Culture is a term that incorporates concepts of race, ethnicity, religion, language, and other factors. The ability to provide culturally congruent care is referred to as cultural competence. The Institute of Medicine (2009) defines cultural competence as, “a defined set of policies, behaviors, attitudes, and practices that enable individuals and organizations to work effectively in cross-cultural situations (p 80). According to the Institute of Medicine (IOM) 2009, cultural competence gives individuals the ability to have appropriate and congruent policies, behaviors, attitudes, and best practices for individuals to address the complexity of tailored medicine to include diverse values, beliefs, and varied behavior patterns in particular groups. It is the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring of delivery to meet patients’ social, cultural, and linguistic needs” (Finkelman & Kenner, 2009).
Cultural competence is a fundamental principle that should be addressed with each patient interaction by health care professionals. Assessment and care of individuals and their families creates a positive nurse-patient relationship that individualizes care that can be family-centered and motivational. Racial and ethnic health disparities can be reduced by providing cultural competent care. According to American Institutes for Research (2002), good health is connected with an individual’s socio-economic status, environmental factors, ethnicity, and gender, (U.S. Department of Health and Human Services, (DSHS); Office of Minority Health (OMH, 2002). Access to healthcare is a barrier that is influenced by cultural, social, economic, and language differences. Patients are not likely to comply with treatment decisions of providers if they don’t understand the rationale or have conflicting health beliefs. Effective communication is essential for removing some of these barriers that will allow for patient centered care and to improve the quality of health care that is delivered to patients and families.
At the end of life, culture may influence decision making around the management of symptoms, preferences for treatment options, and life-sustaining measures, as well as communication with providers, and level of trust and satisfaction of care. The American Association of colleges of Nursing (AACN) recommends fifteen competencies for nurses to provide high-quality care to patients during the transition at the end of life (2008). It is the responsibility of the nurse to consider his or her own cultural beliefs and recognize one’s own attitudes, feelings, values, and expectations about death.
Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of “bad news”; locus of decision making; and attitudes toward advance directives and end-of-life care (Searight & Gafford, 2005). While most patients rely on professional opinion to determine the course of medical care, culture and end of life issues present a unique barrier for the provider. It is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient (Searight & Gafford, 2005). From a western perspective, concealing a diagnosis or withholding treatment options from a patient violates the medical code of ethics. The United States and western medicine emphasizes patient autonomy and self-determination, no matter the prognosis of the disorder versus some cultures that view this as bad karma.
Cultures share the fear and sadness that come with a diagnosis of a terminal disease; however, cultures are very different in how one responds to end-of-life issues. Research has demonstrated that a patient’s reaction to pain is very much engrained in their beliefs, for example, the Hispanic male culture will downplay pain as to not seem macho (Dennis & Duncan, 2012). Another example is at the time of death individualistic cultures prefer to be informed of changes in status so they can prepare spiritually, whereas collectivist cultures will not (Dennis & Duncan, 2012). Exploration of cultural differences is imperative because identifying influences on end-of-life decisions improves the perceived and actual care of patients and families (Bullock, 2011).
Little is known about what interventions are effective in developing clinician’s skills to deliver culturally sensitive end-of-life care. Halm, Evans, Wittenberg, & Wigus (2012) describe the core principles that have been established and adopted by numerous professional organizations in the United states, which include “respect the dignity of both patient and caregiver; be sensitive to patients’ and families’ wishes; use appropriate measure that are consistent with patient choices; assess and manage psychological, social, and spiritual problems; provide access to any therapy; and respect the right to refuse treatment” (p. 336). Halm et al. (2012) performed a 2-stage educational program on end-of-life care beliefs, practices, and preferences of the Latino, Russian, and Micronesian cultures. The researchers in this study found was that the program was not only successful in improving individual perceptions of their own understanding of end-of-life beliefs, values, and preferences of the Latino, Micronesian, and Russian cultures, but also their effectiveness in providing culturally sensitive end-of-life care for patients and families. This study provides evidence that health care professionals must be knowledgeable with specific cultures and also take into consideration individual preferences in order to be effective with providing culturally competent life care.
Goals and Objectives
The purpose of this course is to facilitate student learning and acquisition of a foundation of culturally competent care. A cultural competence course complies with the recommendations from the IOM (2009) and essentials of Baccalaureate education by AACN (2008). The course is designed to assist students in a successful achievement of NCLEX-RN examination competencies. Psychosocial Integrity category comprises 6-12% of the content for the NCLEX-RN examination and includes sub categories of cultural awareness and influences on health, end of life care, family dynamics, grief and loss, religious and spiritual influences on health, and therapeutic communication (NCSBN, 2012).
At the end of this course the participant will be able to:
Define and identify components of an advanced directive and when this is completed for all patients. Describe the process of administering advanced directives and locate a patient’s advanced directive on the unit.
Identify cultural competence and educational resources to facilitate effective communication with patients and caregivers based on assessments during care provided.
Be aware of one’s own beliefs, values, and attitudes on death and dying and identify barriers that would impede caring for an individual whose values, attitudes, and beliefs are different than one’s own.
Perform a cultural assessment on a patient whose culture is different than one’s own and based on cultural knowledge gained.
Methods and Population
The clinical course will consist of second year Baccalaureate Nursing students on a palliative care oncology unit in a culturally diverse setting. The palliative care unit provides the students with a vulnerable population and further emphasizes the diversity of care.
The course will begin with utilization of an experiential learning process. During a pre-clinical conference, student will actively engage with each other on individual/group assessment and determination of cultural views and beliefs in regards to the death and dying process. This exploration will provide insight as the students recognize learned behavior from past experiences. As the clinical instructor I will facilitate the group discussion and guide students into verbalizing a strategy on how to provide care to a patient that has a different set of views, values, and beliefs.
Each student will provide care to a patient whose culture and ethnicity is different than their own. If at all possible, clinical assignments will be given based on the student’s prior knowledge to that specific culture and ethnic background. If this becomes a barrier, research time will be allotted during the clinical day prior to care actually being conducted. A comprehensive psychosocial assessment will be conducted by the student and will include questions about the patient’s culture, beliefs, family values, religion, social behaviors, and spirituality just to name a few. Each student will educate their patient on advanced directives using culturally competent care and language barrier resources. Students will create a culturally competent care plan that includes how care is delivered and communicated. During this time students will have access to unit resources for communicating with those that have a language barrier and internet access for researching cultural differences.
As the clinical instructor, I will provide a rubric for the nursing care plan that will evaluate the integration of family theory, culturally competent practices, analysis of patient specific situations, application of the nursing process, patient and family involvement in the collaborative team decision regarding care, and overall performance during clinical day. Formative evaluations will occur at 2 hour intervals throughout the clinical day. Students will have the opportunity to ask questions and be self-directed in learning needs with clinical resources.
Prior to dismissal at the end of post conference, she students will evaluate learned behavior by completing a detailed description of knowledge obtained. A clinical evaluation will include whether or not the objectives were met and which or activities helped them to meet the objectives.
I will review the evaluations and determine what changes I will make for the next group of students who enroll in my clinical course.
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