Culturally Competent Care

This edition of Standards in Focus highlights the Standards of Practice and Conduct that articulate the expectations regarding culturally competent care* and provides you with the opportunity to reflect on how you apply those standards in your practice.

Note that terms with an asterisk * are defined at the end of this article.

Several of the Standards speak to client-centred culturally safe practice, while other Standards speak to cultural competence and collaborative practice. Category one (I) of the Standards is focused on professional accountability and states that licensed practical nurses conduct themselves as professionals and make decisions that are in the interest of their clients and the public. Standards related to cultural competence state the following.

As an LPN, you must:

• Treat people fairly, with dignity, and without discrimination*, bullying or harassment. (Standard 10)
• Consider the impact of colonization on the cultural, social, and spiritual lives of Indigenous people and take action to ensure your conduct and nursing care does not harm Indigenous people. (Standard 11)

Category two (II) of the Standards is focused on competent practice and states that licensed practical nurses are responsible for safe, compassionate, and ethical nursing practice. Standards related to cultural competence state the following.

As an LPN, you must:

• Engage in learning to enhance your knowledge and ability to provide nursing care for Indigenous people through learning resources developed by or in collaboration with Indigenous people. (Standard 29)

Category four (IV) of the Standards is focused on client-centred practice and states that licensed practical nurses provide nursing services that are client-centred. Standards related to cultural competence state the following.

As an LPN, you must:

• When engaging in practical nursing in a clinical practice setting, provide nursing care that includes:
  • A care or treatment plan developed with the client or their representative and any other person who the client wishes to involve, which considers the client’s needs, circumstances, preferences, values, abilities, and culture*. (Standard 38. b.)
  • Sufficient and timely communication with the client or their representative that considers the client’s needs, circumstances, culture, understanding, and use of health information and enables the client or their representative to make informed decisions about the client’s health care. (Standard 38. d.)

Category five (V) of the Standards is focused on collaborative care and states that licensed practical nurses practice in partnership with clients and a team of health care providers. Standards related to cultural competence state the following.

As an LPN, you must:

• Demonstrate respect for diversity*, and practice in a manner that promotes a culturally safe environment* for clients and members of the health care team. (Standard 46)
• Demonstrate cultural humility*, sensitivity to the dynamics of power, and provide culturally competent care in all areas of nursing practice. (Standard 47)

Category seven (VII) of the Standards is focused on leadership and states that licensed practical nurses apply leadership competencies in their practice, whether or not they practice in formal leadership positions. Standards related to cultural competence state the following.

As an LPN, you must:

• Challenge any forms of racism* and discrimination in the practice environment. (Standard 62)
• Demonstrate an understanding of issues facing marginalized and vulnerable clients and act as an advocate by challenging poor practice and discriminatory attitudes and behaviours relating to their care. (Standard 65)

The entry-level and full competencies for the profession also lay out the expectations for the competencies related to culture, cultural safety, cultural humility, racism, and discrimination. Examples of competency statements include:

• Demonstrate knowledge of, and the ability to respond to, the Calls to Action of the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples.^{2, 3}
• Demonstrates knowledge of diversity between and within different cultures, including ethnicity, disability, social and economic status, age, sexuality, gender identity, faiths and beliefs.
• Advocates for the use of Indigenous health knowledge and healing practices, in collaboration with the client, the client’s community, and Indigenous healers and Elders.
• Demonstrates knowledge of diversity between and within different cultures, including ethnicity, disability, social and economic status, age, sexuality, gender identity, faiths and beliefs.

To read more on the competencies related to culture, cultural safety, cultural humility, racism, and discrimination, please access the CLPNM’s competency documents available on the CLPNM website.

Cultural Competence in Nursing Practice

LPNs in Manitoba care for diverse populations of clients who bring their cultural backgrounds, experiences, and worldviews into the nurse-client relationship.

LPNs can demonstrate cultural competence, cultural humility, and cultural safety by collaborating with clients to integrate culture into client care and developing mutual goals and the best approach to client care.¹

Culturally competent care is composed of four parts:

• awareness of one’s cultural worldview,
• positive attitudes toward cultural differences,
• knowledge of diverse cultural practices and worldviews, and
• cross-cultural skills. ^{13, 14}

Nursing Practice Scenario

The following scenario shows how the four components work together toward the delivery of culturally competent nursing care: ^{13, 14}

A non-Indigenous nurse, Britney Johnson, LPN, who recently started working in a health care centre located in a First Nations community, reflects on her conscious and unconscious biases towards her client population.

