ANA OJIN About Logo
OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.

Find Out More...


Letter to the Editor

Implementing the New ANA Standard 8: Culturally Congruent Practice

m Bookmark and Share
 

Lucy Marion, PhD, RN, FAAN, FAANP
Marilyn (Marty) Douglas, PhD, RN, FAAN
Mary Ann Lavin, ScD, FNI, FAAN
Nancy Barr, RN, MN
Shena Gazaway, MSN, RN
Elizabeth (Libby) Thomas, MEd, RN, NCSN-E, FNASN
Carol Bickford, PhD, RN-BC, CPHIMS, FAAN

Abstract

The American Nurses Association (ANA) is responsible for the contract between society and the nursing profession, including the nursing scope and standards of practice. In 2015, an ANA workgroup produced Nursing: Scope and Standards of Practice, 3rd Ed during a time of social change and an increase of culturally and ethnically diverse consumers. Subsequently, a subset of workgroup members and an invited transcultural nursing expert led to the creation of the new Standard 8: Culturally Congruent Practice, describing nursing care that is in agreement with the preferred values, beliefs, worldview, and practices of the healthcare consumer. This article records the history of the revised scope and standards and new Standard 8, the reasoning behind this standard and its impact on nursing practice, education, and research. The article also guides nurses in the application of Standard 8 to nursing practice and offers discussion about implementing culturally congruent practice through the nursing process. We also discuss cultural congruence for the graduate-prepared nurse; offer brief comments related to evaluation of culturally congruent practice using Standard 8 and future research; and conclude with a call to action.

Citation: Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, L., Bickford, C., (November 18, 2016) "Implementing the New ANA Standard 8: Culturally Congruent Practice" OJIN: The Online Journal of Issues in Nursing Vol. 22 No. 1.

DOI: 10.3912/OJIN.Vol22No01PPT20

Keywords: American Nurses Association, ANA, scope and standards of practice, culturally congruent practice, cultural competence, professional development, shared decision making, access to healthcare

Standard 8: Culturally Congruent Practice. The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles.

American Nurses Association (2015a) p. 69; (Table 1)

In 2015, the American Nurses Association (ANA) published the third edition of Nursing: Scope and Standards of Practice (NSSP) to include, for the first time, the Standard of Culturally Congruent Practice. In this article, we present the history of the revised standards and the new Standard 8; discuss the application of the new standard to nursing practice; consider research related to culturally congruent nursing care; and conclude with a Call to Action for promoting culturally congruent practice for nurses, educators, and researchers.

History of the Revised Standards and New Standard 8

The standards of nursing practice... are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to competently perform.  ANA is responsible for articulating the social contract between the profession and society, which includes the definition of nursing (ANA, 2015a), the nursing code of ethics (ANA, 2015b), and the scope and standards of nursing practice (ANA, 2015a). These three works, which ANA calls the Essentials of Nursing Practice, guide nurses in their practice and inform the public of the profession’s expectations of its licensed members. The scope of nursing practice describes the who, what, where, when, why, and how of nursing practice; and it provides a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership (ANA, 2015a; Nursing Scope and Standards Revision Workgroup, 2015). The standards of nursing practice, as listed in Table 1, are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to competently perform. Performance of the competencies that accompany each standard may be considered as evidence of compliance with that standard, but the list is not exhaustive (ANA, 2015a).

Table 1. Standards of Professional Nursing Practice

Standards of Practice

Standard 1: Assessment

Standard 2: Diagnosis

Standard 3: Outcomes Identification

Standard 4: Planning

Standard 5: Implementation

Standard 5A: Coordination of Care

Standard 5B: Health Teaching and Health Promotion

Standard 6: Evaluation

Standards of Professional Performance

Standard 7: Ethics

Standard 8: Culturally Congruent Practice

Standard 9: Communication

Standard 10: Collaboration

Standard 11: Leadership

Standard 12: Education

Standard 13: Evidence-based Practice and Research

Standard 14: Quality of Practice

Standard 15: Professional Practice Evaluation

Standard 16: Resource Utilization

Standard 17: Environmental Health

Nursing Scope and Standards Revision Workgroup (2015). Reprinted with permission.

