Cultural Competence in Nursing: A Systematic Review

This assignment involves a comprehensive analysis of existing research on cultural competence in nursing. It includes a systematic review of 12 articles that explore various aspects of cultural competence, such as its importance in healthcare settings, strategies for overcoming barriers to providing anti-discriminatory care, and the effectiveness of cultural competence programs. The study also examines factors influencing men entering the nursing profession and challenges faced by them. This assignment aims to provide insights into the complexities of cultural competence in nursing and identify areas for future research.

Introduction
The aim of this assignment is to point out the factors that influence the type of care provided
to the aboriginal individuals. The paper also aims to cover the strategies that would improve
the care to the patient coming from diverse cultural and ethnic backgrounds. Global
immigration has augmented with times. According to Renzahoet al. (2013), immigration in
the past decade has increased from 150 million migrants to 214 million immigrants during the
tenure of 2000 to 2010. Such immigration has affected mainly the public sectors like health
care since the culture and the ethnicity of the clients and workforce are becoming
multifactorious (Markey et al. 2012). This demographical change has its own problems. High
differences in the public health status are posing effects on the cultural minority groups
negatively and primarily ethnic group (Betancourt et al. 2016). In a multicultural setting,
successful delivery of health care is hampered numerous factors, for example, non-verbal
communication and language gap between care givers and patient, lack of awareness or
respect of cultural traditions and institutional as well interpersonal stereotyping and prejudice
(Degniet al. 2012). Accordingly, numerous health-care models have been projected for
shifting from paternalistic type of health-care system to a self-care approach and involving
the patient in the decision making process. Some of the models in this context are the patient-
centered care (PCC) models and cultural competence models (CC) (Renzahoet al. 2013).
Cultural competence may be considered as the act of being respectful and responsive towards
the health care beliefs of a culturally diverse population groups. (Renzaho et al 2013;
Barksdale 2009). According to Renzahoet al. (2013), lack of awareness in the domain of
cultural differences and lack of knowledge among patients, belonging to culturally different
background, bring about adverse health outcomes. These include compromised patient–care
giver relationships and health belief, behaviors and practices of patients. Hence it becomes

difficult for both caregivers and patients to achieve the comprehensive health outcome care
(Betancourt et al. 2016).
The following paragraphs aims to discuss the factors that influence the care provided to the
patients belonging to diversified cultural background. In doing this the essay will begin via
throwing a brief light on significance of cultural competence in nursing and midwifery
practice. Upon discussing the same, the essay will critically discuss the opportunities, barriers
and challenges in implementing cultural competence in healthcare. The essay also plans to
explore, personal, professional organizational and societal factors that influence the cultural
competence care while highlighting the important approaches that can be adopted for
improving the cultural competence in health care field.
Cultural competence and its significance in nursing and midwifery practice
National Center for cultural competence (CC) in the USA has recommended a framework for
cultural competence highlighting its requirements of health-care systems. According to
Renzahoet al. (2013), CC helps in dodging cultural obstacles between health-care provider
and the healthcare consumers and thereby improving the quality of healthcare with patient
centered approach. Cultural competence also vouches for effective development of effective
communication. It also helps in the growth of the clinical capabilities among the healthcare
professionals. This helps in the promotion of the cross-cultural communication among the
nurses and midwifery professionals (Douglas et al. 2014). According to Douglas et al.
(2014), a nurse uses its cross-cultural communication skills for identifying the values, beliefs,
traditions and the unique health care needs of the client and thereby helping to frame person-
centered care. Moreover, Betancourt et al. (2016) further highlighted the consequence of
culturally competent nursing care in the domain of hospital setup. Betancourt et al. (2016) is
of the opinion that the hospitalized patients and their family members are subjected to

