City University of New York
La Guardia Community College
Department of Natural and Applied Science
Practical Nursing Program
PN SCL 118- The Science and Art of Nursing II
Instructor: Associate Professor Iona Thomas-Connor, RN, MA CNE
Date: January 30, 2008
SMALL GROUP PRESENTATION: RESEARCH PROJECT
TOPIC
Practical Nursing Practice: Cultural Competency In The
Practice of Nursing Profession
GROUP MEMBERS:
Alvar, Crispo
Cox, Eva
Ilagan, Norman
Jimenez, Marie
Poltilov, Zoya
Utoh, Ifeyinwa
Yanchen, Tsering
Fall II, 2008
TOPIC
Practical Nursing Practice: Cultural Competency In The
Practice of Nursing Profession
2
TABLE OF CONTENTS
I.
Introduction……………………………………………………..Crispo Alvar



Topic Overview
Purpose of the Group Project Presentation
Importance and Rationale of the Research Project
II.
Cultural Competency Considerations, its Contributions to the Health and Health
Beliefs of Clients and the Practice of Practical Nursing Profession.
 Understanding Culture………………………………....…..Tsering Yanchen
 The Impact of Ethnicity…………………………………….Ifeyinwa Utoh
 The Influence of Religion…………………………………..Normal Ilagan
 The Aspects of Socialization……………………………….Marie Jimenez
III.
Problem Areas Related to Cultural Competency in Communicating and Working
Across Cultures in Practical Nursing Practice………………….Eva Cox
IV.
Legislations and Resolutions Related to Issues on Cultural
Competency…………………………………………………….Crispo Alvar
V.
The Nurse’s Role in Developing Cultural Competency in the
Clinical Arena……………………………………………..……Zoya Poltilov
VI.
Summary and Conclusion……………………………………....Marie Jimenez
VII.
References
3
Introduction
As a concept, cultural competency in the nursing profession has evolved over
time. Cultural Competency has been defined by The National Standards for Culturally
and Linguistically Appropriate Services (CLAS) defined cultural competency as a “set of
congruent behaviors, attitudes, and policies that come together in a system, agency, or
among professionals that enables effective work in cross-cultural situations. Further it
defines ‘Culture’ as an integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of racial,
ethnic, religious, or social groups. And defined ‘Competence’ to imply as having the
capacity to function effectively as an individual and an organization within the context of
the cultural beliefs, behaviors, and needs presented by consumers and their communities”
(Office of Minority Health, 2007).
In the United States, the presence and interests of different cultural constituencies
have made provision of cultural competency health care imperative. This is true because
many minority cultural groups have already experienced a disproportionate burden of
health care disparities - particularly related to the access to health care, and quality of
care. In many ways cultural and linguistic differences has compromises communication
and jeopardize patient’s trust.
Since apparently every aspect of a person’s life is influenced by that person’s
cultural background, each encounter with a healthcare provider must also be shaped by
the cultural frameworks of both the client and the medical professional. In today’s
increasingly diverse society, cultural competence becomes a critical skill in our personal,
professional and social environment. But unfortunately, according to the Surgeon General
Report of 2005, the U.S. healthcare profession is considered still not been very wellprepared to provide culturally competent care to our highly diversified population.
Because nurses such as LPN’s provide direct health care to culturally diverse client
populations in various settings, knowledge of culturally relevant information is essential
for delivery of competent nursing care. It is for this reason, that as Student of Practical
Nursing (SPN) must be made aware, be educated and provided with the initial knowledge
4
about Cultural Competency in the Practice of Nursing Profession. Hence, this small
group presentation.
UNDERSTANDING CULTURE
Culture is the accumulated learning for generational groups of individuals within
structured or non-structured societies. Individuals experience a cultural heritage with
others. It is a heritage that is learned through formal and informal experiences through the
life cycle. Culture consists of the combined heritage of language and communication
style, health beliefs and health practices, customs and rituals and religious beliefs and
practices. Culture is influenced by environment, expectations of society, and national
origin.
The changing demographics of the nation increase the cultural diversity of the
United State population. Knowledge and skills related to cultural diversity can strengthen
and broaden health care delivery systems. Concepts of health, wellness, and illness are
part of the cultural belief. To provide better health care service to a client, nurse need to
recognizing cultural diversity, their values, and their beliefs.
Cultural competence which is the process of working effectively within the
cultural context of another person is so important to achieve best health care and
satisfaction to your client. The U.S. Bureau of the Census predicts that by the year 2050,
about 47% of the total population will be made up of racial minority groups.
Cultural contributions in health care system are:

