Chapter 5: AIDET and Cultural Competency

Introducing Oneself

When initiating care with patients, it is essential to first provide privacy.  Providing privacy means taking actions such as talking with patient in a room with the door shut.  Next, the most important part is to introduce yourself and provide your credentials and role so that the patient feels safe.  Next, discuss what will be occurring. A common framework used for introductions during patient care is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.[10]

• Acknowledge: Greet the patient by the name documented in their medical record. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the patient their preferred way of being addressed (for example, “Mr. Doe,” “Jonathon,” or “Johnny”) and their preferred pronouns (i.e., he/him, she/her or they/them), as appropriate.
• Introduce: Introduce yourself by your name, role and credentials. For example, “I’m John Doe and I am a nursing student working with your nurse to take care of you today.” 
• Duration: Estimate a timeline for how long it will take to complete the task you are doing. For example, “I am here to obtain your blood pressure, heart rate, and oxygen saturation levels. This should take about 5 minutes.”
• Explanation: Explain step by step what to expect next and answer questions. For example, “I will be putting this blood pressure cuff on your arm and inflating it. It will feel as if it is squeezing your arm for a few moments.”
• Thank You: At the end of the encounter, thank the patient and ask if anything is needed before you leave. In an acute or long-term care setting, ensure the call light is within reach and the patient knows how to use it. If family members are present, thank them for being there to support the patient as appropriate. For example, “Thank you for taking time to talk with me today. Is there anything I can get for you before I leave the room? Here is the call light (Place within reach). Press the red button if you would like to call the nurse.”

DIVERSE PATIENTS BASIC CONCEPTS

Let’s begin the journey of developing cultural competency by exploring basic concepts related to culture.

Culture and Subculture

Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. The word “culture” may at times be interchanged with terms such as ethnicity, nationality, or race. See Figure 3.1[1] for an illustration depicting culture by various nationalities. Cultural beliefs and practices bind group or community members together and help form a cohesive identity.[2],[3] Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals.[4] Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. For example, sushi is a traditional Asian dish that has become popular in America in recent years.

Nurses and other health care team members are impacted by their own personal cultural beliefs. For example, a commonly held belief in American health care is the importance of timeliness; medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial.

Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures. The first step in developing cultural competence is to become aware of your own cultural beliefs, attitudes, and practices.

Nurses should also be aware of subcultures. A subculture is a smaller group of people within a culture, often based on a person’s occupation, hobbies, interests, or place of origin. People belonging to a subculture may identify with some, but not all, aspects of their larger “parent” culture. Members of the subculture share beliefs and commonalities that set them apart and do not always conform with those of the larger culture. See Table 3.2a for examples of subcultures.

A person’s culture can also affect encounters with health care providers in other ways, such as the following:

• Level of family involvement in care
• Timing for seeking care
• Acceptance of treatment (as preventative measure or for an actual health problem)
• The accepted decision-maker (i.e., the patient or other family members)
• Use of home or folk remedies
• Seeking advice or treatment from nontraditional providers
• Acceptance of a caregiver of the opposite gender

Cultural Diversity and Cultural Humility

Cultural diversity is a term used to describe cultural differences among people. See Figure 3.2[8] for artwork depicting diversity. While it is useful to be aware of specific traits of a culture or subculture, it is just as important to understand that each individual is unique and there are always variations in beliefs among individuals within a culture. Nurses should, therefore, refrain from making assumptions about the values and beliefs of members of specific cultural groups.[9] Instead, a better approach is recognizing that culture is not a static, uniform characteristic but instead realizing there is diversity within every culture and in every person. The American Nurses Association (ANA) defines cultural humility as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.”[10]

Current demographics in the United States reveal that the population is predominantly white. People who were born in another country, but now live in the United States, comprise approximately 14% of the nation’s total population. However, these demographics are rapidly changing. The United States Census Bureau projects that more than 50 percent of Americans will belong to a minority group by 2060. With an increasingly diverse population to care for, it is imperative for nurses to integrate culturally responsive care into their nursing practice.[11],[12] Creative a culturally responsive environment is discussed in a later subsection of this chapter.

