At the core of both patient centeredness and cultural competence is the importance of seeing the patient as a unique person. For the purpose of this article, cultural competence is viewed as an expansion of patient-centered care. More specifically, cultural competence can be seen as a necessary set of skills for nurses to attain in order to render effective patient-centered care. However, a vexing question remains, “How does the nurse deliver patient-centered care when the patient’s health beliefs, practices, and values are in direct conflict with medical and nursing guidelines?” The purpose of this article is to provide nurses with a set of culturally competent skills that will enhance the delivery of patient-centered care in the midst of a cultural conflict. I will begin by offering a conceptual framework for cultural competence and a description of the cultural skill needed to formulate a mutually acceptable and culturally relevant treatment plan for each patient. Next I will describe effective approaches for cultural encounters. Finally I will present a vignette that illustrates how the nurse can deliver patient-centered care when the patient’s health beliefs, practices, and values are in direct conflict with medical and nursing guidelines
Key words: cross-cultural care, cross-cultural conflict, cultural assessment, cultural competence, cultural conflict, cultural differences, cultural encounters, cultural interactions, cultural skill, patient-centered care, patient centeredness
Betancourt, Green, Carrillo, and Park (2005) have asserted that one of the factors leading to the emergence of cultural competence and patient-centered care as important issues in healthcare delivery was the publication of two landmark Institute of Medicine (IOM) reports — Crossing the Quality Chasm (IOM, 2001) and Unequal Treatment (Smedley, Stith, & Nelson, 2003), which highlighted the importance of patient-centered care and cultural competence. The Institute of Medicine's Report, Crossing the Quality Chasm, identified patient-centered care as one of six aims for high quality healthcare, while Unequal Treatment emphasized the importance of developing cultural competence among healthcare providers so as to eliminate racial/ethnic healthcare disparities. As cultural competence and patient-centered care have gained recognition and popularity, considerable ambiguity has developed in the definition and use of these two concepts across settings (Saha, Beach, & Cooper, 2008). Saha et al. (2008) have argued that advocates of patient centeredness contend cultural competence is merely one aspect of patient-centered care, while proponents of cultural competence have asserted the converse. Beach, Saha, and Cooper (2006) succinctly summarized the differences and similarities between these two approaches in the following way:
Both patient-centeredness and cultural competence aim to improve health care quality, but each emphasizes different aspects of quality. The primary goal of the patient-centeredness movement has been to provide individualized care and restore an emphasis on personal relationships. It aims to elevate quality for all patients. Alternatively, the primary aim of the cultural competence movement has been to increase health equity and reduce disparities by concentrating on people of color and other disadvantaged populations (p. vii).
For the purpose of this article, cultural competence is viewed as an expansion of patient-centered care. Despite these differences, there is consensus that there is an overlap in how patient centeredness and cultural competence are operationalized, and consequently in what they have the potential to achieve. At the core of both patient centeredness and cultural competence, however, is the importance of seeing the patient as a unique person (Beach et al., 2006).
For the purpose of this article, cultural competence is viewed as an expansion of patient-centered care. More specifically, cultural competence can be seen as a necessary set of skills for nurses to attain in order to render effective patient-centered care. However, a vexing question remains, “How does the nurse deliver effective, patient-centered care when the patient’s health beliefs, practices, and values are in direct conflict with medical and nursing guidelines?” The purpose of this article is to equip nurses with a set of culturally competent skills that will enhance the delivery of patient-centered care in the midst of cultural conflict.
This model requires nurses to see themselves as becoming culturally competent rather than being culturally competent. Campinha-Bacote’s (2007) model of cultural competence, called the process of cultural competence in the delivery of healthcare services, serves as a conceptual framework to deliver patient-centered care in the midst of cultural conflict. While Beach et al. (2006) defined patient-centered care as “... perceiving and evaluating health care from the patient’s perspective and then adapting care to meet the needs and expectations of patients” (p.vi), the process of cultural competence in the delivery of healthcare services model of cultural competence (Campinha-Bacote, 2007) has defined cultural competence as the ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, and community). This model requires nurses to see themselves as becoming culturally competent rather than being culturally competent. It involves the integration of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters. Table 1 lists the assumptions of the model, while Table 2 defines each of the constructs of this model. An understanding of the model’s constructs of cultural skill and cultural encounters can assist the nurse in rendering patient-centered care in the midst of a cultural conflict.