Being experienced in different culture group may lead nurse to understand the
complexity of culture. By adapting different culture beliefs and practices, nurse
will obtain cultural information and be knowledgeable in treating a client. Like
their beliefs and practices in times of illness such as scientific or biomedical,
holistic medicine, Yin-yang, and hot-cold theories. Knowing about a client’s
culture and their impact on interactions with health care is crucial for nurses and
leading quality of care and better outcomes.

Skills related to cultural diversity can strengthen and broaden health care delivery.
By understanding their Personal Space could lead to therapeutic communication
and the client will open up and response truthfully without hesitation.

Personal cultural heritage of the nurse can maximize the care of the client.
5
Many nurses can provide a valuable service to the public by providing
information and servicing in many areas where there are shortage of nurses.
Some barriers to culturally competent care are prejudice, ethnocentrism, and
stereotyping. The ways as future nurse to overcome these barriers would be to develop
cultural sensitivity. Cultural sensitivity is the understanding and tolerance of all cultures
and lifestyles. It allows the nurse to understand and accept the behavior of others in
terms of the client’s health and or illness.
Moreover, exposing to different people of different ethnic backgrounds can also
prevent or reduce the likelihood of stereotypes, prejudices, and ethnocentrism. Cultural
exposure can facilitate learning interactions with different types of people. Having
knowledge of cultural diversity is vital at all levels of nursing practice.
IMPACT OF ETHNICITY
The word Ethnicity and culture are some times used interchangeably but in the
main perspective, they are different. Ethnicity is a social construction which indicates
identification with a particular group which is often descended from common ancestors.
Its members share common cultural traits for example; they share (same language,
religion and dress) and they are an identifiable minority within the larger nation.
It’s Impact to the Health care
The health care systems have changed drastically accommodating people from
various aspects of life. In this present dispensation, nurses and other health care providers
have been trained to give maximum care to all patients that walk into any health care
facility regardless of what ethnic group or culture there are from. Nursing practice has
expanded even more and thereby embracing all varieties of people in order to give care,
thus, nurses needs to understand the impact of ethnicity as it relates to individual.
The diversity of ethnicity has made it possible that even when patients are told to
fill out the admission forms, there is a portion where one’s ethnic group is required. Most
times, it is necessary just to use in order to know how to better treat the patient.
INFLUENCE OF RELIGION
Religious and spiritual beliefs are important in many individuals’ lives. These
beliefs can influence attitudes, lifestyle, and feelings about life, pain and death. Some
6
religions specify practices about diet, birth control, and appropriate medical care. Often,
spiritual beliefs assume a greater significance at the time of illness than at other times in a
person’s life. These beliefs assist some people in accepting their illnesses and help
explain illness for others. Religion can both help people live fuller lives and console or
strengthen people during suffering and in preparation for death. According to Rosdahl,
“in the United States, 35,000 churches with 1,500 different identified sects exist. Because
the nurse will be caring for people of different faiths, he should learn about major
religious differences. By doing so, he will be better equipped to determine, with the help
of his clients, sources of spiritual and religious support” (Rosdahl, 2003, p. 94).
IT’S CONTRIBUTION TO THE HEALTH CARE
When caring for clients, nurses need to know that cultural and religious practices
are often connected. Many people eat specific foods in certain combinations or refrain
from eating certain foods because of their religious beliefs. Particularly when ill,
individuals are often unwilling to deviate from their religious dietary customs.
Furthermore, those who are injured or ill need reassurance, and they may talk to a