Race is a socially constructed idea because there are no true genetically- or biologically-distinct races. Humans are not biologically different from each other. Racism presumes that races are distinct from one another, and there is a hierarchy to race, implying that races are unequal. Ernest Grant, president of the American Nurses Association (ANA), recently declared that nurses are obligated “to speak up against racism, discrimination, and injustice. This is non-negotiable.”[13] As frontline health care providers, nurses have an obligation to recognize the impact of racism on their patients and the communities they serve.[14]

Sexual Orientation and Gender Identity

Culture can exert a powerful influence on a person’s sexual orientation and gender expression. Sexual orientation is one area of culture that refers to a person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors.[15] The acronym LGBTQ stands for lesbian, gay, bisexual, transgender, queer, or questioning in reference to sexual orientation. (A “+” is sometimes added after LGBTQ to capture additional orientations). See Figure 3.3[16] for an image of participants in a LGBTQ  rally in Dublin. Historically, individuals within the LGBTQ community have experienced discrimination and prejudice from health care providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this group of people in recent years, members of the LGBTQ community continue to experience significant health disparities. Cultural bias and stigmatization of lesbian, gay, bisexual, or transgender (LGBTQ) people have also been shown to contribute to higher rates of substance abuse and suicide rates in this population.[17],[18],[19]

Another area of culture that nurses should be aware of is gender identity. Some patients feel it is important to understand their gender identity. This refers to their inner sensibility that they are a man, a woman, or perhaps neither. Cisgender is the term used to describe a person whose perceived identity matches their sex assigned at birth.[20] To the extent that a person doesn't believe that their gender conforms with the sex assigned to them at birth, they may identify as transgender or as gender nonbinary. Transgender people, like cisgender people, “may be sexually oriented toward men, women, both sexes, or neither sex.”[21] Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms.[22]Sharing pronouns as part of a basic introduction to a patient can assist a transgender patient to feel secure sharing their pronouns in a health care setting. Asking a patient for their pronoun (he, she, they, ze, etc.) can be considered part of a nursing assessment.

Related Ethical Considerations

Justice, a principle and moral obligation to act on the basis of equality and equity, is a standard linked to fairness for all in society.[23] The ANA states this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety) but also fairness in all operations of societal structures. This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence.[24]

Social justice is related to respect and equity. The ANA defines social justice as equal rights, equal treatment, and equitable opportunities for all.[25] The ANA further states, “Nurses need to model the profession’s commitment to social justice and health through actions and advocacy to address the social determinants of health and promote well-being in all settings within society.”[26] Social determinants of health are nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life.[27] Health outcomes impacted by social determinants of health are referred to as health disparities. Health disparities are further discussed in a subsection later in this chapter.

Cultural Competence

The freedom to express one’s cultural beliefs is a fundamental right of all people. Nurses realize that people speak, behave, and act in many different ways due to the influential role that culture plays in their lives and their view of the world. Cultural compe­tence is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.[1],[2],[3]

Culturally-competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their patients’ cultural beliefs. It takes motivation, time, and practice to develop cultural competence and it will evolve throughout your nursing career. Culturally competent nurses have the power to improve the quality of care leading to better health outcomes for culturally diverse patients. Nurses who accept and respect the cultural values and beliefs of their patients are more likely to develop supportive and trusting relationships with their patients. In turn, this opens the way for optimal disease and injury prevention and leads towards positive health outcomes for all patients .

The roots of providing culturally-competent care are based on the original transcultural nursing theory developed by Dr. Madeleine Leininger. Transcultural nursing incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way.[4] See Figure 5.1[5] for an image of Dr. Leininger. Read more about transcultural nursing theory in the following box.

