culturally competent patient care advanced practice nursing

Culture in Advanced Nursing Practice
Abstract
Culturally competent nurses can assess the psychological, spiritual, physiological, social, environmental, and epidemiological data on a particular cultural group to provide culturally sensitive and patient-centered care. Since Madeleine Leininger first proposed that cultural competency was essential to nursing, various means of incorporating cultural learning and assessment have been incorporated into advanced nursing practice. Culture includes but is not limited to ethnic, linguistic, religious, and national heritage, and can also include subcultural domains, age, socioeconomic status, and political affiliations. Advanced practice nurses have a moral and legal obligation to provide culturally competent care, outlined in Standard 8 of the American Nurses Association (ANA) Standards of Practice. Cultural assessment strategies enable the advanced practice nurse to understand the complex intersections between health status, cultural needs, disease prevalence, spirituality, agency, and more.
Culturally Competent Advanced Nursing Practice
Since Madeleine Leininger first proposed that cultural competency was essential to nursing, various means of incorporating cultural learning and assessment have been incorporated into advanced nursing practice. Cultural competency is important in nursing because “culture affects people’s health and illness experiences as well as nursing care delivery,” (Wagner, 2019, p. 1). Cultural variables impact attitudes and social norms, values, beliefs, lifestyle habits, and more. Advanced practitioners need to remember that culture refers not only to ethnicity but also gender, religion, age, and other factors that impact healthcare attitudes, behaviors, beliefs, and expectations.
Cultural competency becomes relevant to advanced nursing practice on the individual level (such as nurses working with individual patients) and also on the organizational level (built into healthcare policy or institutional policies). For the advanced practice nurse, cultural competency involves self-efficacy along three primary dimensions: “cognitive, practical, and affective,” (Wagner, 2019, p. 1). The nurse practitioner asks the right questions, conducts research, and uses scholarly means to conduct cultural assessments of a particular patient population. Similarly, the advanced practice nurse reviews the literature for evidence-based practice models for working with specific patient populations in clinical care. Cultural competency also includes an affective domain, such as the cultivation of empathy, compassion, and understanding. For all nurse practitioners, cultural competency is an “ongoing process” that requires continual self-reflection (Wagner, 2019, p.1). Advanced practitioners need to formally assess cultural competency.
Cultural assessment strategies are used to detect biases or prejudices that might impact one’s ability to deliver clinical care, and also to know the best approaches to a given situation. Working with the patient, advanced practitioners can determine the patient’s need for familial and extra-familial social support and access to religious and spiritual practices. Cultural knowledge empowers the nurse to make recommendations and use communication styles conducive to patient satisfaction and quality of care. Rather than make assumptions based on stereotyped beliefs about a culture, the advanced practitioner asks the patient directly for input and clarification of needs. The variables of cultural assessment may include factors like communication, space, social organization, time, environmental control, and biological variations (Wagner, 2019). Furthermore, nurses may also want to assess culture along specific domains such as childrearing and parenting practices, marriage and other social contracts, rituals and rites, nutrition, engagement in high risk behaviors, family organization, workforce, and any other intersection between the individual and sociological institutions.
Various strategies can be used to assess the psychological, spiritual, physiological, social, environmental, and epidemiological data on a particular cultural group. Advanced practitioners keep in mind Standard 8 of the American Nurses Association (ANA) Standards of Practice covers Culturally Congruent Practice: that is, “nursing care that is in agreement with the preferred values, beliefs, worldview, and practices of the healthcare consumer,” (Marion, Douglas, Lavin, et al., 2016, p. 1). Nurse leaders create an organizational culture and climate conducive to cultural competency. It has been suggested that cultural competence is “learned over time and is a process of inner reflection and awareness,” (Young & Guo, 2016, p. 94). Regular staff meetings ensure that members of a healthcare team are providing culturally competent care collectively.
