IntroductionThe goal of nursing is to provide “culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness, or death in culturally meaningful ways (Jarosova, 2014). The purpose of this concept analysis is to describe and examine a word and its usage in language and to differentiate different angles of the concept (Walker & Avant, 2005). Cultural competence can be ambiguous depending on who is interpreting the concept. This analysis will lay out inconsistencies and debates that exist and will review terminologies in this area. This concept analysis will also include defining attributes, case scenarios, and a review of the antecedent and consequences of the concept. This will allow for providers and educators to understand the concept and deliver quality care as well as improve communication in this area. Review of Literature The term “cultural competence” refers to the multi-cultural knowledge base that nurses need, together with the ability to apply such knowledge in practice (Jirwe, Gerrish, & Emami, 2006). Nurses who are culturally competent are conscious of cultural differences, and base their care accordingly. They avoid stereotyping, generalizing, and discriminating. Cultural competence can be difficult to understand but once broken down it comes down to two words, culture and competence.Merriam Webster dictionary, 2017, defines culture as “the customary beliefs, social forms, and material traits of a racial, religious, or social group. It is the attitudes, values, goals and practices that certain groups carry out as a norm.” The cultural background impacts an individuals beliefs, language, religion, family structure, and body image. One culture’s interpretation of pain, disease, treatments, providers, and hospitals can be different from that of another culture’s. An individual’s culture is not determined simply on their ethnicity or race but rather a multitude of factors such as age, gender, education, religion, socioeconomic status, geographic region, occupation and much more (Sitzman, & Eichelberger, 2011). Cultures have been studied by multiple disciplines for ages. Nutrition and mental health are two disciplines that also utilize culture. In this portion of the review of literature, different uses of cultural competency will be discussed and compared to it’s use in nursing. Dietitians and nutritionists need to be aware of cultures and their beliefs on nutrition. Psychologists need to be aware of cultures and their beliefs on mental illness. Finally nurses, who reside in multiple aspects of health care, need to be aware of cultures and their beliefs in health. Healthy meals in one culture can be considered unhealthy in another. Registered Dietitians have the unique training to provide guidance on diet, food, and nutrition to ethnically diverse clients (Hack, Hekmat, & Ahmadi, 2016). The College of Dietitians of Ontario acknowledges the importance of cultural competence in Counseling by stating dietitians are “to recognize the cultural beliefs, values, attitudes, traditions, language preferences, and health practices of diverse clients” (Hack et al., 2016). However, in nutrition, not much has been published on cultural competency curriculum and the impact that food related beliefs have on behaviors in health. The majority of dietitians in Canada, rated culture competencies as “important” in dietetics curriculum (Huycke, Ingribelli, & Rysdale, 2017). Without proper education on different cultures and their nutritional needs, care provided to clients was affected negatively. When talking to immigrant families concerning “eating ordinary, healthy food regularly, adjustments were barely made” (Holmberg, Pettersen, Terragni, & Glavin, ( 2016). Time constraints and language and cultural barriers were common challenges. The nurses suggested that culturally adapted information materials and visual aids from health authorities could improve communication (Holmberg et al., 2016). “Taking a course, which emphasizes cultural traditions, foods, and eating practices, supports students’ acquisition of cultural knowledge” (Hack et al., 2016). A study was conducted in 2015, that “evaluated a culturally- salient, community based healthy lifestyle interventions” (Kandula et al., 2015) to reduce atherosclerotic cardiovascular disease (ASCVD) in individuals of South Asian origin. South Asians are a highly growing population in America and they are less active, have a poor diet, and are overweight compared to other Asian Americans (Kandula et al., 2015). They are at high risk for developing ASCVD. This pilot study tested the effectiveness of a South Asian Heart Lifestyle Intervention, “a culturally tailored group lifestyle intervention” (Kandula et al., 2015). In the 6 month study, participants were encouraged to eat a clean diet, increase daily activity, and attend group classes. At the end, participants were able to make changes in their lifestyle by utilizing culturally salient techniques provided by the study group. This study utilized culturally competent care and got positive results.Mental health is a challenge, in and of itself, but it is considered an even bigger challenge in cultures that don’t believe it exists. According to a U.S. Census Bureau in 2012, Asian Americans are one of the fastest growing ethnicity populations in America. They have been shown to experience a lot of mental illnesses but delay seeking treatment due to mental illnesses being perceived as “moral transgressions that can cause strong feelings of shame, guilt, and stigma” (Cheng, Tu, & Yang, 2016). Many who have mental illnesses resorted to social withdrawal as a primary form of coping instead of seeking assistance. If providers knew these facts, they’d be more opt to seek out these types of clients and encourage them to get a prognosis and recover instead of lurking in the shadows. These types of populations from cultures who undermine mental illness can join together