Nurses have an ethical and moral obligation to provide culturally competent care to the patients they serve.[7] The “Respectful and Equitable Practice” Standard of Professional Performance set by the American Nurses Association (ANA) states that nurses must practice with cultural humility and inclusiveness.  The ANA Code of Ethics also states that the nurse should collaborate with other health professionals, as well as the public, to protect human rights, fight discriminatory practices, and reduce disparities.[8] Additionally, the ANA Code of Ethics also states that nurses “are expected to be aware of their own cultural identifications in order to control their personal biases that may interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the patient’s culture … nurses should possess knowledge and understanding how oppression, racism, discrimination, and stereotyping affect them personally and in their work.”[9]

Developing cultural competence begins in nursing school.[10],[11] Culture is an integral part of life, but its impact is often implicit. It is easy to assume that others share the same cultural values that you do, but each individual has their own beliefs, values, and preferences. Begin the examination of your own cultural beliefs and feelings by answering the questions below.[12]

Reflect on the following questions carefully and contemplate your responses as you begin your journey of providing culturally responsive care as a nurse. (Questions are adapted from the Anti Defamation League’s “Imagine a World Without Hate” Personal Self-Assessment Anti-Bias Behavior).[13]

• Who are you? With what cultural group or subgroups do you identify?
• When you meet someone from another culture, country or place, do you try to learn more about them?
• Do you notice instances of bias, prejudice, discrimination, and stereotyping against people of other groups or cultures in your environment (home, school, work, TV programs or movies, restaurants, places where you shop)?
• Have you reflected on your own upbringing and childhood to better understand your own implicit biases and the ways you have internalized messages you received?
• Do you ever consider your use of language to avoid terms or phrases that may be degrading or hurtful to other groups?
• When other people use biased language and behavior, do you feel comfortable speaking up and asking them to refrain?
• How ready are you to give equal attention, care, and support to people regardless of their culture, socioeconomic class, religion, gender expression, sexual orientation, or other “difference”?

The Process of Developing Cultural Competence

Dr. Josephine Campinha-Bacote is an influential nursing theorist and researcher who developed a model of cultural competence. The model asserts there are specific characteristics that a nurse becoming culturally competent possesses, including cultural awareness, cultural knowledge, cultural skill, and cultural encounters.[14]

Cultural awareness is a deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, attitudes, practices, and problem-solving strategies of a patient’s culture. To become culturally aware, the nurse must undergo reflective exploration of personal cultural values while also becoming conscious of the cultural practices of others. In addition to reflecting on one’s own cultural values, the culturally competent nurse seeks to reverse harmful prejudices, ethnocentric views, and attitudes they have. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures. Although cultural diversity training is typically a requirement for healthcare professionals, cultural desire refers to the intrinsic motivation and commitment on the part of a nurse to develop cultural awareness and cultural competency.[15]

Acquiring cultural knowledge is another important step towards becoming a culturally competent nurse. Cultural knowledge refers to seeking information about cultural health beliefs and values to understand patients’ world views. To acquire cultural knowledge, the nurse actively seeks information about other cultures, including common practices, beliefs, values, and customs, particularly for those cultures that are prevalent within the communities they serve.[16] Cultural knowledge also includes understanding the historical backgrounds of culturally diverse groups in society, as well as physiological variations and the incidence of certain health conditions in culturally diverse groups. Cultural knowledge is best obtained through cultural encounters with patients from diverse backgrounds to learn about individual variations that occur within cultural groups and to prevent stereotyping.

While obtaining cultural knowledge, it is important to demonstrate cultural sensitivity. Cultural sensitivity means being tolerant and accepting of cultural practices and beliefs of people. Cultural sensitivity is demonstrated when the nurse conveys nonjudgmental interest and respect through words and action and an understanding that some health care treatments may conflict with a person’s cultural beliefs.[17] Cultural sensitivity also implies a consciousness of the damaging effects of stereotyping, prejudice, or biases on patients and their well-being. Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the patient and their family members. When a patient experiences nursing care that contradicts with their cultural beliefs, they may experience moral or ethical conflict, nonadherence, or emotional distress.

