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Cultural Competence in Nursing Practice

Gaining knowledge is the first step toward understanding

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Learning Scope #468
Expires Jan. 27, 2016
1 contact hour


You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70% or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).


The author has completed a disclosure form and reports no relationships relevant to the content of this article.

The goal of this continuing education offering is to provide the latest information to nurses about cultural competence and culturally congruent care. After reading this article, the learner will be able to:

  1. Describe the significance of culture in the healthcare setting.
  2. Identify issues across various cultures using verbal and non-verbal communication.
  3. Discuss ways to provide culturally congruent care in the healthcare setting.

Now more than ever, nurses and other healthcare providers must be prepared to care for a diverse group of patients. National data show that 12.9 % of the U.S. population was born in another country.1 A disparity exists between the current nursing workforce and the population of patients. According to Dudas, the current nursing workforce is 83.2% white and thus is not representative of the current patient population in the United States. 1 This author suggests that cultural competence is a key component of preparing nurses to meet the needs of our changing society.

Nurses and other healthcare providers are expected to deliver culturally congruent care.

The American Association of Colleges of Nursing has developed a cultural competency toolkit for nurse educators to use when teaching nursing students about culture and cultural care.2 The Joint Commission has developed standards for cultural competence;3 however, nurses and other healthcare providers do not always understand the significance of cultural beliefs and values. Furthermore, becoming culturally competent is a process that requires lifelong learning and understanding of various cultures.4 As Galanti observed, "cultural competence is a journey not a destination."4

Clinical Vignettes
Why is it so important to become culturally competent and to deliver culturally congruent care? Consider for a moment the following vignettes and think about how you might respond to these situations. What strategies might you employ if you had knowledge of the culture, beliefs and values of these patients?

  • S.G. is a 78-year-old man who is an Orthodox Jew. He is upset because he wants to pray and light a candle for Shabbat. However, real candles cannot be used in the hospital due to fire safety regulations. What might you offer as a compromise?
  • Y.D. is a 55-year-old woman with pneumonia. She has many visitors and the patient who is sharing the room with her is disturbed by the frequent noise and activity. How would your knowledge of the Hispanic culture guide your plan of care for both patients?
  • C.A. is a 35-year-old woman who does not make eye contact when you ask her questions. The student nurse who is shadowing you believes she is depressed. Do you agree or disagree? What do you know about eye contact and different cultures?
  • M.C. is a 70-year-old Asian man who has ecchymotic areas on his back. The nurse suspects elder abuse. However, the nursing supervisor, who is also Asian, explains to her colleague that this may be due to a folk remedy. Would you know how to recognize it?
  • Another patient's family is upset that her religious scapula was removed from her neck and is now lost. Are you familiar with different religions and religious artifacts and their significance?

These vignettes demonstrate how healthcare providers may misinterpret the behaviors of their patients if they do not have adequate knowledge of each patient's culture, beliefs and values. Because of our lack of knowledge and understanding, we may not realize the significance of these practices. It is important to include your knowledge of culture and to conduct an individualized cultural assessment on all of your patients. Don't assume or presume to know how a person will think or feel based on his or her culture.

Many nursing programs and healthcare organizations provide education about culture, so most of us have a basic understanding of the relationship of culture to healthcare. Several terms are used when discussing culture and cultural competence.

Culture is a learned, patterned behavioral response acquired over time. It includes implicit vs. explicit beliefs, attitudes, values, customs, norms, taboos, arts and life ways accepted by a community of people.5

Acculturation is the process by which a cultural group incorporates some of the cultural attributes of the larger society.6 We live in a global society, and it is important to note that as people assimilate into a new area, they will often embrace at least some of the cultural practices. For example, some people who move to America may decide to celebrate Thanksgiving Day or Independence Day, even though this was not something they celebrated in the countries where they previously lived. They may also continue to celebrate special holidays or practice rituals they performed in their previous homelands.

Cultural awareness is being knowledgeable about one's own thoughts, feelings and sensations, as well as the ability to reflect on how these can affect one's interactions with others.5,7 It is important to reflect on your own culture, values and beliefs so that you can become more aware of other cultures. This self-awareness involves both positive and negative views of various cultures, values and beliefs. You don't have to agree with everyone's cultural practices, but as a healthcare provider you are expected to treat people with respect and should not judge others for their beliefs.8,9 Of course, if the practice might be harmful to a patient, you should consult with your administrators.

