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THEORETICAL

Cultural Competence. A humanized way to offer Nursing Care

Teresa Ximena Ibarra Mendoza,¹ José Siles González^2
1Profesora de la Escuela de Enfermería de la Universidad Arturo Prat. Chile. Doctoranda, Programa Enfermería y Cultura de los Cuidados. ²DUE. Doctor en Historia. Licenciado en Pedagogía. Catedrático de Escuela Universitaria. Universidad de Alicante, España

Manuscript received by 8.03.2006
Manuscript accepted by 22.08.2006

Index de Enfermería [Index Enferm] 2006; 55: 44-48

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Abstract

The current social dynamics require that the Nursing treatment becomes a permanent challenge, as it has to consider the values, beliefs and practices of the individuals that are under its care, as much as it has to manifest respect for the differences when the attention is being offered. The present paper is intended to expose the dimensions that the Nursing Professional should consider when offering treatment, given the incidence in the cultural diversity of the human groups under the perspective of the cultural competence.
In the development of this work, cultural diversity is defined as a valuation element in Nursing and the constructs that the model includes in order to acquire the cultural competence. The development of these points is from where it can be understood the role of the Nursing Professional under the transcultural dimension, keeping always as a reference that, in order to offer Quality Nursing Caring, the professional must have knowledge, sensitivity and the attitude for collaborating in it.
The acceptance and respect of the cultural differences, the sensitiveness for understanding how these differences influence in the interpersonal relationships, and the ability to offer strategies for improving the cultural encounters, are essential requisites for the consolidation of the transcultural Nursing Care.

Introduction

    When analyzing the meaning of the couple health-illness for the professional nurse, we come to face the complex phenomenon of caring, which emanates from the relation established with the human being as source of attention while presenting different ethnic groups, religions, genders, customs, beliefs, or educational and socio-economical levels among others. The diversity of cares provided by this professional will not have enough quality unless the vital experiences of these persons, as well as their own interactions with their surrounding environment, are fully covered, understood, analyzed and articulated.^1,2
    Once the enumerated characteristics of the nursing practice are understood, the discussion about the management of Care should revolve around the nursing knowledge. Care management implies the permanent building of a nursing language and its positioning in the social and health organizations. It also implies, care as a communicative act that requires scientific and technological knowledge as well as consciousness of the cultural context in which the subjects of care live, recreate and fall ill.

1. Connection Medicine-Anthropology

    In order to start this analysis, we must remember the fact that the links between Medicine and Anthropology are ancient, deep and complex. Up to the end of the XIX^th century, Anthropology was one of the basic Medical Sciences and as such, it had a fundamental role in the consolidation of the Medical Theory and its political role.³ The medical model is the result of a coyuntural process throughout which the technical Hippocratic-Galenic Medicine, which had a empiric-naturalistic approach, incorporated the biological paradigms of the experimental sciences to end up, at the end of the XIXth century, abandoning the political-social discourse about health and illness.^4,5 Some years later, in countries like France, Germany and USA at a later stage, the hegemony of the medical model strengthened the process of medicalization, that is, the penetration of the view or medical perspective into the popular and illustrated knowledge. This process of medicalization was frequently used as strategy to ensure the monopoly on the health attention.
    This hegemonic implantation of the medical model was making the Medicine become more dependent on the biological parameter, and more focused on the cure than on prevention. It used the anthropological discourse to legitimate the fight against intrusiveness and to deny the possibility and effectiveness of selfcare.⁶ Nowadays, in spite of multiple researches that have reported the need of adopting a more holistic model, this medical model is still valid in the education of the health professionals, within which nursing is not an exception.