In June 2014, ANA commissioned a workgroup of 40 expert nurses, diverse in education, experience, and demographics, to review and revise the 2010 Nursing: Scope and Standards of Practice (NSSP), 2nd Ed. (ANA, 2010). For over a year, the workgroup met regularly via telephone-conference calls. The workgroup first examined and slightly revised the definition of nursing originally published in the 2003 Nursing's Social Policy Statement and later in the 2010 edition (ANA, 2003; ANA, 2010).The workgroup added the terms "facilitation of healing” and “groups” to enhance the definition of nursing:

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations (ANA, 2015a, p. 1).

“Race matters” was an important concept in the dissenting opinion to the Supreme Court decision in Schuette v. Coalition to Defend Affirmative Action. The workgroup next reviewed the scope statements and all standards. This review occurred at a period of global and national angst, in part due to a steady increase of culturally and ethnically diverse consumers within healthcare educational programs, workforce, and delivery systems. Global connectivity and communications continued to grow exponentially while ethnic strife, mass migration, and related humanitarian need spiked to crisis proportions (Médicins Sans Frontières, 2016). In the United States (U.S.), in addition to expression of divergent views on immigration policy, altercations with authorities exposed human-rights deprivation and harm to racial, ethnic, and immigrant groups (Morales, Pilet, & Ruedin, 2015; Shively et al., 2014; U.S. Department of Justice, 2015; 2016). In contrast, the U.S. Supreme Court concurrently expanded the civil rights of same-sex couples to include marriage and related privileges, citing the laws governing marriage as reflecting historically “continuity and change” (Obergefell v. Hodges, 576 U. S., 2015, p. 6). “Race matters” was an important concept in the dissenting opinion to the Supreme Court decision in Schuette v. Coalition to Defend Affirmative Action (Schuette v. Coalition to Defend Affirmative Action, No. 12-682 (S. Ct. Apr. 22, 2014). Within nursing, a comprehensive research review of diverse nursing students’ clinical experiences revealed a need for additional studies to understand more fully the impact of diversity in this group (Koch, Everett, Phillips & Davidson, 2015).

The NSSP workgroup recognized that most nurses, regardless of practice setting or role, would profit from expert guidance to move beyond the lens of their personal views, worldviews, and experiences to more insightful and inclusive education/care for consumers with varied backgrounds (Bond, Cason, & Baxley, 2015; Kamen, Smith-Stoner, Heckler, Flannery, & Margolies, 2015; Messias, McEwen, & Clark, 2015). A subset of workgroup members and a transcultural nursing expert further developed ideas about care for diverse consumers, and seven of these subgroup members authored this article. The sum of these influences and the workgroup members’ collective, multicultural experience led to the development of the following new ANA standard on cultural congruence and revision of the how and why scope of practice statements:

Culturally congruent practice is the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural compe­tence represents the process by which nurses demonstrate culturally congruent practice. Nurses design and direct culturally congruent practice and services for diverse consumers to improve access, promote positive outcomes, and reduce disparities. (ANA, 2015a, p. 31).

This new Standard 8 now provides a framework enabling nurses to become culturally competent role models and leaders for novice clinicians, colleagues, and consumers. Part of the trend to ensure better outcomes and reduce health disparities, namely, new minimum quality indicators, were announced for healthcare organizations and providers — indicators that include culturally appropriate care (American Geriatrics Society Ethnogeriatrics Committee, 2016). Moreover, steps have been taken to create a discrimination-free healthcare environment for lesbian, gay, bisexual, and transgender (LGBT) individuals (American Geriatrics Society Ethics Committee, 2015). This new Standard 8 now provides a framework enabling nurses to become culturally competent role models and leaders for novice clinicians, colleagues, and consumers. 