Cultural skill is the ability to collect relevant cultural data regarding the patient's presenting problem (Campinha-Bacote, 2007). This process involves learning the skills of how to conduct a cultural assessment, an essential task in delivering patient-centered care. Leininger (1978), defined a cultural assessment as a “systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the context of the people being served” (pp. 85-86). The goal of a cultural assessment is to obtain accurate information from the patient that will allow the nurse to formulate a mutually acceptable and culturally relevant treatment plan for each patient problem.
The literature is saturated with cultural assessment tools, frameworks, and mnemonics that can assist nurses in conducting a cultural assessment. A brief review of some of these tools is useful in providing nurses with a selection of cultural questions that can enhance a patient-centered approach to care.
Kleinman (1980) emphasized the importance of obtaining patients’ explanations of their illness. He referred to this as the patient’s explanatory model. Explanatory models (EMs) are notions about sickness and its treatment. There are five major questions that EMs ask in order to explain the patient’s perception of the illness, specifically the (a) etiology, (b) time and mode of onset of symptoms, (c) pathophysiology, (d) course of illness (including both severity and type of sick role), and (e) treatment for an illness episode. Kleinman finds it useful to ask the following open-ended questions in eliciting the details of the patient's explanatory model:
- What do you call your problem? What name does it have?
- What do you think has caused your problem? Why do you think it started when it did?
- What do you think your sickness does to you? How does it work?
- How severe is it? Will it have a short or long course?
- What do you fear the most about your sickness?
- What are the chief problems your sickness has caused for you?
- What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? (p. 106).
Leininger (2002) encouraged healthcare professionals to conduct a holistic ‘culturalological’ assessment in the major areas of worldview and social structure factors including cultural values, beliefs, and practices; religious, philosophical, or spiritual beliefs; economic factors; educational beliefs; tech...it may be beneficial to incorporate selected aspects of the patient’s culture into the patient-centered plan. nology views; kinship and social ties; and political and legal factors.
To provide ease in the skill of conducting a cultural assessment, a number of authors have developed mnemonic cultural assessment tools. Some of these authors include Berlin and Fowkes (1982); Carillo, Green, and Betancourt (1999); Dobbie, Medrano, Tysinger, and Olney (2003); Fong (1985); Kagawa-Singer and Kassim-Lakha (2003); Levin, Like, and Gottlieb (2000); Like (2004); and Stuart and Lieberman (1993).
For example, Berlin and Fowkes (1982) suggested the mnemonic, LEARN, in conducting a cultural assessment. This mnemonic represents the following 5 steps:
- L isten
The first step is to listen to the patient’s perception of the presenting problem. The nurse then explains his or her perception of the patient’s problem, whether it is physiological, psychological, spiritual, and/or cultural. The next step is to acknowledge the similarities and differences between the two perceptions. At times it is easier for the nurse to acknowledge cultural differences, than to acknowledge and focus on similarities that the nurse and the patient have in common. In order to provide a culturally relevant treatment regimen, it is important for nurses and all healthcare team members to recognize differences, but build on similarities. The fourth step focuses on recommendations, which must involve the patient. Finally, the nurse works to negotiate a treatment plan, recognizing that it may be beneficial to incorporate selected aspects of the patient’s culture into the patient-centered plan.
