Why is a basic understanding of ethnopharmacology part of being a culturally competent nurse?

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Reducing health disparities and achieving equitable health care are vital objectives for the United States healthcare system. Cultural competence is viewed as a “foundational pillar for reducing disparities through culturally sensitive and unbiased quality care” (Agency for Health Care Research and Quality, 2014, p. 1). Culturally competent care respects diversity, while considering factors such as language, communication styles, attitudes, beliefs, and behaviors that attribute to health and wellness (Agency for Health Care Research and Quality, 2014). The purpose of this paper is to suggest the use of a framework to help student nurses understand cultural awareness and to stimulate through self-reflection their examination of values and actions promoting culturally competent care.

Standards for Culturally Competent Care in
Nursing Education
The nursing profession has supported the importance of culturally driven health care. The Commission on Collegiate Nursing Education (CCNE, 2008) suggests that diversity education in nursing programs is the first step in preparing a nursing workforce that can provide compassionate, culturally safe care to diverse individuals and populations. The National League for Nursing (NLN) states that nursing faculty must make preparing competent and culturally safe student nurses a priority in curriculum design and implementation (2012).

Most nursing programs have heeded the call for culturally competent nurses and address this importance in college and program mission statements or course outcome statements. Additionally, accrediting bodies and approval boards such as the American Association of Colleges of Nursing (AACN, 2008) and the NLN (2012) have expectations that culturally sensitive care is included in curricula. Despite the call, there is conflicting and limited research to help us determine which are the best methods to teach cultural diversity to the next generation of nurses.

Student nurses’ perceptions of cultural diversity are frequently influenced by society’s definitions of these topics. These are often related to shared patterns of values and learned behaviors that have transferred over time. Student nurses’ ideas are based on multiculturalism and celebration of diversity, as well as discouragement of discrimination and increased acceptance; but these societal definitions and personal values can mislead nursing students to accept culture as merely differences in practices or beliefs. These misunderstandings encourage student nurses to assume that groups can be objectively categorized or defined by a particular essence or practice instead of culture being defined as a dynamic and complex process. Student nurses recognize cultural world views at large but fail to appreciate specific social, historical, religious and ethnic experiences that play a unique role in determining the cultural needs of each individual (Vandenberg & Kalischuk, 2014).

The Transcultural Assessment Model: Six Dimensions
The Transcultural Assessment Model was developed in response to student nurses’ need to assess and design care for culturally diverse patients (Giger & Davidhizar, 2002). This model provides a framework that can be incorporated into nursing education curricula. The model assesses differences between individuals in cultural groups by inquiring about six cultural dimensions: communication, time, space, social organization, environmental control, and biological variations. This assessment framework can be utilized by student nurses to facilitate the design and delivery of sensitive care (Giger & Davidhizar, 2002).

Cultural awareness involves individuals exploring their own cultural and professional backgrounds while scrutinizing personal bias and understanding diversity issues in health care delivery (Sarafis & Malliarou, 2013). Cultural awareness is enhanced when student nurses use reflection to evaluate and understand their own values related to the Transcultural Assessment Model criteria (Thorpe & Loo, 2003). By reflecting on each of the dimensions, nursing students gain insight into more complete cultural care practices. Student nurses can understand and apply the dimensions more holistically if they have assessed each dimension in their own lives and formulate plans for culturally competent care through the use of ponder/focus questions (McClimens, Brewster, & Lewis, 2014).

Communication
For student nurses to deliver safe, culturally competent care, a mutual understanding of the patient’s cultural needs must be achieved through communication. Communication, verbal and non-verbal, account for a large portion of the cultural disconnect between student nurses and their patients (Momeni, Jirwe, & Emami, 2008). When communication barriers were present, patients often expressed concerns and fears of being misunderstood as well as a strong sense of insecurity during interactions with nursing staff (Cioffi, 2003). Nursing students may ask themselves these questions and formulate possible solutions: “Have I ever been misunderstood, either through spoken words or body language?” and “Have I ever been treated differently related to mental health or learning disabilities?”

Time
To understand individualistic views of culture, student nurses must assess patient views about passage of time, points in time, and duration of time. Many countries and cultures are oriented with a focus on the past. These cultures value tradition and doing things as their predecessors have done. This can lead to reluctance in accepting new technology or treatments. Some cultures stress the present and may seem relatively unconcerned with the future. These individuals may disregard preventative measures and may show up late or miss appointments (Giger & Davidhizar, 2004). Student nurses may question their personal and cultural views related to time: “Is the past, present, or future most important to me?” and “How does my view of time reflect in my personal heath choices?”

