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Are you competent in cultural care?
A diverse group of people call the United States home, so nurses routinely encounter patients of different cultures in their practice. But how confident are you in your ability to meet varied cultural needs? Your competency is key, not just to achieve excellent patient outcomes, but also to protect yourself from being named in a lawsuit.
What is cultural competence?
According to the U.S. Office of Minority Health (OMH), culture refers to patterns of behavior of racial, ethnic, religious, or social groups. Cultural competence is the ability to meet the needs of diverse patient populations so that delivered healthcare is safe and equitable. The National Quality Forum (NQF) says culturally competent care tries to eliminate misunderstandings and improve patient adherence with treatments.
OMH notes that cultural competence is essential for closing the disparities gaps in healthcare because cultural and language can affect someone’s beliefs about health, disease, and the behaviors that lead to both. Being respectful of—and responsive to—individuals’ cultural needs ensures more effective communication so that a patient’s needs can be better met. The Joint Commission (TJC) recognizes the importance of patient-centered communication with its new standards, effective July 1, 2012, which address cultural competency. (For more information about the standards, read Appendix C in Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals, available online at www.jointcommission.org/Advancing_Effective_Communication.) In addition, almost all hospitals and most healthcare providers are subject to federal civil rights laws such as Title VI of the Civil Rights Act of 1964 and Age Discrimination Act of 1975.
Organizations develop policies to guide staff so they can practice within legal and regulatory guidelines. You need to know—and follow—those policies to avoid being named in a lawsuit if a patient’s cultural needs aren’t met.
Developing cultural competence
There is one important caveat to remember when building cultural competence—don’t stereotype. Culture is just one factor that shapes us; others include environment, socioeconomic status, genetics, and psychological factors. All these factors shape different people in different ways.
The first place to start is to assess your own competence. One useful online resource is the Cultural Competence Health Practitioner Assessment, which you can access on the National Center for Cultural Competence website at http://nccc.georgetown.edu/features/CCHPA.html. Be aware of your own possible biases.
Another assessment tool is to determine how closely you follow professional standards such as those from the American Nurses Association. One of the competencies for Standard 3 (Outcomes Identification) is “Defines expected outcomes in terms of the healthcare consumer, healthcare consumer culture [italics added for emphasis], values, and ethical considerations,” and a competency for Standard 4 (Planning) requires nurses to consider culture when developing an individualized care plan. For example, patients need to be asked on admission about their preferred language for discussing healthcare issues so education information in the plan is provided in the preferred language. To not do so could place the patient in jeopardy because of misunderstanding. In cases of legal action, attorneys will examine whether you followed these standards.
The next step is to educate yourself. Appendix E in TJC’s Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals contains a comprehensive list of resources for cultural competency training. You can use this list to ensure your cultural competency is sufficient for your practice.
Lack of knowledge is no excuse in a court case. Take the example of a female patient of a culture that requires a woman to be cared for by someone of the same sex. The female patient who is examined by a male nurse who does not discuss the situation with the woman beforehand may view the action as an attack. The nurse’s lack of understanding would not negate the perception.
Meeting patients’ cultural needs in practice
The TJC Roadmap publication is also a valuable resource for integrating culture into your clinical practice. It contains a checklist of how to improve effective communication (including cultural competence) across the care continuum, including admission, assessment, treatment, end-of-life care, and discharge and transfer. These tools can help you be sensitive to patients’ cultural needs. A nurse who cared for a patient of a culture where care in the home is valued would need to work with the discharge planner to confirm appropriate options are provided to ensure patient safety.
Be sure to document results of your assessment of a patient’s culture in the medical record. Flag any key information through use of stickers or other techniques to ensure other healthcare providers are aware of cultural needs. At times, it may be challenging to meet a patient’s cultural needs. It’s important to keep an open mind so you can negotiate a mutually agreed upon solution.
One of the NQF’s guiding principles of cultural competency is that it should be an ongoing process. It’s important to update your cultural competence skills in the same way you update your clinical skills. Doing so will help ensure your patients receive the care they need and help you avoid a day in court.
What you need to know about integrating cultural competence into care
The best way to understand a patient’s cultural needs is to simply ask. One general question that might be helpful is, “Are there any cultural, religious, or spiritual beliefs that might influence your care?” There are also more formal assessment tools such as the TransCultural Nursing Assessment Tool, available at www.culturediversity.org/assmtform.htm.
Below are a few examples of action steps you might want to consider to help patients and avoid the possibility of being sued. In each case, the most important point is to provide options that are acceptable to the patient.
Identify if the patient has cultural-based modesty issues about care provided by staff of the opposite sex.
Determine if there are certain garments or items that need to be worn.
Identify any special dietary needs. For example, a patient may fast on certain holidays.
Collaborate with patients and families to develop solutions to requests that can’t be met.
Provide education materials that in the patient’s preferred language and have translators available. This is especially important in the case of informed consent so patients understand what they are signing.
Document communication strategies used and the patient’s response in the medical record.
American Nurses Association. Nursing: Scope & Standards of Practice, 2nd Ed. 2010. Silver Spring, Md.: Author.
Byrne, MM. Cultural aspects of health. In: Ignatavicius DD and Workman ML, Medical Surgical Nursing: Critical Thinking for Collaborative Care. 5th ed. Saint Louis: Elsevier; 2006:54-62.
Campinha-Bacote, J. Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online Journal of Issues in Nursing. 2011;16(2):May. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No2-May-2011/Delivering-Patient-Centered-Care-in-the-Midst-of-a-Cultural-Conflict.html. Accessed Feb. 6, 2012.
The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals. Accessed Feb. 6, 2012.
National Quality Forum. Cultural competency: An organizational strategy for high-performing delivery systems. No. 14, April 2009.
National Center for Cultural Competence. Cultural and Linguistic Policy Assessment. http://www.clcpa.info/. Accessed Feb. 6, 2012.
The Office of Minority Health What is cultural competency? http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11. Accessed Feb. 6, 2012.