In the field of healthcare it is imperative that each patient’s culture is both acknowledge and respected in an attempt to provide the most comprehensive care possible. Culture is a “complex social concept that encompasses the entirety of socially transmitted communication styles, family customs, political systems, and ethnic identity held by a particular group of people” (Arnold & Boggs, 2011, p. 524). It is also important to include that culture encompasses the way of life and beliefs of a particular group of people at a particular time (Cambridge Dictionary). We must take all of these components into consideration when interacting with patients, as all aspects of culture must be considered when attempting to provide culturally competent care. Throughout this paper I will define what cultural competency is in a therapeutic relationship, followed by explaining why it is important when building a therapeutic nurse-patient relationship, and finally, illustrate how it can be employed through different phases of this relationship.
Defining Cultural Competence and Therapeutic Relationships
Peplau (1997) stated that human relationships are becoming more essential than ever before, with particular importance for people who are enduring the added stress of critical health problems. The development of positive and trusting therapeutic relationships has long been recognized as an integral component of nursing practice, and is a vital part of administering effective care (Feo). Cultural competence is one of the most important components of creating a therapeutic relationship. It is defined throughout nursing literature in a substantial variety of ways, but all with the same underlying message: it is fundamental for working effectively in cross-cultural situations. The American Academy of Nursing (AAN) uses a definition from the Office of Minority Health, where cultural competence is described as “a set of behaviours, attitudes, and policies that enable the nurse to work effectively in cross-cultural situations”. They believe it is built on foundational principles of both social justice and human rights. Smith brings forth a crucial point about cultural competence, stating that it is a “continuous process of providing culturally sensitive, respectful, and empathetic care to all patients”. This means that cultural competence is a ceaseless learning process, throughout which it is vital that health care provides regularly seek learning opportunities to enhance the quality of culturally competent care they provide (Smith).
The Importance of Cultural Competence
Cultural competence is important for a wide multiplicity of reasons, one being that it leads to higher participation in health promotion. Minorities are less likely to participate in screenings, and less likely to seek treatments for recognizable symptoms (Arnold & Boggs, 2011, p. 204). For example, in a study by Gordon and associates (2006), it was found that there was lower levels of participation in cancer communication by ethnic minority clients. This may be because for many minority clients, accessing healthcare can be a very frustrating process. For minority populations, in particular new immigrants, seeking treatments and compliance with treatment is often problematic, as an inability to effectively describe health problems complicates communication with the health care provider (Arnold and Boggs, 2011, p. 204). This can lead to culturally inappropriate care.
Cultural competence can also help reduce health disparities. These disparities are “inequalities in healthcare access, quality, and/or outcomes between groups of people” (Kersey-Matusiak). Miller (2008), states that these inequities are exacerbated by actions that are related to ethnocentrism, and are perpetuated by a lack of awareness, and moral blindness. Nurses, however, have the potential to bridge these gaps in cultural knowledge and health care, especially via the nurse-patient relationship.
How Cultural Competence Can be Implemented in the Nurse-Patient Relationship
In order to develop cultural competence it is important to be aware of our own cultural values, attitudes and perspectives. In addition to self-awareness, it is imperative to develop knowledge and acceptance of cultural differences in others. This acceptance of cultural differences translates into the ability to be aware of your own cultural biases, and helps prevent projecting those biases onto clients (Arnold & Boggs, 2011, p. 203).
Many sources provide various guidelines by which nurses should abide to ensure that culturally competent care is always provided. These guidelines can be applied throughout the different disciplines of nursing, from clinical practice to research, education to administration, and particularly for nurses who are involved in direct patient care. The American Academy of Nursing built a task force of members from the Expert Panel on Global Nursing and Health, the Transcultural Nursing Society, and their own association to compose a list of these guidelines which could be implemented across the diverse field of nursing practices. These guidelines consist of: “knowledge of cultures; education and training in culturally competent care; critical reflection; cross cultural communication; culturally competent practice; cultural competence in healthcare organization and systems; patient advocacy and empowerment; multicultural workforce; cross cultural leadership; and, evidence-based practice and research” (American Academy of Nursing). These guidelines can then be translated into Hildegard Peplau’s four phases of a nurse-patient relationship: pre-interaction; orientation; working; and termination. Each of these phases is characterized by specific interpersonal skills and tasks (Peplau, 1997). The first phase is pre-interaction, which occurs before the nurse and client meet. The next is the orientation phase, when they first engage and begin assessment. Following orientation is the working phase, when planning and implementation of the plan are present. Finally, there is the termination phase, when evaluation of the effectiveness of the plan is performed, following which the nurse and client end their relationship (Arnold & Boggs, 2011, p. 89). Two of these phases in which the guidelines set by the American Academy of Nursing are of particular importance are the orientation and working phases.
