Are You Culturally Competent?
"The practice of nursing today demands that the nurse identify and meet the cultural needs of diverse groups, understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide nursing care, and identify and use resources acceptable to the client" (Andrews and Boyle 2002).
In reviewing the manuscripts for this issue, I harkened back to the work of one of our first nursing theorists, Madeline Leininger. Her work on transcultural nursing focused on the comparative study of cultures to understand similarities (culture universal) and differences (culture specific) across human groups (Leininger 1991). In her characterization, culture is:
- a set of values, beliefs and traditions, that are held by a specific group of people and handed down from generation to generation;
- beliefs, habits, likes, dislikes, customs and rituals learned from one's family;
- learned, shared and transmitted values, beliefs, norms and life way practices of a particular group that guide thinking, decisions, and actions in patterned ways;
- learned by each generation through both formal and informal life experiences.
She also discussed the concepts of cultural awareness, culturally congruent care, and culturally competent care. The first being an "in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people." The second refers to "care that fits the people's valued life patterns and set of meanings, generated from the people themselves, rather than based on predetermined criteria." And the last, being "the ability of the practitioner to bridge cultural gaps in caring, work with cultural differences and enable clients and families to achieve meaningful and supportive caring." While this work was published almost 40 years ago, the relevance is no less and perhaps even more applicable to nursing practice in Canada today. Notwithstanding the continuous influx of new Canadians from a multiplicity of cultural and ethnic backgrounds, we have been brought to a heightened awareness and an imperative to act in response to the long-standing, ignored health and social needs of our Indigenous communities. Among 94 Calls to Action identified by the Truth and Reconciliation Commission of Canada (TRC) (2015), seven specifically focused on health, including the need to increase the number of Indigenous health professionals and their retention in Indigenous communities and also to ensure cultural competency training for all healthcare professionals.
We call upon medical and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism (TRC 2015: p. 3).
Providing the focus for this issue, the papers by Butler, Exner-Pirot and Berry (2018a, 2018b) challenge our traditional structures and processes in nursing education suggesting that we need new thinking about leadership and community engagement that supports reconciliation. Through the creation of a Strategist for Outreach and Indigenous Engagement, the University of Saskatchewan set the stage for an inclusive, culturally relevant nursing program that appreciates the important role of Indigenous nurses specifically. As a consequence of this role, they have realized significant recruitment and retention improvements of Indigenous students. Further their "Learn Where You Live" model affords distributed access to nursing education in rural, remote and northern regions of Saskatchewan, building capacity in Indigenous communities. Bill and Gillis (2018) underscore the significance of these efforts and the importance of "authentic" partnerships with Indigenous communities. Beyond the work of the Canadian Indigenous Nurses Association and Indigenous Services Canada, nurse leaders in all practice and academic settings need to identify and leverage partnership opportunities with Indigenous communities; there are benefits to be realized for all, particularly in the interest of true reconciliation.
The modified LEADS scale development effort described by Gilbert and Kelloway (2018) in this issue reminds us of key dimensions of leadership including being self-aware. While the LEADS framework is silent on the concept of cultural competence, I would suggest that it is essential for leaders to also be self-aware of their biases, prejudices and assumptions about people from different cultures. Hunt-Smith and Butler (2018) also reference the LEADS framework as they describe its application to a widespread dissemination of a Diabetes Management e-Learning Module in Newfoundland and Labrador's Eastern Health region. Utilizing the LEADS domain of "Engage Others," they describe their partnership with St. Elizabeth to engage nursing and allied health professionals. The concept of engaging others implies an acknowledgement and valuing of individual perspectives and experiences and a recognition of cultural differences.
In examining the effectiveness of multisource feedback and coaching with nurse practitioners, Graham and Beuthin (2018) found that the approach was promising as a professional development strategy. In the future, perhaps a dimension of this multisource feedback model could be framed using the LEADS framework and more specifically, aspects of cultural competence among nurse practitioners.
The TRC Calls to Action for the health sector should prompt reflection among all healthcare leaders. If you have not already done so, I encourage you to review and familiarize yourself with the TRC reports. As leaders in practice, policy, research and education, we share the responsibility to identify any occasion to respond to the Calls to Action, particularly those related to health and social issues. Making cultural competence core to the values of every healthcare organization and explicit to the learning outcomes of every nursing curricula is an essential next step. As Canadians, at the very least we owe our Indigenous communities awareness, understanding and sensitivity. Take time to step back and identify opportunities to bridge the long-standing cultural divide in our country and redress the wrongs of our collective history.
Lynn M. Nagle, RN, PhD, FAAN
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Andrews, M.M. and J.S. Boyle. 2002. "Transcultural Concepts in Nursing Care." Journal of Transcultural Nursing 13(3):178–80.
Bill, L. and L. Gillis. 2018. "Commentary: Indigenous Nursing – Learning from the Past to Strengthen the Future of Healthcare." Canadian Journal of Nursing Leadership 31(1): 28–31. doi:10.12927/cjnl.2018.25475.
Butler, L., L. Berry and H. Exner-Pirot. 2018a. "Conceptualizing the Role of a Strategist for Outreach and Indigenous Engagement to Lead Recruitment and Retention of Indigenous Students." Canadian Journal of Nursing Leadership 31(1): 8–17. doi:10.12927/cjnl.2018.25477.
Butler, L., H. Exner-Pirot and L. Berry. 2018b. "Reshaping Policies to Achieve a Strategic Plan for Indigenous Engagement in Nursing Education." Canadian Journal of Nursing Leadership 31(1): 18–27. doi:10.12927/cjnl.2018.25476.
Gilbert, S. and E. K. Kelloway. 2018. "Development and Validation of the LEADS Scale." Canadian Journal of Nursing Leadership 31(1): 32–41. doi:10.12927/cjnl.2018.25474.
Graham, R. and R. Beuthin. 2018. "Exploring the Effectiveness of Multisource Feedback and Coaching with Nurse Practitioners." Canadian Journal of Nursing Leadership 31(1): 50–59. doi:10.12927/cjnl.2018.25472.
Hunt-Smith, H. and M. Butler. 2018. "LEADS Case Study: Partnering to Offer a Diabetes Management e-Learning Module to Nursing and Allied Health Staff." Canadian Journal of Nursing Leadership 31(1): 42–49. doi:10.12927/cjnl.2018.25473.
Leininger, M. 1991. Culture Care Diversity and Universality: A Theory of Nursing. New York, NY: National League for Nursing Press.
Truth and Reconciliation Commission of Canada (TRC). 2015. Truth and Reconciliation Commission of Canada: Calls to Action. Winnipeg, MB: Truth and Reconciliation Commission of Canada Office. Retrieved May 14, 2018. <http://www.trc.ca>.
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