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Course: Medical Surgical Nursing

Topic: Cultural Competency for the Medical-Surgical Nurse

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Define “unconscious cultural competency” as it relates to patient care.
Outline the nurse’s progression toward the achievement of unconscious cultural competency.
Explain Purnell’s Cultural Competence Model (PCM).
Describe how the medical-surgical nurse uses the PCM in practice.

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Cultural Competency: Levels of Awareness

Unconscious Incompetence (also called the state of blissful ignorance): The individual is unaware of cultural differences.

Conscious Incompetence: The individual recognizes there is a gap, and skills must be developed in order to resolve the incompetence. The individual is motivated to learn.

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Cultural Competency:

Levels of Awareness (Continued)

Conscious Competence: The individual knows that cultural differences exist. Behavior is adjusted accordingly. Learning has begun, but there is room to grow.

Unconscious Competence: Culturally appropriate behavior is second nature to the individual. Instincts have been reconditioned by the new culture.

Culture Matters, n.d.

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Unconscious Cultural Competency: Definition

Attitudes or stereotypes that unconsciously alter an individual's perceptions or understanding of their experiences.

These attitudes affect behavior, interactions, and decision-making.

Boiko et al., 2017,

as cited in Marcelin et al., 2019

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Unconscious Cultural Competency: Highlights

Unconscious biases are attitudes or stereotypes that unknowingly alter people’s perceptions, thereby affecting behavior and decision-making.

Unconscious bias can influence behaviors.

Individuals underrepresented in healthcare can have different experiences with recruitment, hiring, promotion, and compensation due to unconscious bias.

Boiko et al., 2017,

as cited in Marcelin et al., 2019

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Critical Thinking Question

Fill in the blanks:

At this stage, the individual is unaware of cultural differences: __________ ___________
The individual recognizes there is a gap and skills must be developed: _____________ ___________
Learning has begun, but there is room to grow: _________ ________
At this stage, culturally appropriate behavior is now second nature to the individual: ___________ ___________

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Unconscious Cultural Competency in Nursing:

Where Do We Stand?

37% of the U.S. population consists of individuals from ethnic and racial minority groups.

Cultural competence in nursing practice requires an awareness that many belief systems exist.

Alvernia University, 2016

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Unconscious Cultural Competency in Nursing:

Where Do We Stand? (Continued)

Nursing cultural competence is defined as the level of performance in:

Attitudes
Knowledge
Skills
Judgments

It is the ability to provide legitimate, effective, and respectful service to people based on the understanding of similarities and differences between or among diverse cultural groups.

Cain, 2016

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Unconscious Cultural Competency in Nursing:

Where Do We Stand? (Continued)

Cultural safety means an environment absent of discrimination.

Healthcare providers and their clients feel respected and involved in decision-making and care.

Cultural competence defining attributes:

Cultural awareness
Cultural sensitivity
Cultural knowledge
Cultural skill

Cain, 2016

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Cultural awareness refers to the development of the consciousness of nurses of the different values, beliefs, norms, and lifeways of clients.
Cultural sensitivity refers to nurses' appreciation, respect, and comfort for the cultural diversity of clients.
Cultural knowledge refers to nurses' attainment of a sound educational base about various cultural groups to better understand the different beliefs, values, and behavior of clients. Necessary knowledge usually involves "dos" and "don'ts" in interacting with clients from different cultures.
Cultural skill refers to the ability to perform a cultural assessment to collect relevant cultural data on a client's current health problem, as well as to accurately incorporate related data into care planning and provision in a culturally sensitive manner. This skill is guaranteed through effective communication, which includes both verbal and nonverbal language that can be understood by those of other cultures.
Dynamic process means nurses are "becoming culturally competent rather than being culturally competent" through consistent encounters with diverse clients. Culture, which is influenced by many variants, has a dynamic nature; thus, cultural competence cannot be a static situation.

(Cain, 2016)

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Critical Thinking Question

Provide examples of how the nurse can utilize cultural competences in a transcultural scenario.

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Answer:

Cultural awareness refers to the development of the consciousness of nurses of the different values, beliefs, norms, and lifeways of clients.
Cultural sensitivity refers to nurses' appreciation, respect, and comfort for the cultural diversity of clients.
Cultural knowledge refers to nurses' attainment of a sound educational base about various cultural groups to better understand the different beliefs, values and behavior of clients. Necessary knowledge usually involves "dos" and "don'ts" in interacting with clients from different cultures.
Cultural skill refers to the ability to perform a cultural assessment to collect relevant cultural data on a client's current health problem, as well as to accurately incorporate related data into care planning and provision in a culturally sensitive manner. This skill is guaranteed through effective communication, which includes both verbal and nonverbal language that can be understood by those of other cultures.
Dynamic process means nurses are "becoming culturally competent rather than being culturally competent" through consistent encounters with diverse clients. Culture, which is influenced by many variants, has a dynamic nature; thus, cultural competence cannot be a static situation.