Space
Humans vary greatly in their comfort level related to personal space. Some of these spatial concerns are related to personal preferences, while others are a reflection of cultural principles. Student nurses must be aware of their patients’ comfort level related to body distance during conversation, proximity to family members, perception of space, eye contact, and personal and cultural touch practices (Giger & Davidhizar, 2004). Student nurses may question, “What is my personal comfort level related to touch, eye contact, and conversational distance?” and “Can I identify a situation where I was made uncomfortable by another individual related to my personal space?”

Social Organization
Humans often learn and adopt cultural beliefs through social organization. Individuals from culturally diverse backgrounds will all manifest different degrees of acculturation into the beliefs of their dominant culture. In some circumstances, cultural values stem from the opinion of elders or patriarchs, while others place value on position in family. In this context, student nurses need to factor in geography, socioeconomic status, religious affiliation, gender and sexual orientation, as well as age and life cycle status (Giger & Davidhizar, 2004). Student nurses could self-evaluate by pondering these questions: “What role do my parents and family member play in my beliefs?” and “Have my cultural views changed related to my current stage of life?”

Environmental Control
Environmental control can be explained in the patient’s ability, within their cultural system, to plan activities that control their environment as well as their perception of personal control over factors in the environment (Giger & Davidhizar, 2004). Examples of assessment factors which play a role in environmental control are locus of control, folk medicine, and health beliefs. Student nurses need to understand that these issues play an extremely vital role in the way patients define illness and wellness, utilize health care resources and respond to health associated experiences (Eggenberger, Grassley, & Restrepo, 2006). Questions that student nurses might ponder are: “Am I superstitious and do I believe that I am in complete control of my health and wellness?” and “What non-medical/alternative methods do I believe in and utilize to obtain health?

Biological Variation
When assessing a patient’s cultural underpinnings, biological variations need to be evaluated carefully to avoid stereotypes and discrimination. These factors include race, body structure, genetic variations, nutritional preferences and psychological characteristics (Davidhizar, & Giger, 2008). Nursing examples include diseases related to specific ethnic groups as well as rural versus urban health. Student nurses must remember the uniqueness of individuals and that a person’s association with an ethnic group does not mean that the individual patient will follow the socially accepted definition of his/her biological foundation (Vandenberg & Kalischuk, 2014). Questions that a nursing student might reflect upon with patients are: “What is an accepted stereotype related to your ethnic group that is not true about you?” and “What health care practice do you not participate in that most of your ethnic group does?”

Conclusions
As a challenging health care environment results from new technologies, scientific advances, and cultural diversity, today’s student nurses are faced with uncertainty, unknown boundaries and unfamiliar practice questions. It is crucial that student nurses understand their personal values, culture, and biases, as well as those of their occupation through knowledge and reflection of cultural assessment tools. This reflection will foster cultural awareness and promote competent practices that will allow student nurses to give safe, patient centered care (Leduc & Kotzer, 2009). Nursing curriculum that integrates cultural care theories and conceptual frameworks across the curriculum will give graduate student nurses the tools needed to tackle the challenge of reducing health disparity in the United States (AACN, 2008). Facilitating cultural competency through reflective awareness, empathy, active listening techniques, and appropriate theoretical frameworks can assist health care providers in delivering culturally safe care (Institute for Health Care Improvement, 2014).

 References
Agency for Health Care Research and Quality (2014). Improving cultural competence to reduce health disparities for priority populations. Retrieved from http://effectivehealthcare.ahrq.gov/ehc/products/573/1934/cultural-competence-protocol-140709.pdf
American Association of Colleges of Nursing (2008). Cultural competency in baccalaureate nursing education. Retrieved from http://www.aacn.nche.edu/leading-initiatives/education-resources/competency.pdf
Cioffi, R. N. (2003). Communicating with culturally and linguistically diverse patients in an acute care setting: Nurses’ experiences. International Journal of Nursing Students, 40(3), 299–306.
Commission on Collegiate Nursing Education. (2008). Standards for accreditation of baccalaureate and graduate degree nursing programs. Washington, DC: Author. Retrieved from http://www.aacn.nche.edu/Accreditation/pdf/standards.pdf
Davidhizar, R., & Giger, J. N. (2008). Understanding ethnopharmacology: Implications for cultural relativism. Journal of National Black Nurses’ Association, 19(1), 63–68.
Eggenberger, S. K., Grassley, J., & Restrepo, E. (2006). Culturally competent nursing care for families: Listening to the voices of Mexican-American women. The Online Journal for Issues in Nursing, (11)3. Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume112006/No3Sept06/ArticlePreviousTopics/CulturallyCompetentNursingCare.html
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McClimens, A., Brewster, J., & Lewis, R. (2014). Recognizing and respecting patients’ cultural diversity. Nursing Standard, 28(28), 45–52.
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Vandenberg, H., & Kalischuk, R. G. (2014). Conceptualizations of culture and cultural care among undergraduate nursing students: An exploration and critique of cultural education. Journal of Cultural Diversity, 21(3), 99–107.

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