2. The Culture

    A second but not less important aspect that should be considered, is the own culture of each nurse, related to his religious beliefs, his familiar relationships, his mother tongue, etc. This personal culture is entwined with other subcultures inherent in the context, such as the professional identity or the identity of the institution in which the profession is fulfilled, among others. This cumulus of cultures and subcultures may originate cultural barriers between the professional and the patient, giving as a result deficient care or a questionable quality of this care.
    The Cultural Competence can be defined as the complex integration of knowledge, attitudes and abilities that increases the communication between different cultures (cross-cultural communication), and the effective/appropriate interactions with the others.⁷ Using this definition, it could be stated that in order to favour nursing care with a certain quality, the professional should have knowledge, sensibility and the will to collaborate on it.
    The social commitment that the nurse has to care for the individual, family and community, requires that in addition to the knowledge of the technique, the instrumental aspects of caring, and beyond the intellectual understanding, the knowledge of this other person exists through a holistic relation. The current social dynamic makes the nursing care becomes an ongoing challenge, as it must take into account the values, beliefs and practices of the individuals under care, as well as showing respect for the difference when offering such care.
    Care is one of the central issues of the profession. Even if it has had many different meanings, all of them have as common feature of interaction between human beings. This fact implies, from one side, a way of being, throughout which the person gets out of himself and focuses on the other with effort and solicitousness. On the other side, this fact implies a concern and interest from the person providing care, which makes this person, feel involved and emotionally bound to the other.⁸
    Caring implies understanding and this necessarily includes a process of empathy, identification and projection; besides, as human phenomenon, care contains a dimension of inter-subjectiveness which requires openness, sympathy and generosity.
    Although care as such is a permanent partner of the human being, as he/she will never stop loving and nor caring for others, nor will stop concerning for somebody, in the case of the profession of nursing these two meanings of care are valid if it expects to promote life, prevent illnesses and encourage healthy actions.
    If we observe the changing, plural and diverse nature of our society, we can notice that the type of originated relations are culturally heterogenic. This condition points out the need of including the transcultural dimension in the professional education, in order to offer a humanistic care, focused on the well-being of people, and open to cultural diversity, through the process of attention.
    Leininger was the first nurse who conceptualized the Transcultural Nursery,⁹ based on an anthropological perspective. She proposed the Model of the Raising Sun to illustrate the Theory of the Universality and Diversity of the Cultural Care.¹⁰ This theory indicates that in the same way that people from all around the world have universal and diverse characteristics according to their culture, health care has similarities and differences according to the cultural context in which it takes place. For this reason, to make nursing care efficient and culturally congruent, these similarities and differences must be identified and understood by the professionals assisting this people.
    During the last decades Nursing has analysed the concept of integral human being, which considers the human condition being at the same time physic, biological, psychic, cultural, social, spiritual and historic. Nevertheless, the professional practice is not as integral practice as this discourse indicates. The most of the patients are taken care on emphasising biological aspects or bio-psychological aspects in the best case, doing little efforts to widen the perspective towards an integral dimension. An example of this could be the social factor that mainly appears when inserting some elements of the environment or family.
    The transcultural dimension is an opportunity to include the humanistic stamp in the nursing care as it promotes the discovery of the cultural perspectives of the patients, of their practices, and their values associated to care. When those last ones are considered, even the most difficult person to treat can be sensitized.
    As an example of the former argument, it can be pointed out the fact that the exploration of the logic basis of the causal histories of the patient, related to his processes of health or illness, can help to a better understanding of his expectations and perceptions related to the effectiveness of his care practices.¹² This knowledge helps the nurse to plan interventions facilitating not only an informed decision from the patient side about the care that is provided to him, but also the negotiation and restructuring of the care plan. The most important fact is in this case, the fact that the patient feels that he is treated and valued as a unique human being, being respected with his characteristics of individuality.
    Working towards the transcultural flexibility is an aspect on which it is necessary to go more deeply into. It represents an effort which implies not only changing the security and comfort of the recipes ready for every situation of care, but also having an empathic relation with the individuals/families/communities, communicating with ability in the different cultural scenarios, added to acquiring cultural knowledge of the different communities in order to identify the differences and similarities of care. The final objective is to offer sensitive and competent actions from the cultural perspective. Considering this "Cultural Diversity" implies the assimilation of the fact that, today's society is defined by relations of people, cultures, traditions, ways of life and political and religious differences. As a consequence of this consideration, the processes related to health-illness cannot be abstracted from this pluralist reality, in which this diversity, as a positive strength, defines a challenge to understand our personal differences, while we recognize our similarities in the human values and needs.
    From the perspective of the nurse, taking care of the individuals, families or communities under this point of view, implies the definition of a programme of care culturally congruent and competent. In other words, it implies having the capacity of feeling the other, recognizing the subjectiveness of the human being.

