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The focus of this chapter will be on cultural competence, which has been defined by the Academy of Nursing (1993), as a collective noun to refer to the complex integration of knowledge, attitudes, skills, and critical thinking, which enhance cross-cultural communication and appropriate, effective interactions with others. In order to enhance cultural competence in the transcultural nurse, this chapter will summarize the principles, concepts, and practical considerations needed to provide effective nursing care across diverse groups. Concepts such as; cultural values across populations, cross-cultural communication, traditional/folk medicine beliefs, clinical decision making in nursing actions and evaluation of care will be explored.
Nurses must examine culture values of the group that they are working with if they are to provide culturally congruent nursing care that is meaningful in its cultural context. As stated in Chapter 5, Culture values refers to the powerful, persistent, and directive forces that give meaning, order, and direction to the individual's, group's, family's, or community's actions, decisions, and lifeways, usually over a span of time. Among the greatest challenges for the nurse is to provide care from the client's values and care meanings using what may be relevant or helpful from professional knowledge and experience. Care institutions cannot be culturally competent unless practitioners and clients work together to identify, plan, implement, and evaluate each caring modality.
Culture values are frequently contained in literature, metaphor, proverbs, and folklore of cultural groups. For example, the Anglo-American value of cleanliness is evident in the proverb "Cleanliness is next to godliness." In fact, the Anglo-American obsession for bodily cleanliness and the compulsion to eliminate body odors is reflected in the multimillion dollar business for manufacture of deodorants, perfumes, aftershave lotions, and similar products. In other cultures, the natural odor of the body is valued and little effort in made to disguise it.
As elaborated in Part II of this text, each cultural group has certain values that are reflected in folklore and literature. Below is a summary of core metaphors and themes that reflect the traditional values of cultural groups discussed in this text.
| Racial/Cultural Group | Core Cultural Values |
|---|---|
| Anglo American | Rugged individualism, self-reliance, self-determination, independence and freedom, competition and achievement, technology dependent, instant time and actions, youth and beauty, equal sex rights, leisure time highly valued, reliance on scientific facts, less respect for authority and the elderly, generosity in time of crises, focus on nuclear family, materialism. |
| African American | Extended family networks, flexible kinships, religion valued (many are Baptists), reliance on spiritual forces, technology valued (cars, television, etc.), sports heroes, interdependence with own racial group, suspicion of mainstream society, courage in overcoming adversity, folk healing modes. |
| Hispanic American | Extended family valued, interdependence with kin and social activities, patriarchal, exact time less valued, high respect for authority and the elderly, highly influenced by religious beliefs (many Roman Catholics), use of traditional folk-healers, defer to status and authority, value language (Spanish) and traditions. |
| Asian American | Filial piety, collective group harmony, hierarchical affiliation, patriarchal, respect and obligation to elders, politeness, interdependence, loyalty and honor to family, education, achievement, self-sacrifice, self-restraint and control, non-assertiveness in interactions, fatalism, "saving face", |
| Native American | Harmony with nature, coping with natural and human obstacles in life journey, spiritual guidance, folk healers, practice of cultural rituals and taboos, authority of tribal elders, pride in cultural heritage, respect and value children, community responsibility for families and individuals. |
Between cultures and even within one culture, values vary along a continuum. The nurse's comfort level and knowledge of clients across cultures are important factors in transcultural nursing care. Therefore, it is important to assess each client within the context of his or her level of loyalty to the traditional beliefs inherent in his or her culture group. When interacting with clients from various cultural backgrounds, it is also important for the nurse to be aware of his or her own cultural values, attitudes, beliefs, and practices in order to assess the appropriateness of response to clients across cultures.
The following framework describes different levels of responses the nurse might have toward culturally diverse clients.
Levels of Response
In general, healthcare providers expect behavior to consist of undemanding compliance, an attitude of respect for the health care provider, and cooperation with requested behavior, especially while in the hospital, clinic, or other health care facility. If nurses find themselves becoming annoyed that a client is asking too many questions, assuming a defensive posture, or otherwise feeling uncomfortable, it might be appropriate to pause for a moment to examine the source of the conflict from a transcultural perspective.
During illness, culturally acceptable sick role behavior may range from aggressive, demanding behavior to silent passivity. For example, Asian and Native American clients are likely to be quiet and compliant during illness and provide the nurse with answers they think are expected, in order to maintain a harmonious relationship with the nurse. Basically, it is important for the nurse to be aware of the nonverbal behaviors of their culturally diverse clients to provide effective, transcultural nursing care.