Britney’s reflection and growing self-awareness help her realize that her body tenses up whenever she hears that the health centre invites and encourages Indigenous cultural ceremonies and spiritual practices to be performed on-site as a part of client care.

Britney takes time to examine her attitude toward these cultural activities and reflects on why they are making her feel tense. She acknowledges that she does not know the history or the significance of these ceremonies and that the “unknown” makes her uncomfortable.

Britney decides to reach out to a community Elder to increase her knowledge of Indigenous ceremonies and spiritual practices that are important to the residents of this First Nations community and how these practices are connected to their views on medicine and health care. Along with learning about the ceremonies themselves, Britney also learns strategies from the Elder on how best to communicate with her Indigenous clients.

Britney uses her newfound awareness, attitude, and knowledge in her nursing practice. For instance, during a recent shift, Britney speaks to a client’s daughter over the phone and learns that the client, who has a language barrier, will be at the health centre the next day for an assessment. Britney asks if the client would like an Indigenous language translator to be present, and she asks how many people will be accompanying the client to the appointment. Britney does this so that the client can have better access to health information through someone who speaks their language and so that she can prepare the assessment area with enough chairs to accommodate the client’s family. Britney is now more aware that all her clients are individuals with unique relationships to their own cultures and unique health care needs. Therefore, Britney now strives to consistently apply her new skills and abilities to gather and incorporate relevant cultural information about her clients while using culturally sensitive communication techniques and planning client care.

Standards 11 and 29 more specifically refer to the expectation that nurses educate themselves about Indigenous history and current issues so that the nursing care that they provide to Indigenous clients is not harmful in any way. ¹ In the scenario presented above, Britney sought out education about Indigenous ceremonies and culturally sensitive communication techniques to improve her nursing practice with her Indigenous clients. Britney is meeting her Standards of Practice and Conduct by increasing and maintaining her cultural competence and engaging in the process of cultural humility.

Cultural humility in nursing practice involves self-reflection, self-critique, and self-evaluation of nurses’ own cultures, beliefs, assumptions, and biases, to acknowledge and address power inequities between nurses and clients. ^{7, 10}   Standard 47 states that LPNs must demonstrate cultural humility, sensitivity to the dynamics of power, and provide culturally competent care in all areas of nursing practice. ¹ LPNs are expected to approach clients in a humble, respectful, and genuinely inquisitive manner to gather information and acquire knowledge regarding their client’s cultural perspectives and contexts, rather than assuming that they understand the client’s culture. ⁷

Furthermore, Standards 10, 62, and 65 refer to the expectation that nurses must challenge racist and discriminatory behaviours in their practice environments and that they need to advocate for their vulnerable and marginalized clients. ¹   Standard 46 states that LPNs must show respect for diversity and practice in a manner that promotes a culturally safe environment for clients and the health care team. ¹ Nurses who demonstrate cultural competence and cultural humility provide care consistent with their client’s cultural needs. They actively take steps to ensure safe health care environments free of discrimination or intolerance. ¹⁴ 

LPNs who engage in culturally competent care reinforce the importance of diversity and inclusivity in nursing practice. ¹² Inclusive nursing practice for nurses involves awareness and acknowledgment of one’s own biases and judgments about clients based on many factors (e.g., age, gender, race, culture, weight, sexual orientation).^{12, 13} Nurses must engage in self-reflection that actively addresses their biases towards others to deliver safe, ethical, and culturally competent nursing care. ¹² Through self-reflection, nurses, can interact with clients from a place of cultural humility and create culturally safe environments where clients feel that their unique culture, healthcare practices, preferences, and decisions are valued and respected. ²

Reflection Exercises

Because self-reflection is an important part of cultural humility, consider the following questions as you reflect on how culture impacts your nursing practice and your interactions with the people around you:

• Is there a culture that you identify with?
• How would you describe your culture? ⁹
• Do you believe your clients have the same priorities as you when it comes to the importance of ethnicity, religion, family, work, diet, and health? ⁹
• What is your perception of Indigenous cultures?
• Can you identify any potential biases or stereotypes in your sources of information about Indigenous cultures? ⁴
• How do you approach and communicate with clients whose culture is different from yours? For example, how might your verbal and non-verbal behaviours be interpreted by a client from another culture? ^{9, 12}
• Reflect on areas of health care where cultural variations in beliefs and values may frequently occur. In your role as a nurse, how do your cultural values impact your relationships with culturally diverse clients? ⁹ How do your Standards of Practice and Conduct apply to these situations?