3. Cultural diversity as element of evaluation in Nursing

    Taking into account their incidence in the cultural diversity of the human groups, some of the dimensions that the nurse should consider when offering care will be analyzed.

a) Ethnicity and religion. Normally those two elements are connected. Religion can act, to say it somehow, as a moulding for the values, beliefs, and practices related to health. Religion acts as guide for the daily living, for the interactions between individuals... For example, decisions about what should be eaten or not, the medicines which can be ingested, the way to face illness or death are, among others, aspects which can be defined by the religion and ethnic group to which the persons belong.^13-15

b) Immigration. Among all the changes that the human being has to adapt along his life, few of them are as wide and complex as the ones linked to the phenomenon of migration. Practically everything surrounding the emigrant person changes: from aspects as basic as food or family and social relations, up to the weather, the language, the culture, the status, etc. It could be said that there are very few things remaining as same as before around the person who emigrates.¹⁶
    Nowadays people move from one place to other for multiple reasons and in very diverse circumstances. In any case, this phenomenon produces in them three common outstanding characteristics that are important to consider in the assessment made by the nurse: the break-up, the difference and the difficulties of access.¹⁷
    Break-up, because the most of the emigrant people have left behind the support of their traditional values, the family circle, their friends, the social and familiar ways of life and the contact with the ethnic group.
    Difference, that is associated to the new culture to which they are exposed, leaving behind a series of conceptions and attitudes about the world, and about how a person should behave in it. This difference is also seen in the language that can be very different to their mother tongue. This can derive into immigrants socially isolated in their new environment.
    Difficulties of access, due to the fact that usually immigration affects the individual making him move back in his level of social status compared to his society of origin. This situation is associated to important physical risks to which the immigrant is exposed as he counts on limited economic resources, and the social security protection and health services become difficult to obtain.
    Refugees and displaced people within each country are included in this category of immigrants. Those people are grouped in marginal areas of the cities, or in camps that are supposed to be temporary, or have no home at all. These individuals are generally separated from the rest, either because of their culture or their mother tongue. The nurse faces the difficult task of overcoming these differences, improving his cultural sensitivity and his interpersonal communication in favour of the no-discrimination, the sensitivity and the tolerance.

c) Residence and Regional Differences. They constitute another dimension that influences the cultural diversity of the society. Urban, suburban and rural areas define important variations in the ways of life of people. As it happened with the dimensions mentioned before, these variations demand the acquisition of a deep knowledge about them in order to offer competent cares with high quality adjusted to the cultural reality of each human being.

d) Generational Relation. Different generations within a family may hold diverse perspectives of life, which will affect with a higher or lower intensity their values, beliefs, and health practices for example.
    These changes of perspective are fundamentally due to the continuous and rapid evolution of the world related to the phenomenon of globalization, in which the elder adults are the ones who manifest the bigger difficulties to assimilate and adapt to the vertiginous change.

