Developing Cultural Competence in Practicing Nurses: A Qualitative Inquiry

Background/Introduction: Multicultural societies are becoming more prevalent across the globe. Nurses, providing holistic care to patients from many cultures, must demonstrate culturally competency in their daily practice so as to provide patient-centered care (Maher-Lorentz, 2008). The American Nurses Association has, since 1991, advocated for culturally appropriate nursing care to be delivered to patients in all settings (ANA, 1991). The Joint Commission has indicated the importance of culturally appropriate communication for patient-centered care and included this in the 2012 accreditation standards (The Joint Commission, 2010). Research regarding culturally-competent care among nursing students has been recently conducted in nursing education. However, few studies, both empirical and qualitative, are available to understand the perceived experience of nurses caring for clients of diverse cultural backgrounds. Starr and Wallace (2009) explored the self-reported cultural competence of 31 Public Health Nurses practicing in a Public Health Department in the Southeastern United States. They concluded that “the nurses had cultural competence knowledge and attitudes but were unable to fully and consistently enact these in practice.” (Starr & Wallace, 2009, p. 48). Cioffi (2006) interviewed eight acute care nurses practicing in Australia and concluded that relationships between these nurses and culturally diverse patients were strained and detached. Additional information is needed to demonstrate the perceived relationships between nurses and culturally diverse patients in order to develop strategies to promote safe, effective culturally sensitive care. Such information can be used to create programs to educate practicing nurses on culturally competent care and improve patient outcomes in the clinical setting.

Method: The research question for this qualitative inquiry was: How do practicing staff nurses perceive and report their development of cultural competence? A subsequent research question for this qualitative inquiry is: How do practicing staff nurses perceive their experiences caring for and working with people from a culture different from their own culture? Ten participants comprised the purposive sample of staff RNs practicing at a Level 1 Trauma Center who responded to advertisement to participate. This facility was selected for its diverse patient population and staff composition. Participants were from any educational preparation (ADN, BSN, and MSN) and any length of nursing experience who deliver direct patient care. In-depth, semi-structured individual interviews were conducted and all findings in written or oral dissemination used a pseudoname to blind the employer and others to protect the participant identities. A $50 honorarium was provided upon completion of the interview.

Data collection from this study addresses the following objectives:

• Explore the participants’ definition of cultural competence;

• Identify any formal training in culturally-competent care and any theory-practice gaps;

• Elicit perceived experiences of participants who provide care for clients with different cultural backgrounds than their own;

• Highlight any positive or negative experiences reported by staff RNs who care for clients with diverse cultural backgrounds; and

• Illuminate the perceived value of developing concepts of cultural competence (skills, awareness, knowledge).

Data analysis was conducted simultaneously with data collection. Each researcher analyzed the verbatim individually before coming together to find consensus in the final interpretation of themes.

Findings: The sample was comprised of 10 practicing RNs at one hospital in the Northeast Region of Florida. Nine participants were White and one was African-American with 80% female and 20% male. Most (80%) participants had a BSN degree while 2 had an ADN degree with one of these currently enrolled in a BSN program. Half (50%) of the participants had less than 5 years of experience as an RN while 25% had 6-10 years of experience, and 25% with greater than 20 years of experience. The majority of participants reported that they received cultural competence training previously as part of a college course, online education, or employer-sponsored programs. All reported previous experience with patients of cultural backgrounds that were different from their own including patients from the Middle East, Asia, Latin America, and the Pacific Islands among others. Approximately 65% of participants ranked their cultural competence level as 4-7 on a scale of 0 (no cultural competence) to 10 (highly culturally competent).

Three themes were constructed from analyzing the data:

• Recognizing Culture and Cultural Competence: Acknowledging Differences and Respecting Viewpoints
• Negotiating Cultural Competence: Overcoming Barriers to Achieve Benefits
• Moving Toward Cultural Competence: Developing, Practicing, and Engaging

Recognizing Culture and Cultural Competence was described as understanding culture to be a “way of living”. Cultural competence was the awareness of differences and accepting them by “being OK with it.” Competence does not imply expertise but having the knowledge that differences exist and the RN “cannot know it all.” Participants’ reflections noted that central to this theme is a cultural understanding and respect.

Negotiating Cultural Competence was the balancing act between recognizing the benefits and needing to overcome the barriers in successful delivery of culturally competent care. Barriers that were gleaned from the transcripts were language barriers, lack of knowledge of cultures, family involvement, specific requests for like-gendered care, and lack of time. The participants recognized the many benefits of providing culturally competent care as better patient outcomes, patient satisfaction, nursing care was facilitated and “easier”, increased patient understanding of their medical condition, and financial benefit for the hospital.

Moving Toward Cultural Competence was expressed as the ability to establish trust/rapport with the client through providing culturally competent care. All participants had a good understanding of the definition of culture. The participants remarked that a movement toward cultural competence was vital for “good nursing care” and that it took time and effort on the part of the nurse to be accommodate a client’s culture. If culturally competent care was not provided, participants noted that they experienced internal conflict.

 

Conclusion/Recommendations: Findings from this study were congruent with Campinha-Bacote’s Process of Cultural Competence in the Delivery of Healthcare Services (2002, 2010). Her model highlights the centrality of cultural encounters in becoming culturally competent and further developed through ongoing cultural encounters. Having multiple encounters with patients from other cultures aids the practitioner in developing the other constructs of cultural awareness, skill, knowledge, and desire.

Limitations to the findings of this study included a small, homogenous sample of self-reporting participants from one hospital who were offered an honorarium for their time. Despite these limitations, the researchers are confident that saturation was achieved in the data collection phase. One unanticipated finding that was realized and may have influenced the findings was the fact that many participants in this study have lived abroad in military or mission work.

Findings from this study have implications for nursing practice and education. Participants expressed the need for mandatory formal education and continuing educational opportunities for nurses on the topics of cultural competence as well as multiple ongoing encounters with diverse patient populations to promote confidence and competence in providing cultural care. Nurse educators need to facilitate opportunities for students to examine their own cultural beliefs and values. In addition, they should arrange repeated encounters with diverse patient populations through clinical learning experiences and integrate formal education within the curricula to apply theory to practice.