nurse about their illness and spiritual beliefs. As nurses you must, respect their
confidences and maintain a nonjudgmental attitude. Suggest a visit from a spiritual
leader, but do not contact such a person without first asking if the client wants such
counsel.
Finally, you will want to consider your personal values when seeking a nursing
position after graduation. Nursing offers a wide variety of job opportunities to the new
graduate. In choosing a job, you certainly cannot expect to avoid all conflict or problem
situations, but you will want to avoid working in an area where there is constant conflict.
Before you accept a position, you may want to consider whether it has the potential to
conflict with your basic beliefs. For example, if you are ethically opposed to abortion, it
would be wise to avoid employment on an obstetric unit or in a community clinic where
therapeutic abortions are performed routinely. In this situation, making your views
known and refusing certain assignments after you begin employment might result in
termination because the employer may justifiably assert that you agreed to fulfill all the
responsibilities of the position when you accepted employment. If you strongly value
7
your own ethnic or cultural approach to health care, you might choose to work in a health
care setting where that approach is part of the philosophy.
ASPECTS OF SOCIALIZATION
As with many other professional disciplines, nursing is a profession where
socialization is a part of everyday nursing care. According to Blais et. al., “professional
socialization is associated with the specialized knowledge, skills, attitudes, values, and
norms needed to perform the Professional role” (Blais et. al, 2005, p. 13). Therefore, as
future nurses, we should consider the socialized aspect of nursing because it creates an
impact on the delivery of nursing care for the patient. The two major aspects of how
socialization contributes to health and health beliefs of patients and nursing practice are
the following: current nursing shortage and public image of nursing.
The shortage of nursing has become a current trend within the past couple of years
where there are not enough nurses in the workforce. Because of the shortage, attempts to
relieve this trend by creating more accelerated nursing programs and hiring nurses
outside the United States are not enough interventions to relieve the burden of the
shortage (Chitty & Black, 2007). In addition, the shortage of nurses plays a role in
providing patient care. According to Chitty & Black, recent studies have indicated that
“the impact of the nursing shortage on patient outcomes affects quality of care...[and
found that] the ability of nurses to maintain patient safety was a problem…[while] the
shortage had impacted the amount of time the nurse could spend with patients”(Chitty &
Black, 2007, p. 64). Therefore, it is imperative to think about ways in which we, as
future nurses, can overcome this problem so that we can efficiently provide the best care
that our patients deserve.
One of the unique characteristics of the nursing profession is the privilege to wear
uniforms. However, over the past couple of years, there have been unlicensed assistive
personnel that also use similar uniforms as nurses which make it difficult for patients to
differentiate one who is a nurse and one who is not. According to Chitty & Black, “…a
part of nursing’s identity problem is attributable to the disappearance of the traditional
dress mode” (Chitty & Black, 2007, p. 49). In other words, currently is not a universal
dress code for nurses which create a problem because not everyone who wears scrubs to
work is a licensed professional. Therefore, it is important to reestablish a universal dress
8
code for nurses so that patients can easily identify nurses and make nursing what is
should be: a recognizable profession.
Identifying the Potential Problems Areas in Communicating and
Working Across Cultures
The number one potential problem in communicating is the language barrier.
They are also other factors, including age, attention, gender, prejudice, stereotyping, and
ethnocentrism that influence communication as well.

Age, the very young or old clients may be unable to communicate fully because
of physical or intellectual development. Attention, a lack of concentration can
occur.

Gender, a male or female client may feel uncomfortable speaking to a member of
the opposite sex.

