Nursing students learn numerous facts about culture throughout their nursing education. These facts provide the foundation to understand the components of culture. However, facts often place patients and their respective cultures into a box, thereby failing to facilitate the idea that culture is fluid and includes many more aspects of a person besides language, religion, clothes, and food. In the fall semester of 2020, our group took the senior-level baccalaureate nursing course, "Cultural Competency in Health," which was offered within the RN-to-BSN program at Wittenberg University in Springfield, Ohio. This course taught us how to critically think about the components of culture instead of knowing just facts. It helped expand our understanding of culture, enabling us to facilitate change and improve our nursing care by being more culturally aware. Having completed this course, we can safely say that our understanding of culture and its importance in the delivery of patient-centered nursing care is much different now than it was earlier that semester.

Understanding one's culture

A key insight that we learned from the cultural competency course is the fact that no matter who you are or where you come from, we are all a part of some kind of culture. At the beginning of the course, many of us expressed the sentiment that we did not belong to a certain culture, or that we did not have a personal cultural influence on our lives. In our survey of the literature, however, we learned the importance of discovering and embracing our own cultural beliefs before we can appreciate those of other people.1

For us to learn more about ourselves, we were given the option to complete an online genealogy DNA test (and utilize cultural information provided through that forum), or to perform an analysis of our ancestors (as far back as possible) based on what we have been told by our family members. All students in the class opted for the online DNA test. Through this exercise, it was amazing to see our personal histories unfold before our eyes. Many of us were able to make connections between what traditions our families carry out today and the cultures from which it appears that we came. This exercise helped us determine that culture is less of a tangible thing and more of a way of being that represents what one values.2 People are born surrounded by certain aspects of culture that they can choose to accept or reject later in life if they feel that culture is imposed upon them. Throughout a lifetime, they can develop and choose other meaningful things to incorporate into their personal culture. For us, culture is representative of how one chooses to live their life and present themselves to the world.

Providing culturally congruent care

Having recognized that everyone is a part of at least one culture (and usually many, many more), we determined that healthcare workers are in the unique position to be surrounded by groups with cultures that others may not understand or even notice. For example, in Dopesick by Beth Macy, the author talks about the opioid epidemic and how people with this lifestyle have developed their own culture, troubling as it may be to others.3 Another example is how we, as nurses, must choose to accept people for who they are; this is part of the culture of our profession. This way of being allows us to foster therapeutic relationships and provide the best care possible by being nonjudgmental and unbiased when we walk into each patient's room. This understanding was enhanced when our class watched the documentary The American Nurse, which follows the experiences of nurse Tonia Faust, a director of a hospice program for incarcerated individuals.4 Faust notes in the documentary that she doesn't want to know what the inmates did to be sentenced to prison; she looks beyond their past and simply wants to help provide dignified and compassionate care for the dying.

Nurses must keep an open mind about diversity and refrain from making assumptions about someone's culture. In our class, we discussed the importance of culturally congruent care, which means giving the best individualistic care aligned with the patient's personal beliefs and practices. This phrase arose during a discussion on whether healthcare providers can ever truly be competent in all cultures. Our group concluded that while it may be impossible to be completely competent in that venue, it is very plausible to be congruent or in alignment with what patients value. We have learned that the most important way to provide the best culturally congruent care we are able to give is to simply listen to our patients. Some patients may be able to readily identify cultural beliefs, preferences, and needs when asked. Others may not understand the width and breadth of their cultural identity and are unable to provide the nurse with a quick answer. In this case, being ready with specific questions to ask the patient can be very helpful. For example, ask about their health practices, food preferences, beliefs about medication or surgery, who they consider "family," thoughts on who should be involved in their care, how they choose to spend their time, and what gives their life meaning.

We have learned more fully that once you understand the cultural needs and desires of your patient, it is your responsibility to respect those needs and desires and advocate for them by ensuring other healthcare providers respect them as well. With diverse communities across the globe, it is no longer a choice to be culturally congruent; it is an expectation of care.5 Especially when working in a very diverse area, it is important to provide this care and help others understand the need for culturally congruent care. As nurses, we teach one another how to be culturally congruent through experiential learning. This is not something that can be boiled down to a set of bullet points or rules; it is something we learn through real-world experience and from watching others provide culturally congruent care. As nursing students, we have learned this from our nursing mentors and professors. We have embraced that it is now our responsibility and privilege to model and share this "way of being" with other nursing students and coworkers.

Recognizing self-biases and other strategies

In order to provide the best culturally congruent care possible, we recommend to first examine yourself and your own beliefs. It is critical to know oneself before being able to know and appreciate others. We found it helpful to take some of the Project Implicit(R) Implied Association Tests available online and reflect on the implications of the results.6-8 Challenge yourself to confront your biases, recognizing that everyone has inherent biases even if they do not knowingly act on them. Mindfully work to overcome biases and actively advocate for positive change in your workplace. Consistently ask each patient what they need and want in order to give them the best personalized care. Practice different ways to ask these types of questions so you can feel comfortable including this assessment in all your patient encounters. We also recommend familiarizing yourself with available resources that support culturally congruent care. Mentally add these resources to your database of ways to provide exceptional care and use them frequently as appropriate. Finally, be a role model by respecting each patient and the unique life experience that they bring to the nurse-patient relationship. Consistent appreciation for the human experience reminds us of our duty to show respect and compassion for every patient. Others will benefit from your example and hopefully use that learning to grow personally and professionally. Multiplied over time across healthcare, this can translate into the provision of culturally congruent care for the global population.

Respecting patients' cultural needs and desires requires nurses to be advocates, educators, and caregivers regardless of where we practice. We can do this by drawing from our experiences and understanding about culture-as we did from our cultural competency class-while remaining open to change and to learning new things from the diverse patients entrusted to our care. Perhaps the best outcome of our learning experience in this course is recognizing that culturally congruent care is a cornerstone of nursing that will help us become better nurses and promote the acceptance of people from different cultures.

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