4. Culture and Nursing

    The cultural knowledge for nursing involves providing cultural care, for which the professional must posses abilities to ease the cultural competence on it.¹⁸ Cultural competence implies the acceptance and respect for the cultural differences, sensitivity to understand how these differences have an influence on the relation nurse-patient and vice-versa, and the ability to find strategies to improve the cultural gatherings according to the needs stated by the patient.¹⁹
    Capinha-Bacote²⁰ developed a conceptual model that provides to nursing a guide to help making efficient and culturally competent interventions. This model defines cultural competence as the process with which the provider of health fights to acquire the ability to work effectively within the cultural context of a client, a family or a community. According to Capinha-Bacote,²¹ this process requires the health providers more to be perceived as becoming culturally competent, than actually being culturally competent.
    The constructs included in the model to acquire cultural competences are: cultural consciousness, cultural knowledge, cultural ability, cultural desire and cultural gatherings. These constructs are interdependent among each other and they can be experienced no matter the place or situation in which the professional is offering care. Any of them can be exercised to improve its reach and effects.
    -The term cultural consciousness defines the deliberated and cognitive process throughout which the professional of health becomes a sensitive detector of the values, beliefs, ways of life, practices and strategies for problems solving in the culture of the clients. This process considers the knowledge of the own values and the prejudices that each one has about other cultures, added to a deep exploration of the own culture. This exercise is essential as it exists a tendency to be ethnocentric and impose the own values and beliefs to the others. Not being conscious about the own values and beliefs entails the risk of being imposer when offering care. Nevertheless, being conscious about the personal perspective, does not warranty culturally competent interventions.
    -The cultural knowledge is understood as a search process to obtain different views of the world in the different cultures. Cultural knowledge is focused on knowing the viewpoint or the vision about the world of the client; that is, the emic perspective. It is important to be aware of the fact that the preconceived ideas, the rationalizations based on arbitrary ideas, and the inability to practice self-criticism, are the origin, in the most of the cases, of the ethnocentrism. With it, the potential deficiencies and weaknesses of the professional are covered. This scheme can lead to a merciless behaviour of the professional in the view of the deficiencies and weaknesses of the others.¹⁸
    -The ability in this model is understood as the skill to collect cultural data related to the health history of the client, in order to perform his/her cultural evaluation. Regarding this concept, Leininger (1978) defines the cultural evaluation as an assessment or systematic examination of the individuals, groups and communities and their values, beliefs and practices, in order to determine their needs and the interventions that should be made within their context. During the interviews and observations, the professionals of health can obtain information about the perceptions of the clients, added to information on possible modalities of treatment. In this sense Bushy (1992) states that it is important to explore, as an example, if the person trusts its own care, or if he likes the traditional folklore practices. If this is the case, it is interesting to know which are those practices and if they are oriented to the promotion of health, the prevention of illnesses or the recovery. Likewise it is important to know whether the person is being treated by quacks, and if he is interested in sharing the information about the interventions that this person of the community is offering him. In the same direction, it is remarkable the fact that many patients would prefer to have quacks and nurses supporting them as a part of the proposed plan of care. If this is the case, it is necessary to know how these cultural quacks can be contacted. Finally, as a part of the cultural ability, it is necessary to find out if the patients want to have a special person, a friend or a relative, present during the process of care. In that case it is necessary to know which one would be roll of that person within the procedure.
    -The cultural gatherings refer to the processes throughout which the professionals are encouraged to directly engage in cultural interactions with clients from diverse cultures. Sometimes, these professionals think that they know all about a cultural group just because they know two or three members of it. It might happen that those two or three members sustain or not the beliefs and practices of the group in general. This is due to the fact that, inside every group there might be what is called intra-group variations. Nevertheless, interacting with different groups might be difficult and uncomfortable. The good intention and the non-verbal communication can be misunderstood by the patients.
    -Finally, the cultural desire is understood as the motivation that the providers of health care have on the issue of willing to compromise in the process of cultural competence.

Conclusions

    The acquisition of cultural competence to provide a sensitive and culturally competent care is a task to which nurses should engage. There are diverse strategies throughout which the world of our patients can be understood. Research has an important role within those strategies. For example, values, beliefs and practices related to health and their own procedures of care can be identified in a systematic manner through ethnographic analysis. Besides, ethnographic researches have contributed with substantial elements to determine health behaviours within groups, and differences in those health behaviours among groups. According to Leininger (1991), this type of knowledge qualifies the professionals of nursery to offer a culturally congruent care, abandoning the ethnocentric positions and easing the decision about which practices, beliefs, and values can be preserved, which ones should be negotiated, and which ones, in sufficiently justified cases, should be restructured.
    The decisions and actions of care determined by the professional will be beneficial and satisfactory for clients/patients if based on the evaluation of benefits and risks of beliefs, values and ways of life.
    The protection and maintenance of the cultural care is crucial, due to the fact that nowadays multiple strengths capable of devaluating human life exist. The consumer society, the high technologies and the lack of sensibility are some of the pressures that avidly affect and produce the loss of some of the autochthon values, with the subsequent loss of copious possibilities of care generated in the pure diversity of the human being. Nursing must identify, for the individuals that take care of, those practices and values worthy of keeping them due to their promotion of the well-being and the appropriate life conditions to preserve health. In this sense, in case the belief or practice is beneficial or does not represent danger for the life of the patient, it could be preserved. On the other hand, in case the practice could end up becoming a risk for health or favouring an illness, an agreement should be negotiated, supporting the belief but suggesting or adapting a more beneficial practice. Finally, if the practice or belief is potentially harmful the nurse must hold a firm position in the explanation of the risks. He or she must help the person to substitute the practice by a healthier one, always recognizing the autonomy and decision of the individual himself.
    Having into account these three ways of acting would favour a differential care, based on the singularity of the human being. Nevertheless, if at the same time the universality of the practices and values in the different communities was recognized, the generalities of the method could be determined. In this sense, as Morin indicates,²² this cultural model can prevent the destructive effect of a technical-civilitational domination that would eliminate one of the biggest treasures of cultures: their diversity. On the other side, it is also useful in order to appreciate the human being as a unique being.
    Nevertheless, not only the ethnographic researches favour the development of the cultural competence. This cultural competence can also be acquired through activities like counselling, intense immersion experiences in different cultures, formal education or informal education through workshops on transcultural care.
    The incorporation to the nursing work of a transcultural way of thinking promotes a wider consciousness about the human complexity. This will promotes the discovery of the multiple aspects that each human being posses within his condition of human, instead of reducing the human being to the minimum part of himself or the worst fragment of his past.
    The acceptance and respect for the cultural differences, the sensitivity to understand how these differences influence the relations among individuals and the ability to offer strategies to improve the cultural gatherings are essential requisites for the transcultural care in nursing to consolidate.