numerous stresses. The scenario is extremely evident in critical care, palliative care and
emergency unit of the hospital as here the patients suffer from life-threatening situations.
Under these circumstances, culturally competent care is strikingly evident.
In addition, Betancourt et al. (2016) stated that the absence of cultural awareness and failure
to convey culturally proficient care could augment the anxiety level of seriously ill patents
and thereby resulting in derisory care or adverse health outcomes. In the domain of providing
care to the Muslim-American, Ezenkwele and Roodsari (2013) highlighted important cultural
factors that manipulate the delivery of care in the emergency unit. These factors include
modesty, role of gender the concept of will of god, the role of the family members, structure
of the family, prohibition towards extramarital and premarital sex, special dietary codes,
religious cleanliness and praying. Thus, practicing in a culturally competent manner will help
to generate cultural awareness among the nurses and thereby helping them to deliver optimal
care to the minority population.
However, it is imperative to take into consideration the heterogeneity and diversity of
the minority inhabitants while employing culturally competent care on an individual basis
(Ezenkwele and Roodsari 2013). According to Betancourt et al. (2014) people who belong
under the ethnic minority are more susceptible towards developing communicable disease or
chronic condition. Patients who are suffering from chronic conditions demand more person-
oriented health services and hence increasing their amount of interaction with the healthcare
system. If the nursing or other healthcare professionals are not working together to deliver
culturally competent care, the patients who are suffering from chronic conditions are more
likely to become victim of negative health consequences. This results in complete
dissatisfaction in care. For instance, African-American population are reported to undertaking
less partnership with the healthcare professionals, less participation in medical decision-
making and lower level of satisfaction under the care plan (Betancourt et al. 2014).

Furthermore, reports published by Betancourt et al. (2014) highlighted that Asian
Americans, Latinos and African-Americans are more likely to generate nurture a thought that
they could have enjoyed a better care support had been of a different race or ethnicity.
Nevertheless, according to Barksdale (2009), there is a major problem that, there is not
adequate provides in the health care domain to procure culturally competent care to the ethnic
minority group and thus creating controversy towards culturally competent care. Dauvrin and
Lorant (2015) have recommended that culturally competent care model can be implemented
among the healthcare professionals via strong leadership characteristics. Because,proper
leadership models affect the social relationships, and this helps in implementing and
developing care (Dauvrin and Lorant 2015).
Opportunities and Challenges in implementing culturally competent healthcare
Approaches that focus on expand in knowledge about numerous groups, especially through a
list of common health behaviors and beliefs and principal “dos” and “don’ts” provide the
main starting point for the healthcare professionals to know more about the nature of health
practices of a particular ethnic group (Truong et al. 2014). This approach leads to the
generation of stereotypes and may ignore the variation that exists within the groups. To
illustrate, Barksdale (2009) highlighted that the African Americans are taught never to
disclose their personal or health related matters or their weak points to the white people and
this create a societal challenge in procuring culturally competent care. Correspondingly,
personal challenges, which are highlighted by Barksdale et al. (2009) under the domain of
culturally competent care, include fear or unwillingness to learn new culturally competent
care model and to provide a new approach and bias approach of providers, as they are
unmotivated towards providing culturally competent care. Likewise, In the domain of
organizational challenges, there occurs certain sort of miscommunication between the
administrative authority and patient family members towards providing competent care