Conclusion

It is an expectation that all practical nurses engage in self-reflection and interact with clients from a place of cultural humility. Through cultural humility, nurses can create culturally safe environments where clients can perceive respect for their unique cultures, health care practices, preferences, and decisions. ² LPNs should see cultural humility as a process of listening without judgment, with an openness to learning about clients’ cultures, to partner with clients in the delivery of more inclusive, culturally safe, and culturally competent nursing care. ⁸

For further reading about cultural humility and creating a culturally safe environment for clients, consider accessing the resources listed in the references section below.

More learning resources to promote culturally safe practice environments are accessible through the CLPNM website. ¹¹

Definitions of Terms

Cultural Humility is the process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. ^{4, 10}

Culturally Competent Care involves applying the knowledge, skills, attitudes, or personal attributes required by nurses to maximize respectful relationships with diverse populations of clients and co-workers. Underlying values for cultural competence are inclusivity, respect, valuing differences, equity, and commitment. ⁶

A Culturally Safe Environment is an environment, which is safe for people, where there is no assault, challenge, or denial of their identity, of who they are and of what they need. It is about shared respect, shared meaning, shared knowledge, and experience, of learning together with dignity, and truly listening. Strategies for promoting a culturally safe environment include modelling correct behaviour and encouraging a climate of inclusivity and mutual respect. ⁵

Culture includes, but is not restricted to, race, ethnicity, gender, sexual orientation, socioeconomic status, age, physical ability, religious beliefs, political beliefs, and ideologies. ^{1, 2, 3}

Discrimination involves treating a person or group differently, to their disadvantage and without reasonable cause, based on a group characteristic, such as ancestry, sex, or disability. ¹

Diversity is the ethnic, social, or gender variety in a group, culture, or institution. The concept of diversity reflects an understanding that everyone is unique and recognizes individual differences. These can be along the dimensions of race, ethnicity, gender, sexual orientation, socioeconomic status, age, physical abilities, religious beliefs, political beliefs, or other ideologies. ^{1, 2, 3}

Racism involves practices or attitudes that have, whether by design or impact, the effect of limiting an individual’s or a group’s right to the opportunities generally available because of attributed rather than actual characteristics. 

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References

1. College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Standards of practice and conduct for Manitoba’s practical nurses. 
2. College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Entry-level competencies for the licensed practical nurse in Manitoba.
3. College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Nursing competencies for the licensed practical nurse in Manitoba.
4. First Nations Health Authority (FNHA). (2018a). Creating a climate for change. Retrieved from https://www.fnha.ca/Documents/FNHA-Creating-a-Climate-For-Change-Cultural-Humility-Resource-Booklet.pdf
5. Nova Scotia College of Nurses (NSCN). (2017). Standards of practice for registered nurses. Retrieved from https://cdn1.nscn.ca/sites/default/files/documents/resources/RN%20Standards%20of%20Practice.pdf
6. Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., Milstead, J., Nardi, D., & Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 1-13. doi: https://doi.org/10.1177/1043659614520998
7. Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18(174), 1-17. doi: https://doi.org/10.1186/s12939-019-1082-3
8. First Nations Health Authority (FNHA). (2018b). FNHA’s policy statement on cultural safety and humility. Retrieved from https://www.fnha.ca/Documents/FNHA-Policy-Statement-Cultural-Safety-and-Humility.pdf
9. College of Nurses of Ontario (CNO). (2018). Culturally sensitive care. Retrieved from https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/ask-practice/culturally-sensitive-care/
10. First Nations Health Authority (FNHA). (2022). Cultural safety and humility. Retrieved from https://www.fnha.ca/wellness/wellness-and-the-first-nations-health-authority/cultural-safety-and-humility
11. College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Learning opportunities.
12. College of Licensed Practical Nurses of Alberta (CLPNA). (2019). Practice guideline: Cultural competence and inclusive practice. Retrieved from https://www.clpna.com/2019/12/practice-guideline-cultural-competence-and-inclusive-practice/
13. Deering, M. (2022). Cultural competence in nursing. Nurse Journal. Retrieved from https://nursejournal.org/resources/cultural-competence-in-nursing/
14. Wisconsin Technical College System (WTCS). (2021). 3.4 Cultural competence. In Ernstmeyer, K., & Christman, E. (Eds.), Open resources for nursing (Open RN): Nursing fundamentals. Licensed under CC BY 4.0. Retrieved from https://wtcs.pressbooks.pub/nursingfundamentals/chapter/3-4-cultural-competence/