Prejudice, stereotyping, and ethnocentrism are based on the person feelings and
beliefs at the time of communication.
The nurse and the client may speak a different language. In addition, many clients
regressed to their primary language when they are ill, and even though they speak a
second language, they feel more comfortable communicating in their primary language.
They are many ways of facilitating communication and breeching this barrier. The most
common is the use of a professional interpreter.
The interpreter should have several qualities. The interpreter should.

Know and understand medical language.

Should know the formal slang, and conversational levels of the language that
he/she is interpreting.

Should be able to communicate without inferring judgment, bias, or personal
opinions. A family member can act as an interpreter as well. However, the nurse
must realize that having a family member interpret, compromises the client
confidentiality. For this reason, a bilingual nurse who is familiar with the client’s
cultures and practices can also act as an interpreter.
9
In nursing, an interview is the communication technique used in evaluating if the
client understands his/her health concerns. Therefore, therapeutic communication is
necessary. Here are some therapeutic techniques used during communication.
Nonverbal Technique: Maintaining an openly accepting facial expression, or mirroring
what the client says or does. This indicates to the client something about the nurse.
Use of Silence: Silence gives the nurse and the client an opportunity to collect their
thoughts and prepare to continue the conversation.
Clarification: Is necessary if the client answers a question and the nurse does not
understand the answer.
Reflection: The nurse echoes the client’s words, this allows the client to hear what he/
she has just said. Speaking a different language may make communication difficult, but it
need not prevent interaction with others. A smile is understood in all cultures, and simple
hand signals can be used to communicate needs.
Here are some practical solutions to English language barriers the nurse can use
when working across cultures in clients that are not English speaking.

Learn a second language, especially one that is spoken by a large ethnic
population serviced by the healthcare agency. Example, in Elmhurst Hospital, the
nurse could learn Spanish.

Construct a loose- leaf folder or file cards with words in one or more language
spoken by clients in the community.

Look at the client, not at the translator when asking questions, and listening to the
client’s response.
When English is a second language the nurse can

Determine if the client speak or read English or both.

Speak slowly not loudly, using simple words and short sentences.

Avoid using technical terms, slang or phrases with a double or colloquial meaning
like “do you have to use the john?”

Ask simple questions that can be answered by a “yes” or “no.”
10
As nurses we are responsible for becoming acquainted with predominant cultures.
Not just ours, or in our communities, but locally and globally as well.
Legislations and Resolutions Related to Issues on Cultural
Competency
The Culturally and Linguistically Appropriate Services (CLAS) standards
In year 2000, the U.S Department of Health and Human Services, Office of
Minority Health have developed and issued the Culturally and Linguistically Appropriate
Services (CLAS) standards to serve the following purposes:

Policymakers – to provide them reference standard to draft consistent and
comprehensive laws, regulations, and contract language – e.g. Federal, State
and local legislators, administrative and oversight staff, and program
managers;

Accreditation and credentialing agencies - to serve them guidelines in
assessing and comparing providers offer culturally competent services and to
assure quality for diverse populations – e.g. Joint Commission on
Accreditation of Healthcare; and