Levine, Like, and Gottlieb (2000) put forward still another mnemonic tool called ETHNIC. ETHNIC represents the components of:
- E xplanation
Using this mnemonic model, the nurse again begins by having the patient explain his or her perception of the problem. If the patient cannot offer an explanation, the nurse can ask what most concerns the patient about the problem. It is also important to ask the patient what kinds of treatments a patient has tried for the problem. This may include the use of vitamins, herbs, and home remedies. Next, the nurse determines whether the patient has sought advice from alternative health practitioners, folk healers, friends, or other individuals who are not healthcare professionals. The nurse then negotiates, in an attempt to find an option that will be mutually acceptable to both the nurse and patient, and determines an appropriate intervention, which may incorporate alternate treatments. It is important to collaborate with the patient, family members, other healthcare professionals, healers, and community resources during all phases of this assessment process.
The art of conducting a cultural assessment involves cultural care negotiation. Leininger (2006) has defined cultural care negotiation or accommodation as "... those assistive, accommodating, facilitative, or enabling creative provider care actions or decisions that help cultures adapt to or negotiate with others for culturally congruent, safe, and effective care for their health, wellbeing, or to deal with illness or dying" (p. 8). Cultural negotiation must be reciprocal, for both the nurse and the patient must participate in this process.
A cultural encounter is the act of directly interacting with patients from culturally diverse backgrounds. There are two goals of cultural encounters. One goal is to generate a wide variety of responses and to send and receive both verbal and nonverbal communication accurately and appropriately in each culturally different context (adapted from Sue et al., 1982). The second goal of the encounter is to continuously interact with patients from culturally diverse backgrounds in order to validate, refine, or modify existing values, beliefs, and practices about a cultural group, and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge (see Table 2). “Culture is elastic - knowing the cultural norms of a given group does not predict the behavior of a member of that group, who may not conform to norms for individual or contextual reasons” (LeBaron, 2003, paragraph 11). Ting-Toomey (1999) has contended that effective cultural encounters should consist of ‘mindful intercultural communications’ and has argued that the opposite of mindful intercultural communication is ‘mindless stereotyping’ which involves closed-ended, exaggerated, over-generalized perceptions of a group of people based on little or no external validity.
...the obvious question is, “How does one cultivate compassion in the midst of cross-cultural conflict?” LeBaron (2003) has noted that culture is always a factor in conflict, whether it plays a major role or influences it subtly. LeBaron wrote, “for any conflict that touches us where it matters, where we make meaning and hold our identities, there is always a cultural component” (paragraph 17). Ironically, conflict can provide nurses with an excellent opportunity for developing compassion, the emotional task of sharing in one’s suffering. When cross-cultural conflict arises, the goal is to respond with compassion. However, the obvious question is, “How does one cultivate compassion in the midst of cross-cultural conflict?”
Gallaher (2007), drawing on Aria’s study (1999) of Japanese Soto Zen nuns, offered the following analogy regarding the relationship between conflict and compassion: “How are rocks polished? You put them in a tumbler, they hit against each other, the sharp edges are knocked off resulting in mutually polished stones.” The key term here is mutually. Cultivating compassion requires that we understand situations from the other’s point of view and engage in self-reflection regarding how our actions are affecting the other person (Gallaher). Gallaher (2007) added that by “understanding the point of view of the other, you are more likely to respond with compassion rather than judgment” (paragraph 7). During this reflection process one gradually comes into the awareness that we share more similarities than differences. Our sharp edges have been knocked off resulting in ’polished hearts.’
...respecting the cultural values of others is a two-way street. Compassion will lead nurses into a place of meeting in which there is “deep respect for differences and equally intentional openness to the possibility of connection” (Howard, 2003, paragraph 9). This connection embodies the type of encounter that Chapman (2005) has called ’sacred encounters.’ Sacred encounters occur “whenever we meet another’s deep need with a loving response” (p. 58). More simply put, it is making a meaningful connection in which the patient feels valued, respected, and supported. Chapman has explained that developing sacred encounters does not require twice the amount of time, but it does require more than twice the amount of presence.
During the cultural encounter is it also important for the nurse’s values to be respected. Rendering patient-centered and culturally competent care need not negate the values of the nurse. Nurses can remain true to their personal values while still respecting the values of patients in situations where these values may conflict. The following vignette will demonstrate that respecting the cultural values of others is a two-way street.