The essential features of cultural competence include awareness, skill, and knowledge (Young & Guo, 2016). Awareness includes self-awareness, such as cognizance of biases and beliefs that may impact attitudes towards a patient and that patient’s cultural background. However, awareness also includes awareness of patient needs based on thorough examination of the patient’s cultural background. Researchers also stress the importance of “realistic education and training techniques” for advanced practice nurses working in diverse environments (Young & Guo, 2016, p. 94). Nurses must take care to remember that for some patients, ethnic identity is salient, whereas for others, it may seem a distal aspect of identity. Empirical research has consistently demonstrated the inherent health-related value of having a strong ethnic identity, especially as a strong “protective factor against anxiety and depression” among African Americans (Williams, Duque, Wetterneck, et al., 2018, p. 312). An advanced nurse practitioner working with African American patients can rely on the litany of published knowledge to access information related to healthcare practices, beliefs, behaviors, and attitudes. Nurse practitioners are also urged to communicate directly with patients before making any assumptions based on the literature. After all, geography is also a factor that advanced practice nurses need to take into account. For example, research by Williams, Duque, Wetterneck, et al. (2018) showed that “higher levels of ethnic identity were present among African American in the South compared to other regions,” even when “controlling for gender, age, urbanicity, and years of education. (p. 312). Black Southerners were also less likely to seek professional help for several categories of mental illness including depression, anxiety, and obsessive-compulsive disorder (Williams, Duque, Wetterneck, et al., 2018). The diverse elements differentiating individuals or subcultures within a larger group such as African Americans shows that culture impacts attitudes towards aging and dying, central to many healthcare domains (Coats, Crist, Berger, et al., 2016). Thus, specific nursing care domains may require additional strategies for a cultural assessment of a patient population.
Culturally competent care covers psychological, spiritual, physiological, social, environmental, and epidemiological data as outlined by Spector (2016). As Spector (2016) shows, traditional definitions of health and illness, and also methods of health maintenance and protection may be idiosyncratic. Using empirical research to substantiate patient perceptions, astute self-awareness to impede the infringement of prejudicial beliefs, and by coordinating care with other members of the interdisciplinary or collaborative health care team, the advanced practitioner assures that all African American patients are given culturally competent care. To assess psychological data on African American patients, the advanced practitioner would read about the group but taking care to also factor variables such as gender, age, socioeconomic class, and geographic origin. Because spirituality is also individualized, the best strategy for assessing patient needs would be to ask direct questions, making note of conflicts between the patient’s religious and spiritual practices versus those of family members.
Assessing social and environmental variables is also important for advanced practice nurses. It is possible to talk with the patient and caregivers, as well as review the empirical literature on the intersections between social norms and healthcare and also between environmental factors and healthcare risks. Similarly, social and environmental variables might affect health status and lifestyle habits that impact the patient’s prognosis and ability to comply with suggested lifestyle changes. Epidemiological data would include all statistics related to disease prevalence within the African American community, specifically within the sub-group identified by the patient such as age-related or gender-based differences. The advanced practitioner must rely on scholarly databases to acquire such data.
Demonstrating cultural competency includes assessment of culture, using strategies that incorporate, recognize, and validate client beliefs and practices (“Cultural Awareness and Influences on Health: NCLEX-RN,” 2020). The advanced nurse practitioner identifies singular means of aligning a treatment plan with patient goals and objectives, respectful of diversity while still providing advice as to evidence-based practices. Doing research, working with colleagues, and actively engaging the patient and family members in the process of elucidating cultural differences in healthcare will promote improved patient outcomes and elevate patient perceptions of the quality of care provided.
References
Coats, H., Crist, J. D., Berger, A., Sternberg, E., & Rosenfeld, A. G. (2016). African American Elders’ Serious Illness Experiences. Qualitative Health Research, 27(5), 634–648. doi:10.1177/1049732315620153 
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Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, L., Bickford, C., (November 18, 2016) "Implementing the New ANA Standard 8: Culturally Congruent Practice" OJIN: The Online Journal of Issues in Nursing Vol. 22 No. 1.
Smith, L.S. (2018). A nurse educator's guide to cultural competence. Nursing Made Incredibly Easy 16(2): 19-23.
Spector, R.E. (2016). Cultural diversity in health and illness. 9th Edition
Wagner, J. (2019). Cultural competency. Medicine Libre Texts. Retrieved from: https://med.libretexts.org/Bookshelves/Nursing/Book:_Leadership_and_Influencing_Change_in_Nursing_(Wagner)/03:_Diversity_in_Health_Care_Organizations/3.04:_Cultural_Competency
Williams, M.T., Duque, G., Wetterneck, C.T., et al. (2018). Ethnic identity and regional differences in mental health in a national sample of African American young adults. Journal of Racial and Ethnic Health Disparities 5(2018): 312-321.
Young, S., & Guo, K. L. (2016). Cultural diversity training: the necessity of cultural competence for health care providers and in nursing practice. The health care manager, 35(2), 94-102.