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Purnell’s Cultural Competence Model

Ethnographic model:

Promotes cultural understanding of peoples’ status in the context of health promotion and illness based on ethical perspectives of:

Individual
Family
Community

Deger, 2017

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Purnell’s Cultural Competence Model

Provides a foundation for understanding the various attributes of a different culture.
Allows nurses to view patient experiences and notions about healthcare and illness.
Presented in a diagram with parallel circles that represent aspects of global society as well as the community, family, and person.

Albougami et al., 2016

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Purnell’s Cultural Competence Model

Twelve domains:

Overview or heritage
Communication
Family roles and organization
Workforce issues
Bio-cultural ecology
High-risk behaviors

Albougami et al., 2016

Nutrition
Pregnancy
Death rituals
Spirituality
Healthcare practices
Healthcare professional

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The first domain is culture and heritage, which includes the country of derivation, the geographical influence of the original and present home, political affairs, economics, educational status, and profession.
The second domain comprises important notions relevant to communication, such as primary language and dialects, circumstantial effectiveness and convenience of the language, paralinguistic differences, and nonverbal communication.
The third domain, family roles and organization, involves who heads the household in terms of gender and age. The organization of the family is affected by goals and priorities, developmental tasks, social status, and alternative lifestyles.
The fourth domain is workforce issues, including acculturation, autonomy, and the presence of language barriers.
The fifth domain includes factors of bio-cultural ecology, which encompass observable differences with respect to ethnic and racial origins, like skin color and other physical variations.
The sixth domain is high-risk behaviors, such as using tobacco, alcohol, or recreational drugs. This domain also includes physical activity and levels of safety or precautions taken.
The seventh domain is nutrition. Depending on their place of origin, individuals or groups are accustomed to certain foods and draw meaning from the foods they eat. Food consumption associated with certain rituals may affect health. Some ethnic groups suffer from certain nutritional limitations and deficiencies.
The eighth domain is pregnancy. Pregnancy is viewed differently because there is a myriad of beliefs accompanying this life phase. The act of birthing and the postpartum period involve certain practices that need to be taken into consideration when dealing with a particular ethnocultural group.
The ninth domain is death rituals. Perceptions of death differ from culture to culture in terms of how death is accepted, what rituals are performed, and how one should behave following a death.
The tenth domain is spirituality, which includes religious practice, the use of prayer, individual strength, the meaning of life, and how spirituality relates to health.
The eleventh domain reflects healthcare practices. This domain includes the responsibility for health and the barriers that must be overcome to achieve successful health outcomes. Healthcare practices include traditional practices, magical religious practices, chronic-disease treatment and rehabilitation, mental health practices, and the roles of the sick.
The twelfth and final domain, healthcare professionals, involves the perceptions and roles of traditional and folk healthcare practices (Purnell, 2005, as cited in Albougami et al., 2016).

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Critical Thinking Question

The nurse is preparing to take vital signs and draw blood from a diabetic patient. Upon entering the patient’s room, the nurse explains the procedures. The patient asks if there are any Japanese nurses in the ward so that a foreigner does not have to touch her.

Applying three domains of the PCM, give examples of how the nurse can successfully address the situation.

