Developing cultural competence in nursing-patient relationships

ALTOONA, Pa. — A hospital stay for a patient usually means seeing a doctor or resident once a day. Nurses, however, are present 24 hours a day, and because of this they may have a fuller understanding of a patient’s condition, needs and desires. But at first meeting — beyond the medical chart — patients are still strangers to their nurses, which can be an obstacle to treatment, especially when the patient comes from an unfamiliar country, has a different ethnic and racial background, or practices an unfamiliar religion.

What can nurses do to overcome this problem? Linda Govere, assistant teaching professor of nursing at Penn State Altoona, believes training in cultural competence is the answer.

Govere speaks from personal experience. A native of Zimbabwe who came to the United States 16 years ago, she said that a doctor’s visit helped her realize the importance of understanding a patient’s background. When she requested a female physician for a reproductive-system examination, “they didn’t understand what I was talking about and still went ahead and assigned me a male.” At the time, she was offended, but now acknowledges that it was a matter of cultural differences — “I didn’t understand the whole system,” she said. It made her realize that changes were needed. 

“We all have different cultures and beliefs,” she said. “We can do a better job of being culturally competent.”

The goal in cultural competence is to create mutually positive, respectful, meaningful and effective relations and interactions among people with different ethnic, racial, religious, geographic and social backgrounds, explained Govere.

In order to do that, the nurse has to listen to the patient. Govere believes that if nurses “can take the time to sit down with a patient and say, ‘How can I take care of you today?’” it will go a long way toward giving the patient the best treatment possible. Nevertheless, the answer is also not as simple as a single conversation, she said. As the United States becomes more diverse, the mixing of cultures becomes more complex, and nurses — who may have come from outside the U.S. themselves — need to learn what they need to know for their patients.

Because of her experience and what she has seen from her nursing practice, Govere decided to do a literature search to see if there are any research studies focusing on cultural-competence training programs.

“I found out there are many but they are too broad, with wide variations in training duration,” she said. Her own initial literature review on cultural competence came about while she was working on her dissertation for her doctoral degree. She found out about a federal program on cultural-competence training from the Office of Minority Health in the U.S. Department of Health and Human Services but, she said, it is not yet well known.

The research studies Govere looked at varied greatly in quality and methodological rigor as well as in cultural-competence training content, contact time, assessment tools, measured variables and measurement units.

“We need more research that employs refined experimental designs to develop and evaluate the effectiveness of specialty-specific cultural competence training programs and assessment tools,” she said. Govere is currently working on research focusing on “The Effectiveness of the U.S. Office of Minority Health’s Culturally Competent Nursing Modules on Improving the Cultural Competence of Maternal and Child Health Nurses to Increase Patient Satisfaction.”

To introduce a level of consistency, Govere decided to limit her subjects to one specific area of nursing practice, maternal care. She thought it would be an interesting area to focus on because “you are dealing with the nurse taking care of not only the mother but also the baby, and the family.”

Govere’s first research study was to evaluate a group of nursing students for their cultural-competence levels before and after cultural-competence training. Nine hours of cultural-competence training earned them nine continuing education credits. The final step was looking at their cultural-competence levels before and after to see if the training had made a difference. She found that the training indeed significantly improved the cultural competence of the students.

Govere said she believes “you can never stop learning.” Her path to teaching in the nursing program at Penn State Altoona illustrates that well. After joining her husband in the United States, she started going to school, first as a nurse’s aide for which she trained at the Central Pennsylvania Institute of Science and Technology in Pleasant Gap, Pennsylvania. Govere also earned her practical nurse (PN) diploma and worked as a licensed PN (LPN), while at the same time taking classes at Penn State Altoona to earn her associate’s degree in nursing.

“When I was done, I started on my bachelor’s degree,” she said. “It took me a year to complete the RN to BS and it usually takes two years.”

By 2009 Govere had earned her bachelor’s degree in nursing, after which she thought, “Why stop?” and so she pursued a master’s at Penn State University Park and, finally, her doctor in nursing practice (DNP) at the University of Pittsburgh — only because “when I got it, they didn’t have it at Penn State and the University of Pittsburgh’s DNP program is ranked among the top 10 in the nation.”

Govere’s success with cultural-competence training has inspired her to continue her research.

“My next step is to do research nationally and then globally, focusing on practicing nurses, nursing students and the nursing faculty,” she said.

She hopes these research activities will also make her a more culturally competent instructor and, in turn, help her pass on evidence-based cultural-competence knowledge and skills to her students.

“I want my students to be self-aware and function optimally as global citizens in their nursing sciences career,” Govere said, emphasizing that in this era of unprecedented global activity, cultural competency is essential to all professions. “Self-awareness is a prerequisite to becoming culturally competent,” she added. “It reveals one’s stereotypes, biases, prejudices, assumptions, values and beliefs.”