(Barksdale et al. 2009). Here comes the importance of the opportunity of cultural competence
as it allows generating an approach that is capable to addressing the cultural needs of diverse
ethnic communities. For example, skills such as effective communication and procedure to
recording medical history can be applied to a wide variety of clientele and thereby enabling
them to participate within the decision-making process (Truong et al. 2014).
According to Markey et al. (2012), in Ireland, there is no necessity for addressing the lack of
cultural awareness that results out of unintended prejudices, which occurs as insensitivity and
unawareness. It stems in socialized behaviors and attitudes enacted through systemic practice.
Learned behavior and rooted morals should be challenged for addressing the stereotyping
and unwitting prejudices. Noticeably, the study conducted by Suk et al. (2018) showed that
the culturally competent care model is also crucial for the visiting nurses. In their study
conducted in Korea, it showed that the culturally competent care approach is deficient among
the visiting nurses. Since Korea nurture multicultural population, more qualified and
culturally competent nurse is crucial for procuring effective care. They recommended regular
organized instruction on culturally sensitive care that would be supportive for the visiting
nurses for procuring culturally sensitive nursing care (Suk et al. 2018).
On the contrary, there is constant refutation inside Irish healthcare setting for acknowledging
the insensitive practices as racist. Markey et al. (2012) suggested that defiance of racist
practice is a worldwide issue, and this is the major challenge in the domain of comprehensive
implementation of cultural competence in healthcare. Racing in nursing is however, denied or
avoided as nursing is euphemized as debated construct that conceptualize nurses as caring
professionals. Nonetheless, under the Irish context, fighting against denial of racism is
difficult because the Irish population mostly feels boastful about themselves for having a
“welcoming” culture, which might curb the acknowledgement and confrontation of racism
(Markey et al. 2012). Irish political and social debates have been unenthusiastic for

employing the term racism for describing the fanaticism and prejudices experienced by the
ethnic minorities in Ireland and this impose a challenge towards culturally competent nursing
care. Additionally, Irish population has a fascination towards the term “xenophobia” or “fear
form the strangers” in order to describe the minority class and their intolerance and prejudice.
Markey et al. (2012) have further opined that this tendency of the Irish population towards
describing the term racism in a new way is actually protecting the concept of discrimination
and thus creating challenge to focus on culturally competent care.
Factors influencing culturally competent care
Personal Factors
Personal factors are the attributes that contributes to the cultural competence among the
individual nurses. (Arieliet al. 2012). Firstly,ethnocentricityis one of the main factor which
influence the cultural competent care. Ethnocentricity among the health care professionals
can be defined as the belief of his/ her own culture and ethnic group being superior and the
other cultures are just reference to them (Oelkeet al. 2013). This concept had been found to
be responsible for patient alienation, misdiagnosis and inadequate treatment. According to
Renzahoet al. (2013) there had been a strong inverse relationship between cultural
competence and ethnocentricity. In order to overcome the ethnocentrism, it is necessary to
have an open mind, engage himself in society- integrated activities and absorb new
information from different cultures.
Secondly, Cultural awareness: People of different cultures have different health beliefs,
practices and values. One of the cultural issues that can arise in the nurses involves religious
beliefs and faith (Galanti 2014). Certain religious groups may refuse prescribed medications
and depend more on bush medicines. Cultural awareness also helps the nurses to give

treatment regardless of the gender differences, although the nurses have to remain aware of
the gender differences as different cultures have different needs (Loftin et al. 2013). Cultural
awareness in nursing can be increased by building up the cultural knowledge, encouraging
discussions and by celebrating the diversity.
Thirdly,assessment of the cultural heritage is important to give a patient centered care. It
provides the nurses an in-depth knowledge of the patients’ belief about diseases and
sicknesses (Kirmayer 2012). A nurse trying to preserve her own cultural heritage may be
unsuccessful in delivering care to a patient of complete different cultures. The study of the
cultural heritage helps the nurses to study the patient as a whole, how the family clings to
their cultural beliefs, and the extent of their superstitions. To exemplify, in a certain tribe, the
woman in the post-partum period is provided with roots and herbs for the contraction of the
uterus for delivering the baby. Similarly, many tribes believed in the effectiveness of the
complementary therapies like acupuncture and aromatherapies (Kirmayer 2012). Moreover,
Nurses having an understanding of the cultures can prepare treatment plans using their
traditional methods. The nurses can preserve cultural heritage by acts such as sharing of
different cultural information and tradition for better understanding. Besides nurses should
be committed to the patients irrespective of their race, ethnicity, cultural beliefs, traditions
and gender differences (Galanti 2014). This can be achieved by practicing different course of
ethics, self-reflective practices and clinical reasoning.
Finally, Courage is one of the fundamental values of the nurses and the midwives in giving a
culturally competent care. Courage is important in nursing practice for safeguarding the
people who are vulnerable or raising concerns about the concerns of care such as those with
mental health problems, women, children, LGBTQ community (Peiyinget al. 2012). To
exemplify, people with psychotic disorders are often stigmatized in the society and the health
care professionals often have to become the victims of violence, still their focus always