There are five types of nonverbal behaviors that convey information about the client: vocal cues, such as pitch, tone, and quality of voice; action cues, such as posture, facial expression, and gestures; object cues, such as clothes, jewelry, and hair styles; use of personal and territorial space, especially in regards to interpersonal transactions and care of belongings; and touch, which involves the use of personal space and action.
Unless nurses make an effort to understand the client's nonverbal behavior, they may overlook important information that is conveyed by facial expressions, silence, eye contact, touch and other body language. Communication patterns differ across cultures and can be observed even for such conventional social behaviors as smiling and handshaking. For example, when providing nursing care to Hispanic clients, smiling and handshaking are considered an integral part of sincere interactions and essential to establishing trust, whereas, an Asian American client might perceive the same behavior by the nurse as too forward and invasive.
Eye contact is perhaps the most culturally variable nonverbal behavior among groups. Although most nurses have been taught to maintain eye contact when speaking with clients, this behavior may be given other culturally based meanings by diverse clients. For example, Asian and Native American clients may consider direct eye contact impolite or aggressive, and may avert their own eyes when talking with the nurse. On the other hand, African Americans may use eye rolling in response to what is perceived to be a ridiculous question. Among Hispanic clients, respect dictates appropriate deferential behavior in the form of downcast eyes toward others on the basis of age, sex, social position, economic status, and position of authority. For this reason, the nurse can expect that the Hispanic client will defer by way of eye contact by virtue of their authority as healthcare providers in the nurse-client relationship.
In regards to gender considerations, violating norms related to appropriate male-female relationships among various cultures may jeopardize the nurse's therapeutic relationship with clients and their families. Nonverbal behaviors are culturally very significant, and failure to adhere to the cultural code (set of rules or norms of behavior used by a cultural group to guide their behavior and to interpret situations) is viewed as a serious transgression. For example, for some African-American Muslim groups, modesty for both women and men is interrelated with eye contact. This is achieved by keeping the eyes downcast when encountering members of the opposite sex in public situations and applies to the healthcare setting. The best way to ensure that cultural variables have been considered is to observe the client's level of comfort and when appropriate, ask the client about culturally relevant aspects of male-female relationships. This is best done at the time of admission or early in the relationship.
One of the greatest challenges in cross-cultural communication occurs when the nurse and client speak different languages. When assessing non-English-speaking clients, nurses may find themselves in one of two situations; either struggling to communicate effectively through an interpreter or, communicating effectively when there is an interpreter.
Interviewing the non-English speaking person requires a bilingual interpreter for full communication. Even the person from another culture or country who has a basic command of English (those for whom English is a second language) may need an interpreter when faced with an anxiety-provoking situation, such as; entering a hospital.
Although the nurse will be in charge of the focus and flow of the interview, the interpreter should be viewed as an important member of the health care team. It is tempting to ask a relative, friend, or even another client to interpret because this person is readily available and is likely anxious to help. This violates confidentiality for the client who may not want personal information shared. Furthermore, the friend or relative, though fluent in ordinary language usage, is likely to be unfamiliar with medical terminology, hospital or clinic procedures, and medical ethics.
When using an interpreter, the nurse should expect that the interaction with the client will require more time than when caring for English-speaking clients. It is necessary to organize nursing care so that the most important interactions or procedures are accomplished first, before any of the parties become fatigued.
The following is a summary of suggestions for the selection and use of an interpreter (Andrews, 1992).
Suggestions for the Institutions:
Although use of an interpreter is the ideal, nurses may find themselves in situations with a non-English speaking client when no interpreter is available. Below are suggestions for working with a non-English-speaking client when there is no interpreter available.
The folk medicine system classifies illnesses or diseases as natural or unnatural. This division of illnesses or diseases into natural and unnatural phenomena is common among Mexican Americans, African-Americans, and some southern White Americans. The simplest way to distinguish between natural and unnatural illnesses is to state that according to this belief system, natural events have to do with the world as God made it and as God intended it to be. Unnatural events can therefore be viewed as events that interrupt the plan intended by God and at their very worst represent the forces of evil and the machinations of the devil. Unnatural events are frightening because they have no predictability. They are outside the world of nature, so when unnatural events do occur, they are beyond the control of ordinary mortals.
Unnatural illnesses are thought to occur because an individual may become so grave a sinner that the Lord withdraws His favor, in fact, illnesses may be attributed to punishment for failure to abide by the proper behavior rules given to man by God. The etiology of unnatural illnesses, for those who subscribe to these beliefs, is based on the continual battle between the forces of good and evil as personified by God and the devil. Evil influences may be blamed for any unnatural illness, which may range from nightmares to tuberculosis. An example of a person subscribing to this belief would be a diabetic African-American woman who consistently refuses to inject herself with insulin because she believes her illness is the direct result of punishment by the devil for her sinful youth. However, unnatural illnesses are also thought to occur as a result of witchcraft which is based on the belief that there are individuals who have the ability to mobilize unusual powers for good and evil.
