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graded_unit_6_assignment-3.docxRunning head: CULTURAL INCOMPETENCE IN NURSING
CULTURAL INCOMPETENCE IN NURSING 12
Literature Review: Cultural Incompetence in Nursing
Bettina Vargas
Kaplan University
Literature Review: Cultural Incompetence in Nursing Comment by Tracy Towne: Use citations to support yoru statements so the reader knows it is not just your opinion
In healthcare, cultural incompetence impedes the delivery of quality care at the global, national and healthcare organizational level. In the United States, the minority disproportionate access of healthcare is mainly due to cultural incompetence in nursing and so are the increasing health issues they face, such as high rates of diseases and deaths. At the practicum site, Coral Gables Nursing and Rehabilitation, the effect of cultural incompetence in reference to the delivering poor quality care to a culturally diverse patient population is evident. With this in mind, the focus of this literature review is to provide insight on the trends of cultural incompetence, explore theories used to examine cultural incompetence, gaps in the pre-existing literature and solutions to cultural incompetence. This will help to contextual cultural incompetence and find lasting solutions for eradicating cultural incompetence and prioritizing cultural competence.
Trends
Cultural incompetence in nursing finds its roots in the nursing education and training. According to Bednarz, Schim, & Doorenbos (2010), as the general population records increased diversity, so do the nursing classroom where the minorities are enrolling in nursing education at a higher rate. This increases the need to focus on diversity in nursing education to nurture cultural competent nursing professionals. However, cultural incompetence among the teaching staff in terms of the inability to counter diversity barriers make it difficult to teach a diverse classroom and impart students with cultural competence. These barriers emerge from values and common attitudes held by nursing education and culture such as avoiding unwanted discrimination and the Golden Rule, which is “do unto others as you would have them do unto you” (para. 9). As Hassouneh (2013) indicate, the effect of such barriers, is “unconscious incompetence” as well intentioned faculties are unable to recognize realities, including the fact that each student is unique and deserves unique treatment, thus generating more barriers towards instilling students with cultural competence. The nursing education and training lacks uniformity in accommodating the needs of diverse students. Lack of efficiency in cross-cultural communication, both in written and spoken form aggravates this. Besides, nursing education has no profound way of bringing the different cultures, jargon and professional languages that the students and the faculty possess together to create coherence and increasingly enable the nurses and the faculty to understand each other. The effect is a learning environment that does not accommodate diversity and cannot impart students with cultural competence. Comment by Tracy Towne: Citation needed Comment by Tracy Towne: Author/year? Comment by Tracy Towne: Indicated – use past tense verbs Comment by Tracy Towne: Missing supporting citations
Because of lack of cultural competence skills at the training/educational level, the nursing field records an increasingly growing concern of cultural incompetence at the professional level. McClimens, Brewster and Lewis (2014) research exploring the experience of nursing students upon their placement in a professional environment show a high level of incompetence among the students. The students have difficulty meeting patients’ cultural needs in relation to gender, food and language. As a reflection of most professional environments, signage is in English with minimal translations of languages commonly used in the area where the facility is located. Often, the students, who are now practicing professional nurses experience communication breakdown and mistranslation that compromise patient safety. Nurses cannot balance patient’s eating habits and their professional practice expectations. They have difficulty coping with patients observing Ramadan who cannot drink and eat during certain times, Gambians who cannot use cutlery and they are unable to offer food choices for different cultures as reflected by the patient population. When it comes to gender, some patients prefer male and others female nurses, but most nurses cannot cope with the rejections. The conclusions drawn are that the nurses are cultural incompetent: they do not know the wrong or right way of delivering care to a diverse population. Comment by Tracy Towne: Who says? Citation needed Comment by Tracy Towne: Missing citations – you must support yoru statements
Trends also reveal that cultural incompetence is not a reserve for “fresh” nurses during their initial professional practice settings. It extends to well-grounded nurses who have practiced nursing for years. Hart and Mareno (2013) research on 374 nurses show emerging themes of cultural incompetence, including increased diversity, insufficient resources, as well as, biases and prejudices. In the presence of scarce resources, which are poses a key challenge in dissemination of resources; nurses use their own biases and prejudices concerning patients to deal with the increasing cultural and resource challenges when delivering care. They avoid attending to patients with cultural attitudes they perceive as stubborn, not welcoming, and attend to patients from cultures they regard as friendly, less stubborn. Unfortunately, most still perceive their selves to be culturally competent. This is because as Loftin, Hartin, Branson and Reyes (2013) research show, most nurses rely on cultural competence measurement tools to examine their cultural competence levels. The tools depend on a person’s perceptions and are self-administered, thus lacking any objective measure of how culturally competent they are based on patients’ perspectives. Most nurses often get positive results, which are misleading. The effect is that cultural incompetence continues to prevail because no positive and constructive feedback is available to enable nurses to critically examine their cultural incompetence and make changes. Comment by Tracy Towne: Citation? Comment by Tracy Towne: Citations?
