WHAT IS CULTURAL COMPETENCE IN HEALTH CARE? In the 1960s, health care theorists from various disciplines began to develop theoretical and conceptual frameworks for assessing, planning and implementing culturally relevant services for diverse populations. However, forty years later, we are still discussing the same question.
Changing demographics and economics of today's increasingly multicultural world, as well as longstanding disparities in the health status of diverse populations, challenge health care providers to be culturally competent. While experts in transcultural nursing have offered several models of cultural competence, I assert that these models do not focus on an essential construct of cultural competence: spirituality.
In 1991, I developed a model that identified four constructs of cultural competence: cultural awareness, cultural knowledge, cultural skill and cultural encounters.
Cultural awareness requires self-examination of one's biases toward other cultures and the in-depth exploration of one's cultural and professional background.
Cultural knowledge is accurate information about the worldviews of different cultural and ethnic groups, which the nurse skillfully discerns.
Cultural skill is the ability to collect relevant cultural data regarding the client's presenting problem.
Cultural encounter involves directly engaging in face-to-face cultural interactions with clients from a culturally diverse background. In this process, the nurse may modify personal beliefs about a cultural group and discover possible stereotyping.
My model suggested that a culturally competent nurse could continuously engage in the process of becoming culturally aware, culturally knowledgeable and culturally skillful, while seeking many face-to-face encounters with diverse clients.1 However, in my years of practice as a certified transcultural nurse specialist, I interacted with nurses who met all these criteria. But not all these nurses manifested the true spirit of cultural competence. As I explored what was missing, I saw that these nurses lacked the desire to become culturally competent. This demonstrated a caring component of cultural competence that my model's four constructs did not address.
In 1998, I added to the model the construct of cultural desire, expanded the constructs of cultural knowledge and cultural skill, and modified the pictorial representation of the model to reflect the interdependent relationship of the five constructs. I expanded the construct of cultural knowledge to include the process of learning about biocultural ecology (biological variations, disease and health conditions and variations in drug metabolism found among ethnic groups).
The construct of cultural skill was expanded to include learning how to perform a culturally-based physical assessment.2 In the revised model, cultural competence was depicted as a dynamic process, occurring at the intersection of these constructs. As the area of intersection of the constructs grows, the nurse more deeply internalizes the constructs on which cultural competence is based.
In this revised model, cultural desire becomes the motivation of the nurse to want-to engage in the process of becoming culturally competent, rather than feeling I have-to. Cultural desire includes a genuine passion and commitment to be open and flexible with others, and to respect differences but build on similarities, and to be willing to learn from others as cultural informants. This is a life-long learning process that has been referred to as cultural humility.3
It is not enough for the nurse to merely respect a client's values, beliefs and practices, or to provide a culturally-specific intervention that the literature reports is effective with a particular ethnic group. Instead, the nurse's motivation of desire to provide culturally responsive care becomes central. This desire must come from one's aspiration, not out of desperation.
Christ's love for the church motivates a person to want to engage in the process of cultural competence. Spiritual caring and spiritual love are intrinsic qualities in the nurse-client relationship that cannot be directly measured. However, clients perceive these qualities positively, sensing that they are being cared about and valued. It has been said that people don't care how much you know until they first know how much you care.4 This type of caring and spiritual love comes from the heart, not from the mouth. It results from one's relationship with God. Therefore, the goal of cultural competence is not to offer politically correct comments (from the mouth), but rather comments that reflect true spiritual caring (from the heart).
Cultural desire also involves the nurse's commitment to care for all clients, regardless of their cultural values, beliefs or practices. This may be difficult with clients who engage in behaviors that may be in direct moral conflict with your values (such as abortion, homosexuality or sexual addiction).
Culltural desire becomes the motivation of the nurse to want-to engage in the process of becoming culturally competent.
A colleague shared with me that she was counseling an African American client who was pregnant and didn't want to have the child. The client was considering whether or not to have an abortion. As a Christian, my colleague explained her personal rationale for not having an abortion and shared that it was the client's choice, and whether or not she decided to have an abortion, that she still valued her. She also encouraged the client to return to counseling, regardless of her decision. The young woman decided to have the abortion. However, since she valued the therapeutic relationship, she returned to my colleague for counseling. In this situation, it was cultural desire that allowed my colleague to continue to care for this client by adopting the attitude, "Love the sinner, not the sin."
Commitment to the process of cultural desire also requires the nurse to be available to clients, even when faced with serious cultural incompetence, such as overt racism. My husband and I were practicing in a rural, underserved community in North Carolina. My husband, an African American family physician, was working in the emergency room when a Caucasian man brought his pregnant wife in for an acute situation requiring immediate medical attention. When this man saw my husband, he quickly stated, "I don't want no colored doctor taking care of my wife!!"
Although I knew this comment deeply offended my husband, he thoughtfully responded: "I would like to care for your wife if you would allow me, but I will respect your decision for me to transfer her to another hospital. However, since she is very sick, I am concerned that she will not be able to survive the transfer over 100 miles away to the next hospital. Again, please know that I want to care for your wife."
The man reluctantly responded, "Well, okay, take care of her."
This emotional situation demonstrated the health care provider's commitment, willingness, availability and the want to care for this client, despite the initial feelings evoked by the racist remarks. The health care provider must not personalize clients' negative comments. Some clients may respond to you based on what you represent to them, their stereotypic view of your cultural or ethnic group, or their past negative experiences with an individual whom they believe you represent, not necessarily who you truly are as a person. It is important to give the client an opportunity to engage in a new, positive experience concerning some of their past negative or stereotypical feelings. However, the nurse must also realize that some clients may reject this opportunity.
How can a nurse develop this cultural desire? Unlike the constructs of cultural awareness, knowledge, skill and encounters, some nurse educators may feel that the construct of cultural desire must be caught rather than taught. However, I believe reading and discussing appropriate literature, including Scripture, will facilitate the development of cultural desire.
After ten years of working on the concept of cultural competence, I now believe that the key to cultural competence is found in the construct of cultural desire, which promotes the needed spiritual caring and love to give culturally relevant care to all clients.
Cultural desire is not an additional construct of cultural competence but a pivotal spiritual construct that provides the energy source and foundation for one's journey toward cultural competence. This new model of cultural competence is depicted as a volcano (figure one), which symbolizes that cultural desire stimulates the process of cultural competence. When cultural desire erupts, it creates the desire to become culturally competent by genuinely seeking cultural encounters, obtaining cultural knowledge, conducting culturally-sensitive assessments and humbly seeking cultural awareness. When asked the ten-year-old question, What is cultural competence in health care? I now answer, "It's a spiritual thing."
Bible Passages Related to Cultural Desire
* Those who say, "I love God," and hate their brothers or sisters, are liars; for those who do not love a brother or sister whom they have seen, cannot love God whom they have not seen (1 Jn 4:20).
* I give you a new commandment, that you love one another. Just as I have loved you, you also should love one another (Jn 13:34).
* Let love be genuine; hate what is evil, hold fast to what is good; love one another with mutual affection; outdo one another in showing honor (Rom 12:9-10).
* Owe no one anything, except to love one another; for the one who loves another has fulfilled the law (Rom 13:8).
* Love is patient; love is kind; love is not envious or boastful or arrogant or rude. It does not insist on its own way; it is not irritable or resentful; it does not rejoice in wrongdoing, but rejoices in the truth. It bears all things, believes all things, hopes all things, endures all things (1 Cor 13:4-7).