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Lippincott Nursing Pocket Card - November 2024

Cross-Cultural Nursing Considerations

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Background

  • Within the practice setting, nurses inevitably provide direct care to patients of varied ages, races, ethnicities, and cultures.
  • The historical one-size-fits-all approach in healthcare resulted in negative health disparities, mistrust of the healthcare system, and poor health outcomes amongst minorities and other marginalized groups. 
  • In the U.S., our modern system of healthcare delivery continues to struggle with inequity due to:
    • barriers to effective clinician-patient interactions (e.g., language and literacy issues)
    • systems barriers (e.g., lack of interpreter services or ethnically diverse clinicians)
    • clinician biases
  • With nurses providing high-quality care to an increasingly diverse population, it’s vital for nurses to effectively communicate, build trust, and reach patients across barriers. 

Cross-cultural Care

Each patient is unique, influenced by cultural and social determinant factors such as race, ethnicity, geography, education, income, religion, sexual orientation, and gender identity or expression (Betancourt, Green & Carrillo, 2024). Cultural competence includes respect for people, families, and societies while acknowledging their values, preferences, and expressed needs (Mbango, 2023). Cross-cultural care focuses on the ability to effectively communicate and provide quality health care to all.

Culture
  • Groups use shared customs, beliefs, rules, and values to interpret their experiences and direct their behavior patterns. 
  • An individual’s identified culture shapes their health-related beliefs and affects their experience of the health care system.
 
Misconceptions
  • Traditionally, teaching cultural competency in nursing focused on understanding the norms of a particular culture, as a means to provide culturally sensitive care. This was both impractical and misguided. 
  • The concept of cultural competency oversimplifies large cultures by not taking into account the great variation that exists within cultural groups such as Americans, Europeans, or Latin Americans.
 
Encounter dynamics
  • Three unique cultural perspectives intersect during every healthcare encounter:
    1. The culture of medicine (e.g., belief in scientific evidence and respect for patient autonomy)
    2. The culture of the bedside caregiver (e.g., inherent bias and communication style)
    3. The culture of the patient (e.g., language, norms, beliefs, family support structure)
  • To effectively manage this intersection, caregivers must exhibit respect, empathy, and curiosity as they seek to understand the patient’s perspective and experience.
  • Sociocultural differences between bedside caregivers and patients influence communication and decision-making, with evidence suggesting good communication between patients and caregivers can improve satisfaction, adherence, and health outcomes (Betancourt, Green & Carrillo, 2024). 

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Best Practices

Contemporary methods

  • Components of cross-cultural care include (Betancourt, Green & Carrillo, 2024):
    • The use of interpreters
    • Familiarity with differences in disease epidemiology
    • Comfort in working with patients who are culturally different than oneself
  • Perspective-taking encourages caregivers to consider the patient’s unique sociocultural background, as it may affect:
    • How they present their symptoms (stoic versus emotive)
    • Their threshold for when to seek care (proactive versus reactive)
    • Comprehension of care strategies (limited versus deep health literacy)
    • Expected outcomes of care (holistic/therapeutic versus medical/diagnostic)
    • Likelihood of adherence or compliance with preventive measures, medication regimens, follow-up, and inclusion of alternative modalities
  • There is no single superior paradigm for providing appropriate and meaningful culturally-sensitive care to patients. One method often used is the patient-based approach which includes four basic components:
    • Assessing core cultural issues including styles of communication, trust, decision-making and family dynamics, traditions and spirituality, and sexual/gender issues.
    • Exploring the patient’s understanding of the illness: its cause, meaning, and consequence.
    • Social context such as change in environment (e.g., migration), literacy and language, life control, stressors, and support.
    • Negotiating a mutually acceptable approach to treatment.
  • Available research supports the education of bedside caregivers in cross-cultural care to maximize patient outcomes.
  • Caregivers who acknowledge and respect sociocultural differences show improved attitudes toward patients, with more respectful and effective communication patterns. 
  • Acknowledging the historical racial, gender, social, and ethnic disparities endemic in the healthcare system can lead to more meaningful and effective clinical encounters for both clinicians and patients.
  • Consider recruiting health professionals from underserved, diverse, and LGBTQ+ communities.

Communication Pearls

  • Current research supports a balanced approach to communication, building trust with patients, and acknowledging differences to transcend them.
  • The following are core cross-cultural issues to address with patients navigating the healthcare system:
    • Communication styles
    • Prejudices and mistrust
    • Family dynamics and decision-making
    • Traditions, customs, and spirituality
    • Gender and sexuality 
  • Time constraints are often a barrier to effective cross-cultural nursing, as it takes time to fully assess and establish a trusting relationship with new patients.
  • Use interpreters to assist patients with limited English-language proficiency.  
    • Remember to address the patient, not the interpreter.
    • Be aware of nonverbal communication such as eye contact, touch, body language, and personal space.
      • Direct eye contact is a sign of respect in some cultures but might be avoided in others.
    • Position the interpreter so that everyone can see one another.
    • Avoid medical terminology and acronyms.
    • Instruct the interpreter to alert you if they perceive any communication issues.
    • Keep questions short and ask one at a time.
    • If interpreter services are not available, use online tools such as Google Translate or Medibabble if interpreter services are unavailable (Al Shamsi et al., 2020).
  • Routinely assess for understanding, utilizing a teach-back technique.
  • Ask patient about their desired level of family involvement in their decision-making, respecting their autonomy and their possible desire to include family members or defer to their choices.
  • Use open-ended questions to elicit patient and family input and be willing to incorporate preferred modalities and treatments as appropriate.
  • Discuss religious beliefs and spiritual concerns, focusing on customs that may affect diet, health care, and treatments (e.g., blood transfusions).
  • Be aware, sensitive, and nonjudgmental of how your patient and family members view gender roles.
    • Obtain information on sexual orientation using open-ended questions and gender-neutral terms.
    • Ask patients about the sex/gender of their sexual partners rather than how they identify.
    • Use appropriate terminology for patients’ gender identity.
    • Ask new patients what pronouns they use.
  • Alternative therapies and treatments should be considered as adjuncts to care and included whenever possible per patient and family wishes.
  • Assess how patients’ socioeconomic status affects their medical decision-making, and offer affordable treatment strategies when possible.
References:
Al Shamsi, H., Almutairi, A. G., Al Mashrafi, S., & Al Kalbani, T. (2020). Implications of Language Barriers for Healthcare: A Systematic Review. Oman medical journal, 35(2), e122. https://doi.org/10.5001/omj.2020.40

Betancourt, J.R., Green, A.R., & Carrillo, J.E. (2024, August 29). Cross-cultural care and communication. UpToDate. https://www.uptodate.com/contents/cross-cultural-care-and-communication

Mbango C. (2023). Incorporating global and cultural competencies in nursing education. Nursing, 53(2), 15–17. https://doi.org/10.1097/01.NURSE.0000902952.48970.b9 
 
 

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