Organizations – to serve this as guidelines and making it as bases for selforganizational performance assessment and evaluation – e.g. National
Committee for Quality Assurance, professional organizations such as the
American Nurses Association, and quality review organizations such as peer
review organizations.
There are fourteen (14) CLAS established standards (see Appendix #1) and
these are organized into three themes as follows:
1. Standards 1-3 address culturally competent care
These standards ensure that every health care organization guarantee that all its
staff members respond to each client under their care in a culturally appropriate manner;
implement strategies to maintain a culturally diverse staff and have representative
leadership at all level of organization; and provide culturally and linguistically
appropriate continuing education and training programs.
11
2. Standards 4-7 address language competency
These standards provide that every health care organization offers and provides
appropriate language assistance services; put in place appropriate oral and written notices
of patients right to receive language assistance; involve only qualified interpreters and
encouragement of bilingual staffs; and make available easily understood patient-related
materials or post signage in languages of the commonly encountered groups.
3. Standards 8-14 address organizational support for cultural competence
These standards require that health care organization effect a written strategic
plan with the end in mind of providing clients culturally and linguistically appropriate
services; conduct ongoing organizational self-assessment about CLAS-related activities;
ensure that individual culturally relevant information are in place on health records;
maintain cultural profile and develop collaborative partnership with communities;
provision of culturally and linguistically sensitive conflict and grievances resolution
proceedings; and lastly, the encouragement to make readily available culturally relevant
information to the public.
Among the fourteen (14) CLAS standard are also three varying stringency types
of standards. These are as follows:
1. CLAS mandates are current Federal requirements for all recipients of Federal funds
(Standards 4, 5, 6, and 7)
2. CLAS guidelines are activities recommended by OMH for adoption as mandates by
Federal, State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12,
and 13)
3. CLAS recommendations are suggested by OMH for voluntary adoption by health
care organizations (Standard 14)
Title VI of the 1964 Civil Rights Act
Title VI of the 1964 Civil Rights Act implies that services provided with
funding from the federal government must be delivered without regard to race, color, or
national origin (HHS 2003). In order to satisfy with Title VI, a program, service or
agency whether public or private entities that receive federal financial assistance are
mandated by this law to provide linguistically accessible care to diverse populations at no
cost particularly the Limited English Proficient (LEP) individual – e.g. hospitals,
12
managed care organizations, state and local welfare agencies, physicians, and research
programs, services funded through Medicaid, Temporary Assistance for Needy Families
(TANF), the State Children's Health Insurance Program (SCHIP), Head Start, and other
programs for families and youth.
WHAT DOES IT MEAN TO BE CULTURALLY
COMPETENT?
According to the American Medical Student Association, cultural competency is
"a set of academic and personal skills that allow us to increase our understanding and
appreciation of cultural differences between groups”(American Medical Association,
2000, Cultural Competency in Medicine section, para. 9). Becoming culturally
competent is a developmental process and we will experience it through out the whole
nursing experience.
Culture is a predominant force in shaping behavior, values and institutions. Not
only do cultural differences exist, but they also impact health care delivery. Culturally
competent providers appreciate family ties and realize that they are defined differently for
each culture. Rather than being insulted by another culture's perspective, culturally
competent providers, should welcome collaboration and cooperation. For example, an
Amish woman refuses to take off her customary clothing and put on a hospital gown
before a diagnostic test, or the family from Somalia refuses to leave their child alone in
the hospital. Examples like these we have to keep in mind for the best delivery of care.
The Cultural Assessment
The cultural assessment is a tool to help nurses understand where patients derive
their ideas about disease and illness. Assessments help to determine beliefs, values and
practices that might have an effect on patient care and health behaviors. Although a
completely accurate assessment currently is underdeveloped, there are several areas to
consider when doing an assessment. They include:

level of ethnic identity

language and communication process

migration experience
13

self concept and self esteem

influence of religion/spirituality on the belief system and behavior patterns

views and concerns about discrimination and institutional racism

educational level and employment experiences

habits, customs, beliefs

importance and impact associated with physical characteristics

cultural health beliefs and practices

Current socioeconomic status.
It is impossible to know every cultural variation of the people for whom nurses
provide care, but the best way is to involve patient and their family in determining the
plan of care and to find an alternative that will be acceptable for that culture. All of these
will help us in developing cultural competency in this clinical area.
Conclusion: Final Thought
In wrapping up our discussion on how culture impacts the way in which nurses
should practice, it is important to remember how we can apply these thoughts and what
we contribute as future nurses to field of nursing in relation to culture, ethnicity, religion
and socialization, and how to deal with issues regarding these aspects of culture in the
workplace.
14
REFERENCES
Book Sources
Blais, K. K., Hayes, S. J., Kozier, B., & Erb, G. (2006). Professional Nursing Practice
Concepts and Perspectives (5th ed.). Upper Saddle River: Pearson Education
Inc., 13
Chitty, K. K., & Black, P. B. (2007). Professional Nursing Concepts & Challenges
(5th ed.). St. Louis: Saunders, 49, 64
Kurzen, CR. (2004). Contemporary Practical/Vocational Nursing (5th ed.). Philadelphia,
PA. J. P. Lippincott Company
Rosdahl, C.B., & Kowalski, M.T. (2003). Textbook of Basic Nursing (8th ed.).
Philadelphia: Lippincott Williams & Wilkins, 94
Internet Sources
American Medical Student Association. (2008). Cultural Competency in Medicine.
Retrieved January 20, 2008 from http://www.amsa.org/programs/gpit/cultural.cfm
United States. Department of Health & Human Services. The Office of Minority Health
(2007, November) What is Cultural Competency? Retrieved January 17, 2008
from http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=11
15
APPENDIX
The Culturally and Linguistically Appropriate Services (CLAS) Standards
There are fourteen (14) CLAS established standards and these are organized into three (3)
themes as follows:
1. Standards 1-3 address culturally competent care

Standard 1. Health care organizations should ensure that patients/consumers
receive from all staff member effective, understandable, and respectful care
that is provided in a manner compatible with their cultural health beliefs and
practices and preferred language.

Standard 2. Health care organizations should implement strategies to recruit,
retain, and promote at all levels of the organization a diverse staff and
leadership that are representative of the demographic characteristics of the
service area.

Standard 3. Health care organizations should ensure that staff at all levels and
across all disciplines receive ongoing education and training in culturally and
linguistically appropriate service delivery.
2. Standards 4-7 address language competency

Standard 4. Health care organizations must offer and provide language
assistance services, including bilingual staff and interpreter services, at no cost
to each patient/consumer with limited English proficiency at all points of
contact, in a timely manner during all hours of operation.

Standard 5. Health care organizations must provide to patients/consumers in
their preferred language both verbal offers and written notices informing them
o f their right to receive language assistance services.

Standard 6. Health care organizations must assure the competence of language
assistance provided to limited English proficient patients/consumers by
interpreters and bilingual staff. Family and friends should not be used to
provide interpretation services (except on request by the patient/consumer).

Standard 7. Health care organizations must make available easily understood
patient-related materials and post signage in the languages of the commonly
encountered groups and/or groups represented in the service area.
3. Standards 8-14 address organizational supports for cultural competence (UMCC
2005).
16

Standard 8. Health care organizations should develop, implement, and
promote a written strategic plan that outlines clear goals, policies, operational
plans, and management accountability/oversight mechanisms to provide
culturally and linguistically appropriate services.

Standard 9. Health care organizations should conduct initial and ongoing
organizational self-assessments of CLAS-related activities and are encouraged
to integrate cultural and linguistic competence-related measures into their
internal audits, performance improvement programs, patient satisfaction
assessments, and outcomes-based evaluations.

Standard 10. Health care organizations should ensure that data on the
individual patient’s/consumer’s race, ethnicity, and spoken and written
language are collected in health records, integrated into the organization’s
management information systems, and periodically updated.

Standard 11. Health care organizations should maintain a current demographic
cultural, and epidemiological profile of the community as well as a needs
assessment to accurately plan for and implement services that respond to the
cultural and linguistic characteristics of the service area.

Standard 12. Health care organizations should develop participatory,
collaborative partnerships with communities and utilize a variety of formal
and informal mechanisms to facilitate community and patient/consumer
involvement in designing and implementing CLAS-related activities.

Standard 13. Health care organizations should ensure that conflict and
grievance resolution processes are culturally and linguistically sensitive and
capable of identifying, preventing, and resolving cross-cultural conflicts or
complaints by patients/consumers.

Standard 14. Health care organizations are encouraged to regularly make
available to the public information about their progress and successful
innovations in implementing the CLAS standards and to provide public notice
in their communities about the availability of this information.
17