remains to provide a comprehensive and rational care to the patients (Oelkeet al. 2013).
Loftin et al. (2013) have argued for the requirement to foster courage in nurses such that the
nurses are ready for making any change. The LGBTQ community has always been the victim
of social stigma and shame. Hence, nurses should be courageous enough to move beyond the
society and provide them care (Fredriksen-Goldsen et al. 2013). Personal risk-taking
practices can help out the nurses to develop the sense of courage among the nurses.
Professional factors
Education:The nurse educators face several challenges in teaching cultural competence in
nursing. A nurse without a proper education would not develop the sense of cultural
sensitivity or awareness towards other ethnic groups. This thought would jeopardize the care
provided to the patients. Education helps a nurse to avoid all the cultural and the gender
differences. It provides them with the ethics of beneficence, maleficence and to understand
that, it is the patient that come above all interests.Therefore, it is necessary to develop a
sound educational foundation regarding the diverse ethnic and the cultural groups(Delgado et
al. 2013).
Professional regulatory bodies:The Nursing and the midwifery board of Ireland is the
regulatory body for the nurses for setting out standards for the education and the professional
conduct of the nurses. The codes of conduct published by this organization contain the
instructions that ever nurse should withheld in order to enhance the professional career in
nursing and to gather skills of cultural safety practices. It is of no doubt that autonomy and
accountability is the main ingredient of nursing (Zamanzadehet al. 2013).

Organizational factors
The different organizational factors that affect the nursing are the workload. Excess workload
in nursing can bring burn out and fatigue among the nurses. Secondly, in an organization the
professional nurses should be in a position to perceive all the resources to meet the work
demands. Proper distribution of the workloads, financial management of the hospital
resources and motivation from the managers can help the nurses to cope up with the
organizational factors (Barksdale et al. 2009).
Leadership:Health care delivery often requires a multidisciplinary care approach where the
patient safety depends on each members of the team. For the nurse, being culturally
competent is not sufficient. The nurses need to use their own expertise in order to provide a
culturally competent care (Delgado et al. 2013). Leadership in the nurses can be based upon
positive norms and negative norms. Positive norms in the nurses’ helps to integrate the
concept of cultural competence into their daily practice, whereas the negative norms help the
nurses to provide develop a negative perception of intercultural care. A leader nurse fostered
with the concept of cultural competence can describe the cultural competence among the
health care leaders and the staffs (Galanti 2014).
Mission, vision and values:The values of the nurses help them to deliver culturally competent
care. A nurse is imbibed with the knowledge of cultural care if the patient treats others with
dignity by recognizing and valuing diversity. Delgado et al.(2013) have stated that it is the
core values of nursing that helps the nurses to take decisions while caring for the patients
with diverse cultural background. The mission of encouraging others to contribute to their
full potential for providing support and training to the nurses provides the base for the
cultural competency (Galanti 2014). Some of the other missions include engagement in the
ongoing learning activity in order to increase the professional effectiveness regarding
inclusion and diversity (Harding 2013).