The Vignette: “To Coin, or not to Coin: That is the Question”
A vexing question, yet one important to answer is: “How does the nurse deliver patient-centered care when the patient’s health beliefs, practices, and values are in direct conflict with medical and nursing guidelines?” The following case vignette will be used to illustrate how Campinha-Bacote’s (2007) constructs of cultural skill and cultural encounters can effectively address cultural conflict while maintaining a patient-centered approach to nursing care.
Mrs. Lee is a 28 year old Southeast Asian woman who brings her daughter, Leah (age 2) into the emergency room because “she is sick.” The nurse assesses the child and notes that the child has an elevated temperature (104.0° F) with slightly increased pulse and respirations. Upon a complete nursing assessment and diagnostic workup it was found that Leah had a bacterial infection that required an antibiotic. A concern for the nurse is that while conducting a physical assessment on the child she noticed several symmetrical, striated, and abrasive marks on the back of the child. The nurse is concerned that this may be child abuse, and also that the break in skin integrity might further complicate and compromisethe child’s existing bacterial infection.
The nurse asks Mrs. Lee how the child received these marks and the mother readily responded, “I did it.” To rule out potential child abuse, the nurse takes a patient- centered approach and conducts a cultural assessment (cultural skill) by using selected components of the mnemonic models, LEARN and ETHNIC. First, the nurse asks Mrs. Lee to explain what she thought was wrong with her daughter Leah. Mrs. Lee shares, “She was very hot and crying and I brought her here because I want her to get all the help she can to get better fast.” The nurse then asks Mrs. Lee what kinds of treatments she has tried for this problem. Mrs. Lee becomes very defensive and asks, “Why are you asking me all these questions.” The nurse responds that she wants to learn more about Leah and how she is cared for. Mrs. Lee reluctantly states, “I used cao gio; I think you call it coining in English.” Although the nurse had heard and read about the practice of coining among the Southeast Asian population, she further engages in a conversation with Mrs. Lee to validate, refine, and/or modify the values, beliefs, and practices she has heard about Southeast Asians (cultural encounter). Thus, the nurse asks Mrs. Lee to explain coining. Mrs. Lee responds, “I get some oil and rub Leah’s back with it and then I rub a small coin down the middle of her back until I see a little blood under the skin.” Without getting alarmed or judging Mrs. Lee, the nurse further asks what is the expected result or results of coining. Mrs. Lee adds, “Coining takes away the wind that is causing her fever.” Next, the nurse asks Mrs. Lee if she has sought help or advice from people other than healthcare professionals, such as people from her community. Mrs. Lee answers, ”Sure! There is an elder in our community who sells the oil for the coining. I think he says it has either winter green, eucalyptus, or peppermint oil in it. I really don’t know, but my family trusts him.” After conducting this cultural assessment (cultural skill) the nurse feels confident that the marks on Leah’s back are not child abuse, but rather the culture-specific practice of coining.
The nurse continues the cultural assessment (cultural skill) by explaining her perception of Leah’s problem to Mrs. Lee. The nurse shares that Leah has an infection that needs to be treated with an antibiotic medicine and adds that any open wounds can increase the chance of the infection getting worse. Further, the nurse remarks that she is concerned that the skin abrasions caused by the coining may increase the chance of more infections. Mrs. Lee abruptly interrupts the nurse and remarks, “I am not going to stop my coining! She won’t get better if we just give her your medicine!” During this cultural encounter the nurse demonstrates compassion by respecting the differences between their two perceptions regarding treatment of Leah’s illness and tells Mrs. Lee that she realizes that the coining is being done to help Leah. The nurse connects with Mrs. Lee by acknowledging their common goal is to get Leah better.