Another common metaphor for health and illness is the hot/cold theory of disease. This is founded on the ancient Greek concept of the four body humors: yellow bile, black bile, phlegm, and blood. These humors are balanced in the healthy individual. The treatment of disease becomes the process of restoring the body's humoral balance through the addition or subtraction of substances that affect each of these humors. Foods, beverages, herbs and other drugs are all classified as hot or cold, depending on their effect, not on their actual physical state. For example, Mexican Americans who subscribe to the hot/cold disease theory believe that paralysis, rheumatism, and earaches are caused when cold aires enter the body, whereas cold is thought to harm the body from without. Excesses of heat developed from within the body itself and extending outward are believed to be related to such diseases as cancer, rheumatism, tuberculosis, and paralysis.
The result of imbalance or disharmony is thought to lead to internal damage and altered physiological functions. Medicine is directed at correcting the imbalance as well as restoring body functioning. Treatment is focused on such things as suggestions, practical advice, guidance, prayers, or indigenous herbs, with the goal of reestablishing balance. Although Asian, Hispanic, African, Arab, Muslim, and Caribbean societies believe in the hot/cold theory of disease, little agreement exists across cultures on what constitutes hot and cold illness or treatment.
The presence of an alternate medical (folk medicine) system that is different from, and possibly in direct conflict with, the Western medical system can serve to complicate nursing care. It not only becomes a matter of offering health care in the place of no health care, or offering superior healthcare in lieu of inferior health care, but the nurse must remember that clients from diverse cultural backgrounds have deeply ingrained beliefs about how to attain and maintain health. These beliefs, which may be linked to the natural and supernatural worlds, may influence the individual's decision to follow or not follow prescribed treatment regimens. The nurse might correctly assume that when a low-income African-American, southern White American, Puerto Rican, or Mexican American arrives for professional health care, every home remedy known to the client has already been tried. It is important for the nurse to determine what the client has been doing to combat the illness. If the home remedy is harmless, it is best left in the treatment plan and the nurse's own suggestions added. However, harmful practices must be eliminated. For example, a dysfunctional health practice found among some African-Americans include such practices as using boiled goat's milk and cabbage juice for stomach infection. One of the best ways for the nurse to eliminate harmful practices is to inquire whether or not the practice has worked. If the client acknowledges that it has not worked, the nurse can simply suggest that something else be tried. If the client continues to perceive that a harmful practice is beneficial, the nurse must provide education that will illuminate the dangers of this harmful practice.
The nurse must be cognizant that the client's use of folk medicine practices may cause delay in seeking Western medical treatment, with dire result. For example, if a Vietnamese American parent uses folk medicine practices for an extended period of time in the treatment of a dehydrated baby, the baby may be brought for treatment too late for Western medical practices to be effective. As clients experience success with Western medicine and develop positive relationships with healthcare providers, these clients will be less likely to retain the "old ways" and more likely to seek help before symptoms become severe.
Leininger (1992) suggests three major modalities to guide nursing judgments, decisions, and actions for the purpose of providing culturally congruent care that is beneficial, satisfying, and meaningful to the client's nurses serve. The three modes are; cultural preservation and/or maintenance, cultural care accommodation and/or negotiation, and cultural care repatteming and/or restructuring.
Cultural preservation and/or maintenance refers to assistive supporting, facilitative, or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death.
Cultural care accommodation and/or negotiation refers to assistive, supporting, facilitative, or enabling creative professional actions and decisions that help clients from a designated culture to adapt to, or negotiate with others for beneficial or satisfying health outcomes with professional healthcare providers.
Culture care re-patterning and/or restructuring refers to assistive, supporting, facilitative, or enabling professional actions and decisions that help client reorder, change, or greatly modify their lifeways for new, different, and beneficial health care patterns while respecting the client's cultural values and beliefs.
These models are care-centered and based on using client's care knowledge. Negotiation between the client and the nurse can increase understanding and promote culturally congruent nursing care.
Evaluation of the effectiveness of clinical decisions and nursing actions should occur in collaboration with the client and his or her significant others - which may include members of the extended family, traditional healers, those with culturally determined kinships, and friends. A careful evaluation of each component of the transcultural nursing interaction should be undertaken in collaboration with the client. It may be necessary to gather further data, reinterpret existing findings, redefine mutual nurse-client goals, or renegotiate roles and responsibilities of the nurse and/or the client and his or her support system.