Orientation
The Journal of Transcultural Nursing published an article regarding the guidelines set by the AAN, which provides a more elaborate definition and explanation of each of the ten guidelines for provide culturally competent care. One of these guidelines that would be particularly important in Peplau’s orientation phase of the nurse-patient relationship is the concept of “cross-cultural communication”. It states that a nurse “shall use culturally competent verbal and nonverbal communication skills to identify client’s values, beliefs, practices, perceptions, and unique health care needs”. This would be important in a situation where the nurse is unaware of what is required for the client to feel culturally safe. They will not be able to establish a trusting relationship, which would ultimately prevent the client from gaining the most comprehensive care they could receive. For example, some cultural groups consider making direct eye contact to be a very aggressive action, while others may find that if a nurse is avoiding eye contact, they are disinterested, or deferential (Smith). While these are two opposite behaviours, they can be interpreted in two very different ways, which can ultimately lead to the deterioration of any trusting and therapeutic relationship that has been built between the patient and nurse. To ensure that the nurse is aware of any of these verbal or nonverbal communication cues, they would need to implement the “knowledge of cultures” guideline. Under this guideline, nurses are encouraged to “gain an understanding of the perspectives, traditions, values, practices and family systems of culturally diverse individuals…as well as knowledge of the complex variables that affect the achievement of health and well being” (Journal of Transcultural Nursing). This is congruent with Madeleine Leininger’s Theory of Culture Care (2006). She believes that to provide caer that fits the patient, the nurse must have knowledge about diverse cultures. This knowledge can be developed through personal research, but on a patient-to-patient basis, it is important to use culturally competent communication to find out the patient’s cultural preference, which helps to avoid stereotyping (Ngo-Metzger, August, Srinivasan, Liao, & Meyskens, 2008; Teal & Street, 2008).
Working
With regards to the working phase, Peplau states that “it is important to note that the focus is on the (patient’s) reactions to illness and the work to be done by patients toward their development of understanding of themselves, and toward learning what their current health conditions requires of them” (1997). This is particularly important when providing culturally competent care, as an individual’s perceptions, as well as cultural explanatory models associated with the illness can heavily influence whether or not health recommendations are likely to be followed, especially when those recommendations conflict with the patient’s worldview (Arnold & Boggs, 2011, p. 204). This means that care plans should be altered to ensure that it is appropriate to the patient’s culture, in an attempt to increase adherence. The working phase is also when planning occurs. One of the guidelines most pertinent to this phase is “culturally competent practice”. This is defined as “utilizing cross-cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care” (Journal of Transcultural Nursing). It is necessary to exercise this guideline, as a therapeutic relationship will not be built if the patient doesn’t feel they can trust the nurse to respect their cultural beliefs throughout their care. The care must be adapted in a manner that is congruent with the patient’s culture (Giger, Davidhizar, Purnell, Harden, Phillips, & Strickland, 2007(b), pg. 98).
Reflection
In an attempt to determine whether or not culturally competent care was delivered, Kersey-Matusiak (2012) suggests self reflection, during which the nurse asks themselves three questions: “did the patient demonstrate an understanding of what I was trying to convey or teach?”; “was the patient satisfied with the care he or she received?”; and “ what can I do to improve the quality of care I deliver to members of this group?”. Reflection is a fundamental component of growth and development for a nurse, and also important to ensure that quality nursing care is being given. By reflecting on past cultural experiences, a nurse can ensure that culturally competent communication in the future will lead to therapeutic relationships. Reflecting on past experiences before any patient interaction, and asking these questions after each interaction can lead to a well established therapeutic relationship.
Conclusion
Throughout this paper I have illustrated the important of cultural competence in the nurse-patient therapeutic relationship. Additionally, I explored the various guidelines and techniques that can be adopted to ensure that cultural competence is practiced during a nurse-patient therapeutic relationship, particularly when moving through the four phases of Peplau’s theory of the nurse-patient relationship. As we become a more and more multicultural society, it is vital that nurses use cultural competence as an integral part of their nursing process to ensure the most positive and beneficial healthcare experience for their patients.