Trends reveal the capacity of cultural incompetence among nurses to result in negative health effects in the nursing field and the entire health system in general. The impacts felt by minorities, who comprise of diverse cultural groups and needs that the healthcare system does not address. Strunk, Townsend-Rocchiccioli and Sanford (2013) research on Hispanics reflect the implications of cultural incompetence. Statistics show that with increased immigrations, the Hispanic population will be 8.6 by year 2030. Many Hispanic groups have distinct cultural beliefs. Because they do not receive quality care, partially due to cultural incompetence among nurses, they exhibit disproportionate burden of death, diseases, disabilities, injuries and death in comparison to the non-Hispanic groups. Cultural incompetence among nurses in addressing Hispanic health issues relates to language difficulties and differences in cultural practices and beliefs. As a result, there are missed diagnoses; over 50% of Hispanics having Alzheimer disease remain undiagnosed. Nurses cannot cope with Hispanics cultural beliefs regarding hot illness, such as diabetes, hypertension and pregnancy, and cold illness, such as nosebleeds and pneumonia. Nurses are more likely to treat nosebleeds using icepacks, which is unacceptable in Hispanic culture. Hispanics believe a cold treatment cannot treat a cold illness. The effect is that without cultural incompetence, nurses’ work under stressed environment where they cannot practice their professional fully or address the needs of the Hispanic patients, thus resulting in poor delivery of health services. Overall, the healthcare system is stressed because increased cultural incompetence means that the health needs of minorities are not met, thus overburdening the healthcare system. The government directs most healthcare costs towards addressing minority healthcare needs, which are disproportionate to the majority such as increased rates of cancer among others. If cultural incompetence continues to increase and continually finds its way in the practical settings especially among nurses who are the primary care givers, the costs and the healthcare issues faced by the minorities will continue to increase, thus working against the delivery of quality care to patients. Comment by Tracy Towne: Citation? Comment by Tracy Towne: Whose statistics? Comment by Tracy Towne: You are using no citations to support yoru statements
Gaps in Literature
Most of the literature covers cultural incompetence in the context of nurses’ lack of knowledge in patients’ beliefs, values, customs and practices. However, as Vandenberg (2010) indicates, this results to oversimplification of cultural diversity. Socio-economic, historical, age, physical size, and political factors also account for the cultural incompetence. These factors result in complex cultural situations that are unique for each individual and which nurses should address in a unique manner to ensure cultural competence. Hence, because literature does not direct much attention to these factors, they are less considered in the practical settings, thus adding to increased cultural incompetence among nurses. Comment by Tracy Towne: Citation needed
According to Singleton and Krause (2010), the Joint Commission has already coined limited proficiency in languages, cultural barriers and low health literacy as a “triple threat” to cultural competence. However, there is little integration of cultural incompetence and language. Culture combined with language provide experiential context in which nurses understand health information provided by patients. Knowing patients’ language and culture helps a nurse to know the health literacy level of the patient and patient’s expectations, thus building nurses’ capacity to deliver culturally competent care. Hence, by offering minimal integration between language and culture, nurses lack information to integrate the same in the practical settings, thus adding to their cultural incompetence. Comment by Tracy Towne: Citation needed
Literature in nursing fails to explore objective tools for measuring nurses’ incompetence or competence levels. Jeffreys and Dogan (2010), as well as, Jeffreys and Dogan (2012) researches show lack of tools that could offer objective feedback on nurses’ cultural competence to enable them make changes to improve on their cultural competence. The basis of instruments for measuring cultural competence, such as Cultural Self-Efficacy Scale, Cultural Competency Instrument (CCI) and Nurse Cultural Competence Scale among others are individual ratings or perceptions. The inability of literature to focus on, as well as, highlight objective tools provides nurses with no constructive feedback to help identify and deal with their cultural incompetence. Comment by Tracy Towne: Citation
Theories
Theories discussed in most literature to explore cultural incompetence in nursing include transcultural theory, cultural safety theory and nursing theories of cultural (in) competence. According to Mortensen (2010), cultural safety model is responsible for developing cultural safety guidelines that guide nursing practice in delivering care to linguistically and culturally diverse populations. Cultural safety theory acknowledges multiculturalism, emphasizes the positive outcomes and health gains of cultural competence and the institutional power that health systems and health professionals posses. Non- adherence to principles guiding cultural safety results in cultural incompetence. In contrast, transcultural theory does not adequately focus on institutional power being an impediment to cultural competence or advocate for the elimination of health inequalities within populations. Rather, the theory focuses in on dynamics of social, race and power inequalities are integral in culture care theory and cultural incompetence and competence. Other theories covered in the literature central to providing insight on cultural incompetence include cultural awareness and cultural sensitivity, which lead to cultural incompetence if not adapted. Ideally, cultural competence theories provide insight on cultural incompetence when viewed in the context of what may lack in the care delivered if cultural competence is absent. This results in cultural incompetence, as nurses cannot adhere to practices of cultural competence and derive the benefits of cultural competence in terms of quality care delivery. Besides, the theoretical interpretation of cultural incompetence is nurses’ lack of capacity to counter cultural challenges in healthcare. Hence, the literature largely covers cultural barriers that nurses’ face and difficulties in addressing the barriers to highlight their cultural incompetence. Comment by Tracy Towne: Citations?