and provide social support to those dealing with illness and lead to better community adaptations. It was Madeline Leininger, a well educated nurse, professor, writer, and theorist, who first brought interest into the study of transcultural nursing and cultural competency. Nurses know how to perform an assessment, obtain test results, and carry out the treatment prescribed by a physician on clients because this is what they are trained to do. However, “studies show that nurses lacked cultural competence in face-to-face interactions and were not able to communicate adequately with patients that spoke a different language”(Jirwe, Gerrish, & Emami, 2006). Language is just one aspect of someone’s culture. What about their beliefs on contraception, use of herbal medicine, feelings on touch and making eye contact, or agreeing with a healthcare provider merely to prevent embarrassment to one or the other. With the growing number of diverse clients from a mosaic of cultures, it is imperative for nurses, among others, to understand cultural competency. Research was done in 2015, to analyze the performance of nurses on healthcare practices rooted in African and Indigenous cultures. Seven nurses were interviewed for this research and analysis was based on Leininger’s theory of cultural care and the concept of human rights (Lima, Nines, Kluppel, Madeiros, & Sa, 2016). The nurses in this area were not aware of and did not bother to become knowledgeable of the client’s cultures and practices. Although the sample size was small, the study came to the conclusion that cultural competency in the “context of professional qualifications and exercise is required” (Lima et al., 2016). Nurses would then be better able to provide diverse and comprehensive care. Defining attributes are characteristics of the concept that appear repeatedly in the literature and may help clarify how the concept is used (Walker & Avant, 2005). The defining attributes of cultural competence that nurses should demonstrate are cultural awareness, sensitivity, knowledge, and skill. Defining Attributes Cultural awareness is “an individual’s affective response and ability to acknowledge and critically examine personal biases toward other cultures, lifestyles, and beliefs” (McElroy, Smith-Miller, Madigan, & Li, 2016). Nurses need to avoid stereotyping, generalizing, and passing judgement on practices and behaviors of a culture different from the “norm” evident in their everyday life. Rather nurses are encouraged to explore what the client can educate them on. Mainly nurses need to be conscious that other cultures, with their own beliefs and practices and definitions on what health is, exist. Sensitivity towards another culture refers to respecting other’s cultures. Madeleine Leininger, founder of transcultural nursing, stated that before a client can trust their provider, they need to know that they are respected by the provider. It’s not just a matter of the region a client comes from or the color of their skin, but rather the overall definition of who they are as a person that will allow a client to open up to a provider and show mutual understanding. It is not enough that a nurse has knowledge of diseases and treatments for them. Knowledge is having information about various cultural groups and an understanding of what they believe in, value, and practice. In Madeleine Leininger’s Sunrise Model, factors that contribute to their culture include technology, religion, politics, economics, education, and family lifestyle. What is considered appropriate and what is inappropriate. Nurses should make it a priority to understand cultures that are most abundant in their community. This will help avoid conflict when encountering a client from a different culture and will optimize care provided. Once knowledge is obtained about a specific culture, certain skills need to be applied in carrying out care. Skill is defined as an ability to perform a certain act. Nurses assess a client and ask pertinent questions and collect data before coming up with a plan of care. They need to be able to do so in a culturally sensitive manner. Does the client prefer a male vs female nurse? Would they prefer a family member with them? Is it okay to touch them? Communication skills are key when dealing with individuals from various cultures. This can be done with both verbal and nonverbal actions. Eye contact is one form of communication that some cultures accent while others deter from. Sometimes it is necessary to step back, obtain a reliable interpreter, and then provide a safe and culturally satisfactory form of care.Definition of the ConceptBased on the review of literature and defining attributes cultural competency can be defined as “a multidimensional learning process that integrates transcultural skills (cognitive, practical, affective), involves transcultural self-efficacy (confidence) as a major factor and aims to achieve culturally congruent care” (Prosen, 2015). CasesModel case is an example of the use of the concept that demonstrates all the defining attributes of the concept (Walker & Avant, 2005). It relates the definition to real life scenarios and allows the reader to understand the concept further. This model case is highlighted by the following example. Ms. Smith is an American Catholic registered nurse working in the emergency room at a hospital in New Mexico. An elderly Mexican client with severe abdominal pain comes in to the emergency room during her shift. Ms. Smith dominantly speaks English but has picked up phrases in Spanish due to her community being largely Spanish speaking. Ms. Smith is aware of the client’s different cultural background. She carried out routine assessment of the patient, and it didn’t take much for the nurse to realize that the client spoke broken English. The nurse was able to get the client to relax enough with her soothing words and touch. The client smiled once she