HealthNovember 01, 2019

Considering culture when a healthcare encounter is not a positive experience

Pam Embler, MSN, PhD, RN

Culture does not always look different, sound different, eat different, or dress different.

Learning of a person's patterns and meaningful health/wellness practices requires an open mind and a systematic approach to discovery - the models and theories. The way in which a culturally competent nurse does this is seamless and often goes undetected.

Developing a guide to help nursing students understand cultural preferences and characteristics around the world would be a daunting task for faculty. Culture has been described as an iceberg, with its most powerful features hidden under the ocean surface. 

Culturally competent practices are a journey, not a destination. As outsiders to the cultural beliefs and practices of others, we face the reality that we may only learn bits and pieces of how one's culture differs to our own. I define culture broadly as an identified sense of belonging related to gender, sexual orientation, profession, family dynamic, environmental context, race, or ethnicity. Reflect on these definitions and ask yourself: to which cultures do you identify and is there a tension among them, if any?

Cultural beliefs, practices, and lifeways are predominately learned through human interactions; observing, participating, or storytelling, and this knowledge can change in response to global changes. When we consider one's culture, we must consider the levels in which the constructs of culture exist.

Purnell (2014) states that at the tertiary level, cultural constructs are visible to outsiders, i.e. food, clothing, anything outwardly observable. At the secondary level, only persons of the culture know the “rules of behavior” (p.6). Finally, the primary level holds that the most enrooted and unconsciously held beliefs, patterns, practices, and beliefs are known by and practiced by its members. “Culture is largely unconscious and has powerful influences on health and illness” (p.6).

Becoming culturally competent practitioners

As we consider the challenging task of becoming culturally competent practitioners who provide culturally congruent care, it is necessary to consider terms related to culture care practices and our levels of development. As nurses, we often hear the terms cultural awareness, cultural sensitivity, and cultural competence and they are often used interchangeably. These terms are not all the same, however. Cultural awareness is the appreciation of culture all around us - arts, music, dress, foods, etc. Cultural sensitivity concerns one's sensitivity to another's culture - being careful not to offend. Finally, cultural competence is the pièce de résistance - the healthcare provider has the knowledge, ability, and skill to provide culturally congruent care. This is care that is meaningful for the patient and in concert with their cultural beliefs and practices (Purnell, 2014).

As practitioners, we progress through four stages of cultural competence, according to Purnell (2014). We begin our journey from unconscious incompetence; not knowing we lack knowledge. As we learn and grow, we become consciously incompetent; having an awareness of our lack of knowledge. Over time and through efforts to learn and provide culturally congruent care, we become consciously competent. Finally, the unconscious competent provider acts without thinking to provide culturally congruent care for their patients. Be warned - an unconsciously competent practitioner must check and balance one's self as assumptions cannot be made from one culture to the other.

Where to start

Where to start? Honest reflection, genuine respectful curiosity and a thirst for knowledge, self-determination to remain open, and a concerted effort to maintain a non-intrusive demeanor. 

You should also be aware of your verbal and non-verbal communications when reacting to the cultural meanings, beliefs, patterns, and practices of persons.

1. Checking one's ethnocentrism tendencies is the first step. Be honest with yourself, as this is a natural human tendency to a degree.

2. Admit that you do not know and never assume. We often assume if the person wears American clothing or speaks English that they are acculturated and have abandoned all traditional ways.

3. Read, learn, and ask. Remember the levels of cultural constructs. Many cultures will share what they deem you are worthy of learning.

4. Always be an active listener. Asking a question while you are titrating a medication, changing a dressing, making a bed is not active listening. You may think that you are actively listening, but you are most likely not being perceived this way. During my data collection, it was shared that in Yup" ik Eskimo worldview, persons who hold knowledge, whether they are an elder or not, will determine when to share their knowledge with others. This adage was communicated to me time and again in participant observations and in individual key and general informant interviews. One general Informant explained this as, “it is about common bonds first", “much is not spoken, (you) must be let in.” Similarly, a key informant shared, “watch and the answer to a question will be revealed.” My favorite wisdom, shared early in my immersion, “conversations turn to connections” and “trust before revealed” shaped my observational experiences and the interviews by keeping me cognizant of respectful listening and learning.

5. A personal commitment to never stop learning.

Purnell L. D. (2014). Transcultural health care: A culturally competent approach (3th Ed.). Philadelphia: F.A.Davis.

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