Solutions
Solutions suggested across the sources examined include developing cultural competent nursing educators and tailoring the nursing curriculum to accommodate diversity and help eliminate barriers to instilling cultural competence. At the organizational level, Mortensen (2010) and Kelly (2011) note that the solution lies with training nurses on cultural awareness and creating a culturally sensitive environment with zero tolerance to cultural incompetence to ensure that nurses prioritize cultural competence when delivering care. At the individual level, Douglas et al. (2011) recommend that nurses adhere to Standards of Practice developed for Culturally Competent Nursing care. The standards recommend that nurses promote social justice, and engage in critical reflections regarding their own cultural beliefs in relation to how these affect cultural congruence in nursing. This also goes for gaining knowledge of different cultures, using cross-cultural sensitive skills and knowledge in delivering nursing care, and developing cross-cultural communication and leadership. Comment by Tracy Towne: Citations?
Loftin, Hartin, Branson and Reyes (2013) note that literature on cultural (in) competence should focus on developing frameworks that nurses could use to examine their cultural competence objectively to enable them get constructive feedback that could help improve on their cultural competence levels. Singleton and Krause (2010) recommends integration of cultural incompetence and language when exploring cultural competence to ensure nurses understand the importance of language and knowledge of different languages in ensuring cultural competence. To conceptualize cultural incompetence and avoid oversimplification, as Vandenberg (2010) indicates, in education, training and practice, cultural competence should include socio-economic, historical, age, physical size, and political background among other factors that affect an individual’s cultural background, not just beliefs, values and practices. Hence, literature exploring cultural (in) competence should conceptualize cultural (in) competence theory to include these factors so that nurses can learn more about them and incorporate them in the practical settings.
Synthesis Comment by Tracy Towne: No citations as needed
The trends reveal that nursing incompetence has its roots in the nursing education and training, which lacks to instill cultural competence in nursing students. As a result, when students become nursing professionals, lack of cultural competence skills become evident, as they cannot deal with cultural challenges they face as nurses. Lack of cultural competence in nurses who have been in the practice for long can be tied to lack of objective tools that could offer constructive feed and provoke them to change. In effect, they live in the illusion of cultural competence while in reality they are culturally incompetent. The nursing theories discussed herein mostly focus on cultural competence and although they highlight cultural competence, they show the need to develop cultural competence theories that provide insightful perspectives on cultural incompetence. The gaps highlighted in literature, such as lack of integration between language and culture and absence of objective tools for measuring cultural competence among others are contributory factors to cultural incompetence. Hence, for effectiveness purposes, the solutions integrate all the factors discussed, including gaps in literature to address nurses’ cultural incompetence at the individual, organizational and educational level.
References
Bednarz, H., Schim, S., & Doorenbos, A. (2010). Cultural diversity in nursing education: Perils, pitfalls, and pearls. Journal of Nursing Education, 49(5), 253–260.
Douglas, M. K. et al. (2011). Standards of practice for culturally competent nursing care. Journal of Transcultural Nursing 22(4) 317 –333
Hart, P.L., & Mareno, N. (2013). Cultural challenges and barriers through the voices of nurses. Journal of Clinical Nursing. Doi: 10.1111/jocn.12500
Hassouneh, D. (2013). Unconscious racist bias: Barrier to a diverse nursing faculty. Journal of Nursing Education, 52(4), 183-184.
Jeffreys, M. R., & Dogan, E. (2010). Factor analysis of the transcultural self-efficacy tool (TSET). Journal of Nursing Measurement, 18(2), 120–139.
Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students' transcultural self-efficacy perceptions. Journal of Transcultural Nursing, 23 (2), 188–197.
Kelly, P. J. (2011). Exploring the theoretical framework of cultural competency training. The Journal of Physician Assistant Education 22(4), 38-43.
Loftin, C., Hartin, V., Branson, M., & Reyes, H. (2013). Measures of cultural competence in nurses: An integrative review. The Scientific World Journal, 2013. doi:10.1155/2013/289101.
Mortensen, A. (2010). Cultural safety: Does the theory work in practice for culturally and linguistically diverse groups? Nursing Praxis in New Zealand, 26(3), 6-16.
Singleton, K., Krause, E., (2010). Understanding cultural and linguistic barriers to health literacy. OJIN: The Online Journal of Issues in Nursing, 14(3), Manuscript 4.
Strunk, J. A., Townsend-Rocchiccioli, J., & Sanford, J. T. (2013). The aging Hispanic in America: Challenges for nurses in a stressed health care environment. Medsurge Nursing, 22(1), 45-50.
Vandenberg, H. R. (2010). Culture theorizing past and present: trends and challenges. Nursing Philosophy, 11(4), 238-249.