realized her nurse also spoke some broken Spanish. The nurse requested a Spanish speaking interpreter and then was able to provide more quality care. She asked the client pertinent questions about her pain but also her food preference and if she had any family with her. Once the patient was admitted, her family contacted, and the pain starting to subside, the nurse was able to ask more culture related practices that the client carried out. The nurse was sure to notify the medical assistant, nurses, and the doctors about the client’s cultural beliefs and habits and instructed them on how they could show respect towards this client. Mexican culture does believe in folk medicine and the nurse was good to ask her if she tried home remedies that may have caused or relieved the pain. Ms. Smith continued to do more research on what the client informed her of and got more information once her family arrived. On discharge, the nurse provided the client with written information on abdominal pain and causes and treatments and her medications in Spanish. In this case, Ms. Smith showcased full cultural competency. She did not make the client feel as though she was exaggerating and did not tell her to speak English. She was quick to get an interpreter and even use what ever Spanish she could to get the client to trust her. Ms. Smith respected the client’s culture and made sure her collages understood the client as well. This example demonstrates cultural awareness, sensitivity, knowledge, and skill. All the attributes that make an individual culturally competent. Borderline cases are “those examples or instances that contain most of the defining attributes of the concept being examined but not all of them” (Walker & Avant, 2005). In this example, three of the four defining attributes of cultural competency highlighted above will be presented. An example of a borderline case is the following. Mona is a newly registered nurse working in a hospital in India. She was assigned to a tourist client from America with type II diabetes. Mona couldn’t understand and speak English. She provided care to the client by sticking to routine assessments. Mona used body language and pictures and a lot of pointing at items to communicate with the client. She observed what the charge nurse did when she was with the client and did the same exact things. When the client had questions, Mona would smile and nod her head politely before leaving to get someone else who did speak English. Eventually, the client asked to be assigned a nurse who did speak English and the nurse agreed politely. She was a good nurse and cared for the patient but she lacked certain skills to be able to provide a culturally competent care. She did not speak English fluently but that should not have been the biggest barrier. There were alternate options available. She could have had an interpreter present at times when care was being given. She could have also managed cluster care. If she really was hampered by language as being a barrier, she should have done research on her client’s “American needs”. Although smiling is nice, it doesn’t answer a client’s questions or concerns. It could also have been interpreted as the nurse mocking the client. She truly wanted to be competent in caring for her client but was missing some important links before providing culturally congruent care. Related cases are “instances of concepts that are related to the concept being studied but that do not contain all the defining attributes” (Walker & Avant, 2005). This example will demonstrate ideas that are very similar to cultural competence but lacking in certain characteristics. Mimi’s patient is a 40-year-old Buddhist man. He was admitted after a car accident and was unable to walk due to a broken leg. He informed Mimi, in fluent English, that although he was born and raised in America, he still practices traditional Buddhist beliefs. The Buddha defined health as having well-being and good digestion, not being over-cold or over-hot, balance, and being capable of activity. Mimi had a busy workload that day and was unable to listen to everything the patient required. She passed out medications and did her assessments but never made it back to her Buddhist client to help him get ready for the day. It was against who he was to be laying in bed all day. No one came to help him get ready and perform physical therapy. He was very upset. When food arrived, he refused to eat it because he wasn’t washed and ready for his day to begin. Mimi took it as him refusing to eat and requested the provider put in a psych consult because he could be depressed. Mimi was given the facts that her client practiced his beliefs and wanted to adhere to them regardless of his situation. She failed to respect and value his beliefs. Just simply knowing he still practices his culture’s practices is not enough. The nurse needs to make time to listen to what those practices are and try to incorporate them into the plan of care. If she had a high client volume, she should have obtained assistance from her colleagues and made sure her client was respected and valued. Contrary cases are “clear examples of not the concept” (Walker & Avant, 2005). This case will show you how cultural competency is not at all considered and the exact opposite is done. A 70yr old Filipino man comes in to see a doctor. He was grunting and crying and was short of breath. He kept holding his chest near his heart. He wasn’t even able to get a word in due to his emotions being all over the place. The provider interpreted it as the man having a heart attack. He was immediately transferred to the emergency room to rule out a heart attack. He had his vitals assessed, EKG done, and labs drawn. It was after hundreds of dollars were spent on these unnecessary actions that an interpreter came and relayed to the provider that the man was depressed over a recent loss of a loved one. The