Moving Beyond Culture in Health Assessment

As healthcare professionals, nurses have power. You have power.

If not applied carefully, this professional power can make clients feel marginalized or dismissed. In recent years, progressive developments in theoretical perspectives have guided nursing practice toward more humanistic care and considerations for marginalized clients and communities. New concepts have been introduced to help inform clinical judgement, honour the cultural values/beliefs of clients, and support therapeutic relationship building. These concepts include: cultural sensitivity, cultural competence, cultural humility, and cultural safety. They have helped clarify how personal biases can influence health assessments and other nursing interventions, and have also helped many nurses learn how to minimize their own biases.

Culture can be defined as the beliefs, practices, and values of a racial/ethnic group; it can also include other dimensions such as gender, sexual orientation, ability/disability, age, class, and language (Greene-Moton & Minkler, 2020; Hughes et al., 2019).

Reflect on each client’s culture:

• What are their cultural beliefs, values, and identity?
• What should you do once you are aware of a client’s culture and cultural differences?
• Most importantly, can this understanding of culture help you conduct an inclusive health assessment?

The following discussion explores these questions, beginning with an exploration of how four main concepts of culture relate to health assessments.

Cultural Sensitivity

• In nursing, cultural sensitivity focuses on self in terms of the nurse’s awareness and understanding of a client’s culture as well as attitude toward culture (Srivastava, 2007).
• Cultural sensitivity, therefore, largely rests on the nurse’s ability to be compassionate, considerate, and understanding of clients, including effective communication with clients from different cultures (Foronda, 2008).

Cultural Competency

• In the past, cultural competency has been narrowly operationalized as a checklist of cultural knowledge required by healthcare providers to demonstrate competence when working with various racial and ethnic groups (Curtis et al., 2019; Greene-Moton & Minkler, 2020).
• A nurse who is culturally competent is able to provide effective care to clients from different cultural backgrounds (Sharifi et al., 2019).
• However, if you do not know the cultural beliefs and practices of an ethnic group, does that make you culturally “incompetent”? This kind of ambiguity in the concept of cultural competency has led to the urgency of other effective frameworks for nurses to use, including cultural humility and cultural safety.

Cultural Humility

• Cultural humility is a life-long process of reflection and self-critique in addressing power imbalances within systems to develop mutually beneficial partnerships and relationships (Tervalon & Murray-Garcia, 1998).
• Healthcare professionals should engage in continuous, critical reflection on power and privilege, and find ways to interact with clients of different race, sex, gender, age, and ability that don’t perpetuate oppression.
• It involves being able to “humbly” recognize and be open to the idea that you are a learner as related to understanding a patient’s experience (First Nations Health Authority, n.d.).

Cultural Safety

• Cultural safety requires that nurses recognize power differentials and broader social structures that affect health equity (Curtis et al., 2019).
• Nurses must challenge power imbalances in client care, considering the effects of oppression on health (Parisa et al., 2016).
• Culturally safe practice is essential in addressing health and social disparities and inequities, to ensure equitable and client-centred care.

Integration of Concepts

Nurses can apply these four concepts of culture to understand cultural differences and embrace respectful ways of interacting with clients from different cultural backgrounds. This can be a starting point for broader considerations of historical, social, economic, and political factors that also shape health inequities (Smye & Browne, 2002).

Despite the large body of theoretical work on culture and safe practices, many healthcare professionals continue to be intolerant of differences. So, beyond an understanding of culture, what else is needed for nurses to uphold all the elements of social justice in nursing care broadly and in health assessments specifically?

The next section explores how you can apply an anti-oppressive perspective to ensure health assessments are inclusive. This involves confronting and dismantling oppressive practices that are accepted as the status quo in health assessments and the healthcare system more broadly, especially in the care of marginalized groups.

Activity: Check Your Understanding

References

Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18(1), 174–174. https://doi.org/10.1186/s12939-019-1082-3

First Nations Health Authority (n.d.). #itstartswithme: Creating a Climate for Change. https://www.fnha.ca/Documents/FNHA-Creating-a-Climate-For-Change-Cultural-Humility-Resource-Booklet.pdf

Foronda, C. L. (2008). A concept analysis of cultural sensitivity. Journal of Transcultural Nursing, 19(3), 207-212. http://doi.org/10.1177/1043659608317093

Greene-Moton, E., & Minkler, M. (2020). Cultural competence or cultural humility? Moving beyond the debate. Health Promotion Practice, 21(1), 142–145. https://doi.org/10.1177/1524839919884912

Hughes, V., Delva, S., Nkimbeng, M., Spaulding, E., Turkson-Ocran, R.-A., Cudjoe, J., Ford, A., Rushton, C., D’Aoust, R., & Han, H.-R. (2020). Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. Journal of Professional Nursing, 36(1), 28–33. https://doi.org/10.1016/j.profnurs.2019.06.005

Parisa, B., Reza, N., Afsaneh, R., & Sarieh, P. (2016). Cultural safety: An evolutionary concept analysis. Holistic Nursing Practice, 30(1), 33–38. https://doi.org/10.1097/HNP.0000000000000125

Sharifi, N., Adib-Hajbaghery, M., & Najafi, M. (2019). Cultural competence in nursing: A concept analysis. International Journal of Nursing Studies, 99. https://doi.org/10.1016/j.ijnurstu.2019.103386

Smye, V., & Browne, A. J. (2002). “Cultural safety” and the analysis of health policy affecting aboriginal people. Nurse Researcher, 9(3), 42–56. https://doi.org/10.7748/nr2002.04.9.3.42.c6188

Srivastava, R. (2007). The healthcare professional’s guide to clinical cultural competence. Mosby Elsevier.

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/10.1353/hpu.2010.0233