Recommendations

    The future of the Health Care depends strongly on the role assigned to nurses. Nursing has obtained important achievements in the last 20 years. Nevertheless, the traditional problems added to those emerging from the era of the globalization configure together a complex scene. Improvements in such complex outlook can be achieved by working on the following tasks in order to build up Nursing as a profession that offers culturally competent cares:
    -Revision of the educative models and reorientation of the education plans towards complex social models.
    -Orientation of the nursing education towards the needs of health of the population, and creation of new integral models of education based on concepts and practices within public health and primary health attention.
    -Promotion of the 'critical' thinking.
    -Permanent analysis of the impact of globalization.

References

1. Holmes CA. Alternatives to natural science foundations for nursing. International Journal of Nursing Studies 1990; 27: 187-198.
2. Mitchell GJ y Cody WK. Nursing knowledge and human science: Ontological and epistemological consideration. Nursing Science Quarterly 1992; 5: 54-61.
3. Peset JL. Ciencia y Marginación: Negros, Locos y Criminales. Barcelona: Crítica, 1984.
4. Rosen G. De la Policía Médica a la Medicina Social. México: Siglo XXI, 1974.
5. Menéndez EL. El Modelo Médico y la salud de los Trabajadores, en Basaglia; Franco et al.: La Salud de los Trabajadores. México, Nueva Imagen, 1978; pp. 11-53.
6. Menéndez EL. Grupo doméstico y proceso salud/enfermedad/atención. Del teoricismo al movimiento continuo. Cuadernos Médico-Sociales (Rosario RA) 1992; 59:3-18.
7. American Academy of Nursing. Promoting cultural competence in and through nursing education. New York: American Academy of Nursing, 1993.
8. Boff L. Saber Cuidar. Ética pelo humano-compaixáo pela terra. 3ª ed. Petrópolis. Editora Vozes, 1999.
9. Leininger M. Transcultural Nursing: concepts, theories and practices. New York: John Wiley & Sons, 1978.
10. Leininger M. Culture Care Diversity & Universality: A Theory of Nursing. National League for Nursing, 1991; (15):2402.
11. Leininger M. Caring: an esencial human need. New Jersey: Charles B. Slack, Inc. Library of Congress, 1981.
12. Kleinman A. Patients and healers in the context of culture. Berkeley: University of California Press, 1980.
13. Bohay IZ. Culture Care Meanings and Experiences of Pregnancy and Childbirth of Ukrainians. En Leininger M. Culture Care Diversity & Universality: A Theory Of Nursing, New York: National League for Nursing Publications, 1991; pp. 203-229.
14. McKennis A. Caring for the Islamic patient. Association of Operating Room Nurses. AORN Journal 1999; 69(6): 1.185-1.202.
15. Bushy A. Cultural considerations for primary health care: where do self-care and folk medicine fit? Holistic Nursing Pract 1992. 6(3); 10-18.
16. Atxotegui J. Los duelos de la migración: una aproximación psicopatológica y psicosocial. En Perdiguero E, Comelles JM. Medicina y Cultura. Estudios entre la Antropología y la Medicina. Barcelona: Ediciones Bellaterra, 2000.
17. Populations Reports. Gente en movimiento: nuevo foco de interés en la salud reproductiva. 1995; Serie J; 45.
18. Bacote-Campinha J. A model and instrumental for addressing cultural competence in health care. Journal of Nursing Education 1999; 38 (5): 203-210.
19. Grossman D. Enhancing your 'cultural competence'. American Journal of Nursing 1994; 94(7): 58-62.
20. Bacote-Campinha J. A culturally competent model of nursing management. Surgical Services Management 1996; 2 (5): 22-25.
21. Bacote-Campinha J. Cultural competence in psychiatric mental health nursing: a conceptual model. Nursing Clinics of North America 1994; 29 (1): 8-11.
22. Morin E. Los Siete Saberes de la Educación del Futuro. Paris: Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura, UNESCO, 1999.

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