Cultural imposition intrusively applies the majority cultural view to individuals and families. Prescribing a special diet without regard to the patient's culture and limiting visitors to immediate family borders on cultural imposition. In this context, healthcare providers must be careful expressing their cultural values too strongly until cultural issues are more fully understood.5

Cultural sensitivity is experienced when neutral language - both verbal and non-verbal - is used in a way that reflects sensitivity and appreciation for the diversity of another. It is conveyed when words, phrases, categorizations, etc. are intentionally avoided, especially when referring to any person who may interpret them as impolite or offensive.5,6 Words or gestures often have different meanings across cultures, so it is best to avoid these types of words and gestures.7

Cultural Competence
The first step toward becoming culturally competent is to complete a self-assessment of your own beliefs and biases. Such assessments are readily available on the Internet. Next, you need to develop an understanding of the factors that influence a person's culture, values and beliefs. The next step is to learn about the various cultures and utilize that knowledge when providing patient-centered care.4,7,9 Nursing culture is made up of its history, rituals, myths, routines and stories, along with underpinning assumptions and values. Culture is communicated and maintained through the socialization process and in everyday interaction, through ceremonies, rituals, myths, symbols and artifacts.7,10

One author has observed that "Culture acts to maintain internal cohesion in a group and serves as a defense against external threat and the anxieties which emerge from both real and perceived intrusion from others outside of the culture.10

Models and Theories
Providing culturally congruent care is a goal for which healthcare providers develop an individualized plan of care based on the patient's cultural values and beliefs.9,11 Several practice models have been developed to guide nurses and other healthcare providers in the delivery of culturally congruent care.

Madeline Leininger is credited with the seminal work that led to the development of transcultural nursing .12 Leininger developed the Culture Care Diversity and Universality Theory based on her nursing experiences, life experiences and the anthropological work of Margaret Mead.13 The central purpose of the theory is to discover and explain culturally based care factors that influence the health, well-being, illness or death of people or groups.13

Leininger also developed the Sunrise Model, which presents the emic and etic relationship of patients and caregivers, health and illness, and cultural influences. It encompasses political and legal issues, religious and philosophical beliefs, holistic healthcare, education, illness and death, individuals, families and groups, and care.13

Campinha-Bacote developed the Process of Cultural Competence in the Delivery of Healthcare Services (PCCDHS) in 1991, and it has undergone several revisions. The latest revision to the model was in 2010.12 According to Campinha-Bacote, individuals as well as organizations and institutions begin the journey to cultural competence by first demonstrating an intrinsic motivation to engage in a cultural competence process. 14 Campinha-Bacote emphasized that a cultural assessment is necessary for every patient, because every patient has values, beliefs and practices that must be considered when rendering healthcare services. Therefore, cultural assessments should not be limited to specific ethnic groups, but rather conducted with each patient. The current PCCDHS model includes five constructs:13

  • cultural awareness
  • cultural knowledge
  • cultural skill
  • cultural encounters
  • cultural desire.

According to Campinha-Bacote, the most important construct in the model is cultural encounters that enable the healthcare provider to learn more about various cultures and continue his or her journey to becoming culturally competent.

Purnell developed the Purnell Model of Cultural Competence, which started as an organizational framework while he was teaching undergraduate students about different cultures. The model is depicted as a circle and includes 12 constructs that influence culture. The inner rim of the circle is the person, the next is the family, the next is the community, and the outer rim is the global society.15 Purnell conceptualizes the development of cultural competence along an upward curve of learning and practice. An increasing level of achievement of competence characterizes the model, which views the practitioner moving through four levels: from a stage of unconscious incompetence to conscious incompetence, followed by conscious competence, and finally unconscious competence.16

Although these models differ, they have common themes. Providing culturally congruent care requires a holistic interprofessional approach that is based on the patient's or family's culture, values, beliefs and expectations.

Folk Medicine
Culture has an influence on health and illness, and many people use folk medicine or a combination of modern medicine and folk medicine for some or all health ailments. Some patients may believe their illness is caused by a supernatural vs. physiologic cause. Therefore, it may be helpful to inquire about the "4 Cs of Culture"4 when assessing patients. What do you call your problem? This is an important question because some people may believe their illness is caused by a virus or bacteria, while others may believe their illness is due to a spirit, or mal de ojo (evil eye). This may occur if a jealous person compliments a baby without touching them, causing the baby to become ill.4

The next question is what do you think caused your problem? If someone believes an illness is caused by something supernatural because, he or she is going to seek help from a healer, such as a curandera.4

What are you concerns? How do you cope? It is important to relate care and treatment to the patient's cultural context.4

Many healing practices, rituals and beliefs influence a person's health and illness beliefs and practices. Nurses require some knowledge of these various beliefs and practices. For example, the Asian healing practices of cupping and coining may leave red marks on the patient's skin and are at times believed to be signs of abuse. Coining involves rubbing coins on the affected area and cupping may involve placing a heated glass jar directly on the patient's skin.4 Nurses must seek to avoid misinterpretation of healing practices and to understand the need for patients to incorporate these practices into their personal plan of care.