client was short of breath because he had been crying all day. He hadn’t been eating or drinking. He hadn’t slept in days and he held his chest near his heart because he was trying to indicate that his heart hurt after losing a loved one.This is a clear example of a lack of cultural competency. The provider just assumed the client was having a medical emergency instead of trying to communicate with the client. The provider was not sensitive to the client and lacked any knowledge or skill in caring for a client from another culture. If it was a client who was from the same culture as the provider, the provider would have saved the client a trip to the emergency room. None of the defining attributes of cultural competency were considered in this example. Antecedents Antecedents are “those events or incidences that must occur prior to the occurrence of the concept” (Walker & Avant, 2005). Before anyone can be culturally competent, there has to be the presence of different cultures, cultural diversity. According to the U.S. Census Bureau, 2015, there are 325 million people living in the United States, each bringing their own diverse cultures. “Culture encompasses religion, food, what we wear, how we wear it, our language, marriage, music, what we believe is right or wrong, how we sit at the table, how we greet visitors, how we behave with loved ones, and a million other things,” said Cristina De Rossi, an anthropologist at Barnet and Southgate College in London. This increasing cultural diversity will seek treatment at healthcare settings where encounters will occur everyday. Hospitals and health centers around the world have a presence of diverse cultures. Providers, themselves, have their own cultures that have certain beliefs and practices. With that said, there has to be an overall awareness of cultural differences. Healthcare providers need to be aware that culture impacts care. They need to want to make changes in their surroundings and themselves to incorporate culture into their norm. Consequences of providing culturally competent care should be encouraged by the healthcare organization. Once the pros and cons are discussed, the provider will have to make a decision whether or not it is important. They should listen to and implement a clients’ culture’s practices into the plan of care. ConsequencesConsequences are “those events or incidents that occur as a result of the occurrence of the concept” (Walker & Avant, 2005). Providing culturally congruent care will make the client happy, the nurse more knowledgeable, and healthcare organizations more abundant. Negative consequences can result from a lack of cultural competence. The client and provider will have an open communication, allowing the provider to make a diagnosis and treatment plan for the client. The client will also adhere to the treatment plan as well because their cultural practices were utilized. Nurses will have a better understanding of their clients and stick to the oath of doing no harm to their clients. If anything, nurses will become more knowledgeable about diverse cultures and even educate their colleagues of the matter. Leininger emphasized the concept of respecting a client and their beliefs and practices before earning their trust and therefore provide care. Healthcare organizations that have culturally competent employees will be sought after more by the culturally diverse populations. They will become the focal point of culturally congruent care. Clients will trust them and in turn give them their patronage. Malpractice claims may even decrease if culturally competent care is given. If cultural competency is not attained, there can be negative consequences. Examples of negative consequences include “missed screenings for minority groups; differing responses to medicines; lack of knowledge about folk medicine, which could lead to drug interactions; and diagnostic errors resulting from miscommunication” (Brach & Fraserirector, 2000). Cultural competence isn’t attained overnight or after a one hour lecture on diverse cultures. Providers are simply made aware that this hugely impacts care and to be conscious when experiencing different cultures. Empirical Referents Empirical referents are “classes or categories of actual phenomena that by their existence or presence demonstrates the occurrence of the concept itself” (Walker & Avant, 2005). Basically, what are some assessment tools used to measure cultural competency. “Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R) is a self-assessment tool used to measure cultural competence” (Delgado et al., 2013). “The IAPCC-R is a 25-it’s tool that uses a 4-point Likert-type scale to measure the five cultural constructs of desire, awareness, knowledge, skill, and encounters” (Delgado et al., 2013). The scores are then categorized into four levels: proficient, competent, aware, and incompetent. The higher the score level, the more culturally competent an individual is. The IAPCC-R, however, is made to measure the provider’s opinion. It does not measure the opinion of the client and this is where more research tools need to be produced. ConclusionWith the increasing population of America and a wide range of cultural presence, it is imperative that nurses and other health care providers exude cultural competence. Cultural competence is “a multidimensional learning process that integrates transcultural skills (cognitive, practical, affective), involves transcultural self-efficacy (confidence) as a major factor and aims to achieve culturally congruent care” (Prosen, 2015). Cultural awareness, sensitivity, knowledge, and skills are the attributes that define this concept. Once healthcare providers master these attributes they are able to provide culturally congruent care to clients. This will allow the clients to then trust and respect the healthcare team and adhere to their care plans, leading to a healthier diverse cultures.