Tuesday, June 14, 2011

The Whole World in Your Hands: Why Every Nurse Must be Culturally Competent

Have you noticed a flattened world around you?   The forces driving globalization are well-documented.    Many researchers in leadership have made note of the fact that the world is shrinking and due to the internet, instant communication, and a global economy, the world is on our doorstep1.  
           Globalization is a process that affects virtually all industries today2.   The forces driving globalization in nursing include an increasingly diverse patient population3.  Nurses must understand global political, cultural, and economic factors influencing health care in an age of technological advances, terrorism, and worldwide epidemics4.
       Cultural competency is hardly a new goal for nurses.  Madeleine Leininger introduced her cultural care theory in 1978 and the concept of Transcultural Nursing5.  Nurses who strive to be culturally competent cultivate an attitude of sensitivity to issues of gender, sexual orientation, race, ethnicity, and culture3.   Transcultural nursing has become its own specialty in nursing, with the Royal College of Nursing in Australia establishing a Transcultural Nursing Society 6.
      So why do nurses need to renew their focus on cultural competency?  Some statistics tell part of the story.  In the United States, 90% of nurses are Caucasian and yet, 30% of our patient populations are of ethnicities other than Caucasian and, by the year 2050 that number is projected to be 50%.3  In addition, my own experience with foreign nursing students has been enlightening.
In 1995 and again, in 2002, I had the privilege of working with Saudi Arabian nursing students in the United States.  In 1995, only male students were sent to the United States and these students were carefully selected.  Prior to that time, nurses in Saudi Arabia were all expatriate, and the King of Saudi Arabia decided to that it was time to build a native nursing profession.  These young men were selected to become the first nursing leaders in their country.  They were well-educated with bachelor’s degrees in a variety of sciences and they had been instructed that they would have to adapt to American culture, attend maternal-child and pediatric rotations (like all other nursing students), and willingly accept instruction from females.  To a man, these students accepted these conditions with good will.  I was one of their clinical instructors and they treated me with unfailing respect and good humor and I learned more from them, I suspect, than they did from me.
        What I saw vividly that I did not like was the prejudice of some of my fellow American nurses.  One nurse in particular was unhappy with one of the students, called him out in front of the entire nursing staff, and managed to insult the entire Saudi group in the broad strokes of her remarks.  I have never before felt ashamed of my nationality, but I did that day.  I doubt this nurse would have treated a Muslim patient so insensitively; why was that behavior acceptable when directed toward a student?
        Perhaps you practice in some isolated area of the United States and you never intend to travel.  Maybe you have heard of transcultural nursing but think it only applies to nursing abroad; you live in a fairly homogeneous community, you just want to do your job and go home.  I am asking you to consider the worlds with worlds that exist around you.  Do you live in Utah, as I once did?  Utah’s population is overwhelmingly white and most residents are Latter Day Saints (LDS).  But do you know the differences between the LDS and the Fundamentalist LDS (polygamists)?  When the LDS or FLDS patients arrive in your hospital or clinics understanding the differences in their faith traditions will be important.  Do you understand the Native American populations that exist in Utah?  What about the Tongans who have been recruited to play football at Utah colleges and universities? Utah is but one example. My point is that whether you go out into the world or not, the world is coming to you.   Are you prepared?
         Many solutions to incorporating transcultural care into every aspect of nursing practice have been proposed.   Recruiting non-Caucasian nursing students and removing barriers to education is one such proposal7.  While acknowledging that transcultural nursing must be thought of as part of daily domestic practice and not only as an overseas specialty, some researchers called for nursing students to incorporate overseas experiences into their programs of study while recognizing the difficulties inherent in achieving that goal4.  From my personal experience, I recommend that staff nurses receive transcultural education regarding the influx of foreign nursing students in their midst.
      These are all undoubtedly fine ideas and many educational initiatives and programs can be envisioned from them.   I would suggest to you, however, that intercultural competence begins within yourself, with embracing simple understandings, and making basic decisions.                        
       First, to quote a missionary friend of mine “This is not the world you grew up in.  Different is simply different; not better or worse.”  (L. Stanley, personal communication, 5/31, 2011).   I take her words to heart; she has served where she has been the one who is different in every way; the Sudan and Haiti, for example.  Take a moment to ponder these words and let them sink in.      
       Leininger’s Culture Care Theory (1978) acknowledged the impossibility of understanding every culture a nurse might encounter and that the primary frustration nurses faced was the inability to communicate.   She identified key nonverbal behaviors that a nurse should seek to understand when interacting with someone from another culture.  They are the use of eye contact, touch, silence, personal space, and distance3.   Understanding and responding to these nonverbal cues will aid you in communication.
       To become more culturally competent, it is important that you decide to adopt a caring and boundlessly inquisitive attitude.  If you don’t know, ask8!   Remember also that no individual is a stereotype of his or her culture or ethnicity; individuals vary3.   Cultural assessment, therefore, with each patient is essential to a good care plan.
       Finally, cultural competence begins with you and the decisions you make3.   You need to be aware of your biases and consciously put them aside.  You need to develop skill in interviewing with sensitivity.  Educate yourself and seek out new experiences with different cultures.   Continually assess yourself and seek 
to improve your own cultural competency.                                             In the final analysis, all the educational programs you sit through, all the books you can read, and the trips you can take will be worthless unless you simply decide you want to understand and embrace those who are different.  If you don’t want to lay aside your biases and have no curiosity about those who seem different, then perhaps you should reconsider your calling to the nursing profession.  The world is on our doorstep and in our hands.  How shall we answer?


      need to find out. San Francisco, CA: Jossey Bass.
     across borders. New York, NY: Oxford University Press.
     Cultural Diversity, 15(1), 37-44.
4.  Memmott, J., Coverston, C. R., Heise, B. A., & Williams, M. (2010). Practical considerations in 
      establishing sustainable international nursing experiences. Nursing Education Perspectives, 31(5), 
5.  Maier-Lorentz (2008) and Andrews (2008)
     Comtemporary Nurse: a Journal for the Australian Nursing Profession, 28(1/2), 13-17. doi:10.5172
8.  Reverend Lauren Stanley, personal communication, 5/31/11

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