The nurse focuses on recommendations that involve Mrs. Lee as an active participant in negotiating a mutually acceptable treatment plan (cultural skill). Mrs. Lee firmly shares that coining is the only way that Leah’s fever will go down. After several recommendations by the nurse and several non-acceptances of these recommendations by Mrs. Lee, they finally agree that in addition to complying with the nursing and physician discharge orders, Mrs. Lee can rub the coin lightly on the back of Leah, making sure not to cause any redness, bleeding, or break in the skin. Mrs. Lee states, “I’ll give this a try.” The nurse informs Mrs. Lee that she will ask the doctor to have a visiting nurse come into the home to check on Leah in two days and answer any questions.
The above vignette illustrates how cultural skill and cultural encounters, two constructs of Campinha-Bacote’s (2007) model of cultural competence, can be used as tools to enhance the delivery of patient-centered care in the midst of a cultural conflict. The cultural skill of conducting a cultural assessment allowed the nurse to deliver culturally competent and patient-centered care that incorporated the patient’s values, beliefs, and practices into the treatment plan. Also, a meaningful and deliberate cultural encounter allowed the nurse to “connect” with the patient as a unique, individual person, and not as a stereotype of the patient’s cultural group.
...a patient-centered and culturally competent approach to effectively resolving cultural conflicts must be viewed as a “win and lose” situation for the patient and a “win and lose” situation for the nurse. A patient-centered and culturally competent approach to effectively resolving cultural conflicts should not result in a “win or lose” situation for either the patient or nurse; but rather result in a “win-lose/win-lose” situation in which values of the nurse and patient are respected. A “win or lose” situation for Mrs. Lee would be one in which she either “wins” by being allowed to do her traditional healing practice of coining; or “loses” because she is instructed to engage in a modified version of coining that complies with the nursing and medical regime. A “win or lose” situation for the nurse is one in which the nurse either feels she “wins” by having the patient take the medication and stop coining; or “looses” if the patient engages in traditional coining and does not take the prescribed medication. Rather, a patient-centered and culturally competent approach to effectively resolving cultural conflicts must be viewed as a “win and lose” situation for the patient and a “win and lose” situation for the nurse. This can be referred to as a “win and lose/win and lose situation. In a “win and lose/win and lose” approach both patient and nurse “win” (retain specific aspects of their values in the treatment), and “lose” (each must modify their values in the treatment). Mrs. Lee was allowed to still coin (“win”); however, it was in a modified manner and she had to comply with the nursing and medical interventions (“lose”). The nurse was satisfied that there was agreement that the child’s skin integrity would remain intact and the medication would be taken (“win”). However, the nurse was still concerned that Mrs. Lee may resort back to a coining technique that would comprise the child’s health; hence she got a visiting nurse involved with this family (“lose”).
To deliver patient-centered care in the midst of a cultural conflict, nurses are encouraged to move forward in their process of becoming culturally competent by utilizing the skills presented in this article. Incorporating Campinha-Bacote’s (2007) constructs of cultural skill and cultural encounters into the nurse-patient interaction can enhance patient-centered care during a cultural conflict.
Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN
Dr. Campinha-Bacote is President and Founder of Transcultural C.A.R.E. Associates, and provides clinical, administrative, research, and educational services related to transcultural healthcare and mental health issues. She received B.S. degree from the University of Rhode Island, her M.S. degree from Texas Women's University (Denton, TX), a M.A. in Religion/Theology from Cincinnati Christian University, and her PhD from the University of Virginia. Dr. Campinha-Bacote is Board Certified by the American Nurses Credentialing Center as a Clinical Nurse Specialist in Adult Psychiatric & Mental Health Nursing, and certified by the Transcultural Nursing Society (TCNS) as an Advanced Certified Transcultural Nurse. She is also a Fellow of the American Academy of Nursing and has been inducted into the TCNS as a Transcultural Nursing Scholar. She currently serves as a consultant to the National Center for Cultural Competence (NCCC) in Washington, DC and on several Health Resources and Services Administration (HRSA) grants focusing on cultural competence in the health professions.