So-called hot and cold illnesses are another common issue, especially in the Hispanic culture. Hot conditions include pregnancy and hypertension, and cold conditions include pneumonia and menstrual cramps. Hot conditions are treated with cold remedies and cold conditions are treated with hot remedies.4 These are just a few examples of common folk medicine beliefs that can be incorporated into the patient's individualized plan of care.

Non-verbal and verbal communication are key components in providing culturally congruent care. Because words and phrases may have different connotations, it is best to avoid them.17 For example, "just now" means "later" in South Africa.4 Eye contact also varies among cultures. In American and European cultures, it is a sign of respect. However, in Asian and Muslim cultures, it may be a sign of disrespect. There may also be gender differences with regard to eye contact.4,8 With regard to gestures, the "thumbs up" sign in America means things are good, but in Islamic and Asian countries it is considered an insult. Touching is embraced by the American and Hispanic populations by may be taboo in the Asian, Muslim and Orthodox Jew populations. Healthcare providers need to be aware that some patients will require a caregiver of the same gender, or to have a parent or guardian present when care is being provided.4

This is just a brief overview of some of the common areas that can lead to mistrust and misunderstandings between healthcare providers and their patients. The nursing literature contains a wealth of information that provides comprehensive information on all of these factors. Because things are constantly changing, it is important to stay up to date with current literature about cultural care.

An Integral Role
Culture plays an integral role in healthcare. We may not always agree with our patients' cultural practices, but we must try to incorporate them into the individualized plan of care for our patients, as long as these practices do not cause harm. Becoming culturally competent is a journey that begins with self-assessment and continues with knowledge acquisition and integration of best practices that promote positive patient outcomes. This knowledge should be based on current evidence and standards. Using the following acronym may be helpful:

C: Care enough to learn about your patient's and family's cultural values, and beliefs.

A: Always complete a thorough cultural assessment of your patients and do your best to provide culturally congruent care.

R: Realize that many people develop their own unique culture, beliefs and values.

E: Evaluate your own beliefs and try not to judge others for their cultural beliefs and practices.

Now that you have completed the article go back to the vignettes and consider how you might develop a plan of care to provide culturally congruent care.


  1. Dudas K. Cultural competence: An evolutionary concept analysis. Nurs Educ Perspect. 2012; 33(5):317-321.
  2. American Association of Colleges of Nurses. Tool kit of resources for culturally competent education for baccalaureate nurses.
  3. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals.
  4. Galanti GA. Basic concepts and communication and time orientation. In: Caring for Patients From Different Cultures. 4th ed. Philadelphia: University of Pennsylvania Press; 2008.
  5. Giger J, et al. American Academy of Nursing Expert Panel report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. J Transcult Nurs. 2007;18(2):95-102.
  6. Helman C. Introduction: The scope of medical anthropology. In: Culture, Health and Illness. 5th ed. Oxford UK Butterworth Heinman; 2007: 1-18.
  7. Giger J, Davidhizer R. Introduction to transcultural nursing. In: Transcultural Nursing: Assessment & Intervention. 5th ed. St. Louis: Mosby/Elsevier; 2008: 2-19.
  8. Andrews M, Boyle J. Theoretical foundations of transcultural nursing and culturally competent nursing care. In: Transcultural Concepts in Nursing Care. 5th ed. Philadelphia: Wolters Kluwer & Lippincott; 2008: 3-33.
  9. Jeffreys M. Overview of key issues and concerns and dynamics of diversity: Becoming better health care providers through cultural competence. In: Teaching Cultural Competence in Nursing and Health Care. 2nd ed. New York: Springer Publishing Company; 2010: 3-44.
  10. Chapman L. A cultural revolution? Primary Health Care. 2002;12(7):14-15.
  11. Leininger MM. Culture care diversity and universality theory and evolution of the ethnonursing method. Culture Care Diversity and Universality: A Theory of Nursing. New York: National League of Nursing; 1991: 1-42.
  12. Campinha-Bacote J. Coming to know cultural competence: An evolutionary process. Int J Human Caring. 2011;15(3):42-48.
  13. Leininger M. Culture care theory: A major contribution to advance transcultural nursing and practices. J Transcult Nurs. 2002;13(3):189-192.
  14. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services.
  15. Purnell LD, Paulanka BJ. The Purnell Model of Cultural Comptence. In: Transcultural Health Care: A Culturally Competent Approach. 3rd ed. Philadelphia: F.A. Davis; 2008: 19-55.
  16. Purnell L. The Purnell Model for Cultural Competence. J Multicultural Nursing & Health. 2005;11(2):7-15.
  17. Capell J. Communicating with your clients: are you as "culturally sensitive" as you think? Physiotherapy Canada. 2007;59(3):184-193.

 Deborah Hunt is an associate professor of nursing at The College of New Rochelle in New Rochelle, N.Y.

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