distinctions between cultural competence, cultural awareness, cultural sensitivity and cultural safety and gone so far as to equate patient-centred care with culturally competent care. As a result, our understanding of cultural competence and its importance has been diluted.
Most of us would agree that becoming culturally competent refers to the knowledge, skills and attitudes we develop to ensure patients are cared for in a culturally appropriate manner. Most of the literature has concentrated on the knowledge and skills and not on the attitudes nurses need to be able to cross cultural gaps. The prevailing wisdom is that we should avoid stereotyping and making assumptions. Though this is excellent advice, it is not enough. At the heart of our practice are our attitudes, which determine how and with whom we establish therapeutic relationships. Respect for different world views, humility in the face of power differentials, acceptance of what is important to patients, commitment to equity, openness to traditional healing, and flexibility in integrating cultural practices in the plan of care are essential.
The deeply embedded societal and systemic misconceptions that marginalize and racialize those who are perceived as “less,” simply because they are different, have led (and continue to lead) to shameful actions, even atrocities. I would like to believe that being marginalized and racialized because of attributes such as age, gender and ethnicity is not what patients who are different experience in their interactions with nurses. I fear, however, that this is too often the case.
We continue to socialize new professionals to believe that western medicine is superior and to view a patient as a set of symptoms and, ultimately, a diagnosis. Despite evidence that illness and disease are presented, experienced and treated through the lens of one’s culture, cultural competence continues to be relegated to the fringes of nursing curricula.
In our practice, because we do not view every encounter as a cultural encounter, completing a cultural assessment of every patient is not our priority. When we do complete an assessment, our attitudes can be barriers that prevent us from addressing cultural needs in a manner that ensures each patient and each family is culturally safe while in our care.
It is only when we start valuing difference and embracing diversity as a strength that we will be able to achieve a greater measure of cultural competence.