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The first domain is culture and heritage, which includes the country of derivation, the geographical influence of the original and present home, political affairs, economics, educational status, and profession.
The second domain comprises important notions relevant to communication, such as primary language and dialects, circumstantial effectiveness and convenience of the language, paralinguistic differences, and nonverbal communication.
The third domain, family roles and organization, involves who heads the household in terms of gender and age. The organization of the family is affected by goals and priorities, developmental tasks, social status, and alternative lifestyles.
The fourth domain is workforce issues, including acculturation, autonomy, and the presence of language barriers.
The fifth domain includes factors of bio-cultural ecology, which encompass observable differences with respect to ethnic and racial origins, like skin color and other physical variations.
The sixth domain is high-risk behaviors, such as using tobacco, alcohol, or recreational drugs. This domain also includes physical activity and levels of safety or precautions taken.
The seventh domain is nutrition. Depending on their place of origin, individuals or groups are accustomed to certain foods and draw meaning from the foods they eat. Food consumption associated with certain rituals may affect health. Some ethnic groups suffer from certain nutritional limitations and deficiencies.
The eighth domain is pregnancy. Pregnancy is viewed differently because there is a myriad of beliefs accompanying this life phase. The act of birthing and the postpartum period involve certain practices that need to be taken into consideration when dealing with a particular ethnocultural group.
The ninth domain is death rituals. Perceptions of death differ from culture to culture in terms of how death is accepted, what rituals are performed, and how one should behave following a death.
The tenth domain is spirituality, which includes religious practice, the use of prayer, individual strength, the meaning of life, and how spirituality relates to health.
The eleventh domain reflects healthcare practices. This domain includes the responsibility for health and the barriers that must be overcome to achieve successful health outcomes. Healthcare practices include traditional practices, magical religious practices, chronic-disease treatment and rehabilitation, mental health practices, and the roles of the sick.
The twelfth and final domain, healthcare professionals, involves the perceptions and roles of traditional and folk healthcare practices.

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Purnell’s Cultural Competence Model Applied to Nursing

Migrations may perpetuate problems such as language barriers, unemployment, low education levels, uncertainties about the future, etc.

Individuals experiencing these problems tend to avoid professional help in solving these problems.

The nurse’s cultural awareness identifies these problems and can better address them to the client’s benefit.

Dogu, 2016

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Purnell’s Cultural Competence Model Applied to Nursing

Transcultural care competencies:

Understands complex cultural dimensions.
Assumes a holistic approach to care instead of a biophysical approach.
Understands cultural beliefs and activities that are unique to distinct groups .
Not believing that an individual's own race is superior to others.
Makes cultural evaluations.

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Purnell’s Cultural Competence Model Applied to Nursing

Develops communicative and scientific language skills
Deals with cultural differences and makes interpretations
Uses appropriate cultural teaching techniques
Respect for the sociocultural diversity of women, newborn babies, and their families.

Deger, 2017

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Purnell’s Cultural Competence Model Applied to Nursing

Uses the Nursing Care Plan to apply the PCM
Familiar with each domain of the PCM
Cultural needs identified within each domain
Nursing interventions created to meet identified needs
Evaluate nursing interventions to analyze effectiveness
Offers a holistic approach to nursing care

Dogu, 2016

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Critical Thinking Question

Give examples of how Purnell’s Cultural Competence Model can be applied to transcultural nursing practice.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be acceptable in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

Cultural diversity can be understood as differences in:

Skin color
Race
National origin
Ethnicity
Socioeconomic status
Education
Occupation
Religion

Cain, 2016

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Cultural Considerations: Examples (Continued)

Many subcultures and variations can exist within a cultural or ethnic group.
For instance, the term Asian-American includes cultures such as:

Chinese
Japanese
Taiwanese
Filipino
Korean
Vietnamese

Alvernia University, 2016

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Cultural Considerations: Examples (Continued)

Many people from other cultures seek herbal remedies from traditional healers that can be harmful or interact poorly with Western medicine.

Nurses should ask patients about any alternative approaches to healing they are using.

Alvernia University, 2016

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Albougami, A. et al. (2016). Comparison of Four Cultural Competence Models in Transcultural Nursing: A Discussion Paper. International Archives of Nursing and Health Care, 2(4), 1-5. 10.23937/2469-5823/1510053

Alvernia University. (2016). A guide to culturally competent nursing care. https://online.alvernia.edu/articles/culturally-competent-nursing-care/

Cai, D. (2016). A concept analysis of cultural competence. International Journal of Nursing Science, 3 (2016), 268-273. https://doi.org/10.1016/j.ijnss.2016.08.002

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References

Culture Matters. (n.d.). The four levels of cultural awareness. https://files.peacecorps.gov/wws/interactive/culturematters/Ch6/fourlevels.html

Değer, V. B. (2018). Transcultural Nursing. In (Ed.), Nursing. IntechOpen. https://doi.org/10.5772/intechopen.74990

Dogu, O. (2016). Purnell Model for cultural competence: Nursing care of an afghan patient. Journal of Nursing and health Science, 5(5), 44-48. https://www.DOI: 10.9790/1959-0505074448h

Marcelin, J. et al. (2019). The impact of unconscious bias in healthcare: How to recognize and mitigate it. The Journal of Infectious Diseases, 220(2), 62-73. https://doi.org/10.1093/infdis/jiz214

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