Cultural desire, awareness, sensitivity, and knowledge are the building blocks for developing cultural skill. Cultural skill is reflected by the nurse’s ability to gather and synthesize relevant cultural information about their patients while planning care and using culturally sensitive communication skills. Nurses with cultural skill provide care consistent with their patients’ cultural needs and deliberately take steps to secure a safe health care environment that is free of discrimination or intolerance. For example, a culturally skilled nurse will make space and seating available within a patient’s hospital room for accompanying family members when this support is valued by the patient.[18]

Cultural encounters is a process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

By developing the characteristics of cultural awareness, cultural knowledge, cultural skill, and cultural encounters, a nurse develops cultural competence.

Health Disparities

Despite decades of promoting cultural competent care and the Patient’s Bill of Rights, disparities in health care continue. Vulnerable populations continue to experience increased prevalence and burden of diseases, as well as problems accessing quality health care. In 2003, the Institute of Medicine (IOM) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, sharing evidence that “bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care.”[1] The health care system in the United States was shaped by the values and beliefs of mainstream white culture and originally designed to primarily serve English-speaking patients with financial resources.[2] In addition, most health care professionals in the United States are members of the white culture and medical treatments tend to arise from that perspective.[3],[4]

The term health disparities describes the differences in health outcomes that result from social determinants of health. Social determinants of health are conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.[5]

Vulnerable populations experience increased prevalence and burden of diseases, as well as problems accessing quality health care because of social determinants of health. Health disparities negatively impact groups of people based on their ethnicity, gender, age, mental health, disability, sexual orientation, gender identity, socioeconomic status, geographic location, or other characteristics historically linked to discrimination or exclusion.[6] A related term is health care disparity, which refers to differences in access to health care and insurance coverage. Health disparities and health care disparities can lead to decreased quality of life, increased personal costs, and lower life expectancy. More broadly, these disparities also translate to greater societal costs, such as the financial burden of uncontrolled chronic illnesses.

The Agency for Healthcare Research and Quality (AHRQ) releases an annual National Healthcare Quality and Disparities Report that provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. Quality is described in terms of patient safety, person-centered care, care coordination, effective treatment, healthy living, and care affordability.[7] Although access to health care and quality have improved since 2000 in the wake of the Affordable Care Act (ACA), the 2019 report shows continued disparities, especially for poor and uninsured populations:

• For about 40% of quality measures, African Americans, and Alaska Natives receive worse care than Whites. For more than one third of quality measures, Hispanics receive worse care than Whites.
• For nearly a quarter of quality measures, residents of large metropolitan areas received worse care than residents of suburban areas. For one third of quality measures, residents of rural areas received worse care than residents of suburban areas.[8]

There are several initiatives and agencies designed to combat the problem of health disparities in the United States. See Table 5.1 for a list of hyperlinks to available resources to combat health disparities.

See the following box for an example of nurses addressing a community health care disparity during the water crisis in Flint, Michigan.

Providing culturally responsive care is a key strategy for reducing health disparities.[11] While there are multiple determinants contributing to a person’s health, nurses play an important role in reducing health disparities by providing a culturally sensitive environment, performing a cultural assessment, and providing culturally responsive care. These interventions will be further discussed in the following sections. On the other hand, a lack of culturally responsive care potentially contributes to miscommunication between the patient and the nurse. The patient may experience distress or loss of trust in the nurse or the health care system as a whole and may not adhere to prescribed treatments. Nurses are uniquely positioned to directly impact patient outcomes as we become more aware of unacceptable health disparities and work together to overcome them.[12]

Culturally Sensitive Care

Providing culturally responsive care integrates an individual’s cultural beliefs into their health care. Begin by conveying cultural sensitivity to patients and their family members with these suggestions:[1]

