Culture

Over the past decade or so the discipline of nursing has brought to light the idea of cultural competence as a desired trait for nurses. Even the august Institute of Medicine (2011) has proposed that it is requisite for healthcare professionals that they become more proficient in the care of diverse individuals since it is projected that by 2050 minority groups will make-up 54% of the population in the United States. Indeed, The Essentials of Master’s Education in Nursing (American Association of Colleges of Nursing [AACN], 2011) and The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008) include expectations that nurses provide care in a culturally-appropriate manner. For instance, at the master’s level, the graduate nurse is required to “design patient-centered and culturally responsive strategies in the delivery of clinical prevention and health promotion interventions and/or services to individuals, families, communities, and aggregates/clinical populations” (AACN, 2011, p. 25). Furthermore, at the baccalaureate level, the nursing student is required to be able to “apply knowledge of social and cultural factors to the care of diverse populations” (AACN, 2008, p. 12) and to “collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions” (AACN, 2008, p. 24). There has even been discussion concerning standards of competence of culturally appropriate care. Douglas and colleagues (2011) proposed 12 standards of practice that nurses should use when caring for diverse individuals. Principles of social justice underpin the standards in that nurses are to “promote social justice for all” (Douglas et al., 2011, p. 318) and to advocate for policies that are socially just. The standards also call nurses to reflect upon their own beliefs in order to assess the manner in which personally held values influence care. Posited within the standards is that nurses become aware of “the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations they care for, as well as knowledge of the complex variables that affect the achievement of health and well-being” (Douglas et al., 2011, p. 318). Furthermore, nurses are to use knowledge of cultural diversity in planning and communicating appropriate care within organizations that provide support for such care. The standards also require nurses to act as advocates for diverse groups and empower patients in matters that concern healthcare beliefs and practices. Toward this goal, nurses should work with agencies to establish policies that uphold culturally-competent care and demonstrate cross cultural leadership. Finally the standards urge that there should be formal education on the principles of culturally-appropriate care based on evidence and movement toward a multicultural workforce to ensure that appropriate care is provided (Douglas et al., 2011).

All of the aforementioned standards for nursing education and practice concerning cultural competence are laudable. However, there are numerous examples of care that is not culturally competent. One incident involved an Elder of an Aboriginal group not being able to perform a ritual cleansing of a young 19-year-old as she lay dying in an intensive care unit. Even the small herbal pouch which was placed on her body to protect her and guide her into the spiritual world was removed and tossed aside by the nursing staff who deemed it to be an infection risk. This lack of cultural competence caused much suffering for the family (Bearskin, 2011). If the aforementioned standards had been upheld, perhaps rituals concerning death and dying among the Aboriginal group would have been revered and spiritual distress averted for the family. Another example of cultural incompetence can be ascertained from the study of Iranian immigrants. Martin (2009) found that older Iranians value a balanced life and pay great attention to a happy heart. They also tend toward fatalism and the use of traditional medicine. However, older Iranians perceived Western healthcare providers to be disinterested because of lack of time spent on discussing issues related to a balanced life, such as nutrition and care of the spirit, therefore they lacked trust in the physicians who were treating them and trust is requisite for a healing relationship. Finally, older lesbians and gay men feel it necessary to hide their sexual preferences from care providers who tend to be homophobic. Homophobia is a barrier for older gays and lesbians and prevents them from accessing needed services (Fenge & Hicks, 2011). In each of these cases, if the providers of care had been more open to cultural beliefs, a relationship built on mutual trust may have ensued, facilitating better quality of life for all concerned.

Although the idea of cultural competence is praiseworthy, for this author it is problematic on two levels. First, the idea of coming to understand a culturally-diverse group through preconceived descriptions borders on stereotyping. A member of a group may or may not subscribe to the values of the culture to which he or she supposedly belongs. Furthermore, members of a cultural group may take part in the acculturation process and hold beliefs that are congruent with both the dominant and the minority culture to which they belong. The second issue is purely pragmatic. As the United States becomes more diverse, it will be challenging for a nurse to become aware of the different values held by cultures even within one geographic area. For example, a nurse working in certain sections of Chicago may have a significant number of African American immigrants who require care. Having knowledge of each and every culture would be extremely difficult since there are numerous tribes and sub-cultures existing within the continent of Africa (The Africa Guide, 2012). The challenge grows exponentially if other groups live within the same geographic area. So the question becomes, what is a nurse to do?

There is a simple solution to that question. Instead of coming to a patient relationship with any preconceived notions of cultural differences, the nurse should come to each person with an open mind and simply ask about their values. The remedy for issues related to cultural competence arose for this author while considering the humanbecoming family model as developed by Parse (2009). She explained culture to be an “evolving mystery of unexplainable illimitable knowings cocreated all-at-once with the choosing of pattern preferences of persons with predecessors, contemporaries, and successors” (Parse, 2009, p. 305). Meaning that individuals in essence create their own culture from choosing valued beliefs held by past generations, those held by significant individuals in the present, and contemplation of what may be desirable in the future. The idea of the fluidity of cultural beliefs explains the vast variety of what patients hold to be valuable. Understanding the fluid nature of individual cultural beliefs would eliminate the necessity of formal standards of cultural competency and educational programs related to care of cultural groups. Simply stated, the nurse or other providers of care should just honor and respect the values held by each and every person whether of the dominant or minority view. This would embody the notions contained in the standards of cultural competency, essentials of nursing education, and even the views of the Institute of Medicine (2010).