Societal factors
Nowadays a nurse is an educator, manager and client advocate. Society knows that a caring
nurse can provide solace and comfort to someone in need. Loftin et al. (2013) have identified
four categories of patient perception about the nursing care that is supervising individual
patient, explaining, responding and watching over. In most cases, the public image of nursing
involves low social status, and is experts in doing domestic activities, but the perspectives of
the public are changing (Flodgrenet al. 2012). They are found to be honest and ethical. They
are a professional with 24x7 involvements. These changed perceptions create a pressure upon
the nurses for meeting their standards. Nurses thrive more for their interpersonal
development.
Strategies and approaches for improving culturally competent healthcare
Interventions regarding the improvement of the cultural competency involve the
improvement of the accessibility and effectiveness of appropriate health care for the people
from different ethical and racial minority by augmenting knowledge, awareness and the skills
of the health care providers as well as altering the policies. The interventions can be taken at
the patient- client level or the organizational levels. Galanti(2014) have found that culturally
relevant strategies have brought about glycemic control amongst the African- American
woman having type 2 diabetes. According to Kratzke and Bertolo (2013) there are some
major factors, which should be focused on for example, language. Gender matched, culturally
and linguistically appropriate interpretation should be provided for avoiding any
miscommunication between the patient and the caregiver. There are professional interpreters
that provide hand on supports and personal aids (Holland 2017).
Another factor is the availability of proper insurances for the people, particularly for the
vulnerable groups having low literacy level, or those living in the remote areas and cannot

afford transportation needs (Hernandez and Kose 2012). Some culture supports care to be
provided by the same gender as the patient. Hence, if possible the caregivers should be
gender matched. Respect of modesty is another step towards providing culturally safe care.
Touching of the private parts may be termed as disrespectful for a woman patient (Galanti
2014). Significantly, provision of a chaperon in the examination room is essential regardless
of the gender. It is necessary to be cognizant of the traditions of a culture as they may
influence pregnancy, antenatal care (Varaeiet al. 2012). It is necessary to be aware of the
autonomy of the women against any religious practices. Anticipatory care and guidance,
counseling and education should be provided to patient. Provision of multidisciplinary team
is required for supporting the women health, in particular, the provision of caseload
midwifery during pregnancy (Hernandez and Kose 2012).
Above all, some personal and organizational factors which aids in CC care are,
 “Develop attitudes allied with exceptional transcultural care: By developing certain
fundamental attitudes such as empathy, openness, caring and flexibility will aid to
deliver culturally sensitive care
 Create an awareness of the impact culture has on the beliefs, values, and practices of
the patient and the nurses
 Acquire general knowledge about patients’ cultures
 Complete cultural assessment on admission: Assess patients’ medical history,
physical status, and activity level, as it is essential to develop personalized care plan
for the patient.
 Perform nutrition assessment, medication assessment, pain assessment and
psychosocial assessment which indeed helps the nurses to deliver patient centred
care” (McCalmanet al. 2017).

Moreover, audit and quality improvement approaches play a crucial role in developing
culturally competent care. These approaches were applied across various healthcare facilities
and resulted in better-quality relationships with local peoples, improved health service
availability and occurrence of hospital visits, and the improved participation of clients and
their relatives in their own healthcare and eventually enhanced CC care. Besides, introducing
Cultural Competency Assessment Tool for Hospitals (CCATH) is an option to evaluate
hospital performance in cultural competency and recognize enhancements. Additionally, an
organization can develop culturally competent care by identifying social factors, recruting
aboriginal staff, making a friendly service, supporting access through transport and
assimilating cultural practice (McCalmanet al. 2017).
To Conclude, cultural competency is a popular approach for providing a culturally safe care
to the patients. Cultural safety had always been an essential tool while dealing with patients
with different cultural background and respond to them accordingly. The report has focused
on the role of cultural safety in the nursing and the midwifery practice. It had also focused on
the opportunities and the challenges in implementing cultural competence in health care. The
essay had focused on the concepts such as racism and discrimination in nursing practice.
Cultural awareness nurses help them to understand the culture, help the patients form making
accommodations and may be work around with traditional treatment plans. There are several
barriers in maintaining cultural safety such as the social perception and the stigma. The credit
lies in abandoning all the stigma and step beyond the conventional practices. The report could
also describe about the role of different personal, professional and organizational factors that
can influence the nursing actions. Finally, the strategies like effective communication, proper
governmental policies, gender-matched care can bring about and language interpretation can
bring about culturally competent care in-patient.

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