• Set the stage by introducing yourself by name and role when meeting the patient and their family for the first time. Until you know differently, address the patient formally by using their title and last name. Ask the patient how they wish to be addressed and record this in the patient’s chart. Respectfully acknowledge any family members and visitors at the patient’s bedside.
• Begin by standing or sitting at least arm’s length from the patient.
• Observe the patient and family members in regards to eye contact, space orientation, touch, and other nonverbal communication behaviors and follow their lead.
• Make note of the language the patient prefers to use and record this in the patient’s chart. If English is not the patient’s primary language, determine if a medical interpreter is required before proceeding with interview questions. See the box below for guidelines in using a medical interpreter.
• Use inclusive language that is culturally sensitive and appropriate. For example, do not refer to someone as “wheelchair bound”; instead say “a person who uses a wheelchair.” [2]
• Be open and honest about the extent of your knowledge of their culture. It is acceptable to politely ask questions about their beliefs and seek clarification to avoid misunderstandings.
• Adopt a nonjudgmental approach and show respect for the patient’s cultural beliefs, values, and practices. It is possible that you may not agree with a patient’s cultural expressions, but it is imperative that the patient’s rights are upheld. As long as the expressions are not unsafe for the patient or others, the nurse should attempt to integrate them into their care.
• Assure the patient that their cultural considerations are a priority in their care.
  Guidelines for Using a Medical Interpreter[3]
  When caring for a patient whose primary language is not English and they have a limited ability to speak, read, write, or understand the English language, seek the services of a trained medical interpreter. Health care facilities are mandated by The Joint Commission to provide qualified medical interpreters. Use of a trained medical interpreter is linked to fewer communication errors, shorter hospital stays, reduced 30-day readmission rates, and improved patient satisfaction.
  Refrain from asking a family member to act as an interpreter. The patient may withhold sensitive information from them, or family members may possibly edit or change the information provided. Unfamiliarity with medical terminology can also cause misunderstanding and errors.
  Medical interpreters may be on-site or available by videoconferencing or telephone. The nurse should also consider coordinating patient and family member conversations with other health care team members to streamline communication, while being aware of cultural implications such as who can discuss what health care topics and who makes the decisions. When possible, obtain a medical interpreter of the same gender as the patient to prevent potential embarrassment if a sensitive matter is being discussed.

Cultural Assessment

After establishing a culturally sensitive environment, nurses should incorporate a cultural assessment when caring for all patients. There are many assessment guides used for patient interviews that are adaptable to a variety of health care settings and are designed to facilitate understanding and communication. The Four Cs of Culture model[1] is an example of a quick cultural assessment tool that asks questions about what the patient Considers to be a problem, the Cause of the problem, how they are Coping with the problem, and how Concerned they are about the problem. See the following paragraph for examples of sample answers to the four Cs assessment.

Four Cs of Culture[2]

1. What do you think is wrong? What is worrying you? (In other words, discover what the patient Considers to be the problem and what they Call it.)

• A patient with a diagnosis of pneumonia believes his body is “unbalanced.”

2. What do you think Caused this problem? How did this happen?

• The patient believes this illness is a punishment for a misdeed.

• The patient avoids eating certain foods to treat the illness while also using home remedies such as herbal tea.

3. How serious is this problem for you? How Concerned are you?

• A patient views the illness as being “God’s will” and states, “It’s in God’s hands.”

A more comprehensive cultural assessment tool, inspired by R. E. Spector’s Heritage Assessment interview,[3] is described in the following box.

Culturally Responsive Care

After establishing a culturally sensitive environment and performing a cultural assessment, nurses and nursing students can continue to promote culturally responsive care. Culturally responsive care includes creating a culturally safe environment, using cultural negotiation, and considering the impact of culture on patients’ time orientation, space orientation, eye contact, and food choices.

Culturally Safe Environment

A primary responsibility of the nurse is to ensure the environment is culturally safe for the patient. A culturally safe environment is a safe space for patients to interact with the nurse, without judgment or discrimination, where the patient is free to express their cultural beliefs, values, and identity. This responsibility belongs to both the individual nurse and also to the larger health care organization.

Cultural Negotiation

Many aspects of nursing care are influenced by the patient’s cultural beliefs, as well as their beliefs of the health care culture. For example, the health care culture in the United States places great importance on punctuality for medical appointments, yet a patient may belong to a culture that views “being on time” as relative. In some cultures, time is determined simply by whether it is day or night or time to wake up, eat, or sleep. Making allowances or accommodations for these aspects of a patient’s culture is instrumental in fostering the nurse-patient relationship. This accommodation is referred to as cultural negotiation. See Figure 3.6[1] for an image illustrating cultural negotiation. During cultural negotiation, both the patient and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the patient’s cultural needs. Cultural negotiation is reciprocal and collaborative. When a patient’s cultural needs do not significantly or adversely affect their treatment plan, their cultural needs should be accommodated when feasible.