Betancourt, J., Green, A., Carrillo, J. E, & Park. E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends.Health Affairs, 24(2) 499-505 http://content.healthaffairs.org/.
© 2011 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2011
Beach, MC, Saha, S., & Copper, L. A. (October 2006). The role and relationship of cultural competence and patient-centeredness in health care quality, Commonwealth Fund Publication No. 960. Medicine, 82(2), 193-98.
Berlin, E., & Fowkes, W. (1982). A teaching framework for cross-cultural health care. The Western Journal of Medicine, 139(6), 934-938.
Betancourt, J., Green, A., Carrillo, J. E, & Park. E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends.Health Affairs, 24(2) 499-505 http://content.healthaffairs.org/.
Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services: The journey continues (5th Ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates.
Carillo, J., Green, A., & Betancourt, J. (1999). Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine, 130, 829-834.
Chapman, E. (2005). Radical loving care. Nashville, TN: Baptist Healing Hospital Trust.
Dobbie, A., Medrano, M., Tysinger, J., and Olney, C. (2003). The BELIEF instrument: A preclinical tool to elicit patient’s health beliefs. Family Medicine, 35(5), 316-9.
Fong, C. (1985). Ethnicity and nursing practice. Topics in Clinical Nursing, 7(3), 1-10.
Gallaher, D. (2007). Polishing the heart. Journal of Sacred Work. Retrieved November 1, 2010 from http://journalofsacredwork.typepad.com/journal_of_sacred_work/2007/04/polishing_the_h.html
Howard, G. (2003). Speaking of difference: Reflections on the possibility of culturally competent conversation. New Horizons for Learning Online Journal, 9(2).
Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Kagawa-Singer, M., & Kassim-Lakha. (2003). A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Academic Medicine, 78, 577-587.
Kleinman, A. (1980). Patients and healers in the context of culture. CA: University of California Press.
LeBaron, M. (2003). “Culture and conflict.” Beyond Intractability. Guy Burggess & Heidi Burgess (Eds.). Conflict Research Consortium, University of Colorado, Boulder. Retrieved November 4, 2010 from www.beyondintractability.org/essay/culture_conflict/
Leininger, M. (1978). Transcultural nursing: Theories, concepts and practices. NY: John Wiley & Sons.
Leininger, M. (2002). Transcultural nursing: Theories, concepts and practices, (3rd Ed.) NY: McGraw Hill, Inc.
Leininger, M. M. (2006). Cultural care diversity and universality theory and evolution of the ethnonursing method. In M. M. Leininger & M. R. McFarland (Eds). Culture care diversity and universality: A worldwide nursing theory (2nd ed.) (1-42). Sudbury, MA: Jones and Bartlett Learning.
Levin, S., Like, R., & Gottlieb, J. (2000). ETHNIC: A framework for culturally competent clinical practice. New Brunswick, NJ: Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School.
Like, R. (2004). ADHERE: A mnemonic for improving patient adherence with therapeutic regimens. From The Providers’ Guide to Quality and Culture. [website] Retrieved November 1, 2010 from http://erc.msh.org/mainpage.cfm?file=4.4.0d.htm&module=provider&language= English. Published in Soto-Greene, M., Salas-Lopez, D., Sanchez, J., & Like, R.C. (2004). Antecedents to Effective Treatment of Hypertension in Hispanic Populations. Clinical Cornerstone, 6(3): 30-36.
Smedley, B., Stith, A., & Nelson, A. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
Saha, S., Beach, M. C., & Cooper, L. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100(11), 1275-1285.
Sue, D., Bernier, J., Durran, A., Feinburg, L., Pedersen, P., Smith, C., & Vasquez-Nuttall, G. (1982). Cross-cultural counseling competencies. The Counseling Psychologist, 19(2), 45-52.
Stuart, M., & 0’ Lieberman, J. (1993). The fifteen minute hour: Applied psychotherapy for the primary care physician (2nd ed.). New York, NY: Praeger.
Ting-Toomey, S. (1999). Communicating across cultures. New York: The Guilford Press.