As an example, think about the previous example of a patient for whom a fixed schedule is at odds with their cultural views. Instead of teaching the patient to take a daily medication at a scheduled time, the nurse could explain that the patient should take the medication every day when he gets up. Another example of cultural negotiation is illustrated by a scenario in which the nurse is preparing a patient for a surgical procedure. As the nurse goes over the preoperative checklist, the nurse asks the patient to remove her head covering (hijab). The nurse is aware that personal items should be removed before surgery; however, the patient wishes to keep on the hijab. As an act of cultural negotiation and respect for the patient’s cultural beliefs, the nurse makes arrangements with the surgical team to keep the patient’s hijab in place for the surgical procedure and covers the patient’s hijab with a surgical cap.

Decision-Making

Health care culture in the United States mirrors cultural norms of the country, with an emphasis on individuality, personal freedom, and self-determination. This perspective may conflict with a patient whose cultural background values group decision-making and decisions made to benefit the group, not necessarily the individual. As an example, in the 2019 film The Farewell, a Chinese-American family decides to not tell the family matriarch that she is dying of cancer and only has a few months left to live. The family keeps this secret from the woman in the belief that the family should bear the emotional burden of this knowledge, which is a collectivistic viewpoint in contrast to American individualistic viewpoint.

Space Orientation

The amount of space that a person surrounds themselves with to feel comfortable is influenced by culture. (Read more about space orientation in the “Communication” chapter.) See Figure 5.4[2] for an image illustrating space orientation. For example, for some people, it would feel awkward to stand four inches away from another person while holding a social conversation, but for others a small personal space is expected when conversing with another.[3]There are times when a nurse must enter a patient’s intimate or personal space, which can cause emotional distress for some patients. The nurse should always ask for permission before entering a patient’s personal space and explain why and what is about to happen.

Patients may also be concerned about their modesty or being exposed. A patient may deal with the violation of their space by removing themselves from the situation, pulling away, or closing their eyes. The nurse should recognize these cues for what they are, an expression of cultural preference, and allow the patient to assume a position or distance that is comfortable for them.

Similar to cultural influences on personal space, touch is also culturally determined. This has implications for nurses because it may be inappropriate for a male nurse to provide care for a female patient and vice versa. In some cultures, it is also considered rude to touch a person’s head without permission.

Eye Contact

Eye contact is also a culturally mediated behavior. See Figure 5.5[4] for an image of eye contact. In the United States, direct eye contact is valued when communicating with others, but in some cultures, direct eye contact is interpreted as being rude or bold. Rather than making direct eye contact, a patient may avert their eyes or look down at the floor to show deference and respect to the person who is speaking. The nurse should notice these cultural cues from the patient and mirror the patient’s behaviors when possible.

Food Choices

Culture plays a meaningful role in the dietary practices and food choices of many people. Food is used to celebrate life events and holidays. Most cultures have staple foods, such as bread, pasta, or rice and particular ways of preparing foods. See Figure 5.6[5] for an image of various food choices. Special foods are prepared to heal and to cure or to demonstrate kinship, caring, and love. For example, in the United States, chicken noodle soup is often prepared and provided to family members who are ill.

Conversely, certain foods and beverages (such as meat and alcohol) are forbidden in some cultures. Nurses should accommodate or negotiate dietary requests of their patients, knowing that food holds such an important meaning to many people. If you notice food or beverage that is likely against the cultural practice of a patient, for example, you should confirm with the patient and remove the item from the tray.

Summary

In summary, there are several steps in the journey of becoming a culturally competent nurse with cultural humility who provides culturally responsive care to patients. As you continue in your journey of developing cultural competency, keep the summarized points in the following box in mind.