Originating from the foundational work of Cross, Bazron, Dennis, & Isaacs (1989), the definition of cultural competence has evolved to include key elements for effective work in cross-cultural situations. Cultural competence and cultural congruence in nursing care are not new ideas. The seeds were planted by Madeleine Leininger in her book Nursing and Anthropology: Two Worlds to Blend (Leininger, 1970). Over the next 45 years, the field of transcultural nursing has grown and produced a major theory (Leininger & McFarland, 2002; McFarland & Wehbe-Alamah, 2015); more than a half dozen models (Andrews & Boyle, 2015; Campinha-Bacote, 2011; Giger & Davidhizar, 2008; Jeffreys, 2010; Purnell, 2013; Spector, 2013), and hundreds of published research studies (Douglas & Pacquiao, 2010). Due to these strides, national and international professional groups and schools are now incorporating principles of cultural competence into their policies, standards, and curricula.

The Culturally Congruent Practice standard sets the bar for registered nurses' educational, legal, and societal accountability. Cultural congruence is part of the fabric of nursing practice because of the social contract between the profession and society. The new Standard 8 advances all of nursing practice within the contract. What follows here will provide guidance for the practicing nurse in implementing Standard 8.

Application of Standard 8 to Nursing Practice

Standard 8 is explicated with 13 competencies for registered nursing practice at all educational levels and in all roles, an additional five specific competencies for graduate-level nursing practice, and two more for the practice of Advanced Practice Registered Nurses (for a total of 20). Table 2 provides a list of all these competencies, and Table 3 contains the authors' recommendations for acquiring and applying the Standard’s competencies by all nurses.

Table 2. Standard 8. Culturally Congruent Practice and Associated Competencies

The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles.

Competencies for the registered nurse:

  1. Demonstrates respect, equity, and empathy in actions and interactions with all healthcare consumers.
  2. Participates in lifelong learning to understand cultural preferences, worldview, choices, and decision-making processes of diverse consumers.
  3. Creates an inventory of one’s own values, beliefs, and cultural heritage.
  4. Applies knowledge of variations in health beliefs, practices, and communication patterns in all nursing practice activities.
  5. Identifies the stage of the consumer’s acculturation and accompanying patterns of needs and engagement.
  6. Considers the effects and impact of discrimination and oppression on practice within and among vulnerable cultural groups.
  7. Uses skills and tools that are appropriately vetted for the culture, literacy, and language of the population served.
  8. Communicates with appropriate language and behaviors, including the use of medical interpreters and translators in accordance with consumer preferences.
  9. Identifies the cultural-specific meaning of interactions, terms, and content.
  10. Respects consumer decisions based on age, tradition, belief and family influence, and stage of acculturation.
  11. Advocates for policies that promote health and prevent harm among culturally diverse, under-served, or under-represented consumers.
  12. Promotes equal access to services, tests, interventions, health promotion programs, enrollment in research, education, and other opportunities.
  13. Educates nurse colleagues and other professionals about cultural similarities and differences of healthcare consumers, families, groups, communities, and populations.

Additional competencies for the graduate-level prepared registered nurse:

  1. Evaluates tools, instruments, and services provided to culturally diverse populations.
  2. Advances organizational policies, programs, services, and practices that reflect respect, equity, and values for diversity and inclusion.
  3. Engages consumers, key stakeholders, and others in designing and establishing internal and external cross-cultural partnerships.
  4. Conducts research to improve healthcare and healthcare outcomes for culturally diverse consumers.
  5. Develops recruitment and retention strategies to achieve a multicultural workforce.
Additional competencies for the advanced practice registered nurse:
  1. Promotes shared decision-making solutions in planning, prescribing, and evaluating processes when the health care consumer’s cultural preferences and norms may create incompatibility with evidence-based practice.
  2. Leads interprofessional teams to identify the cultural and language needs of the consumer.

American Nurses Association. (2015a, pp. 69-70). Reprinted with permission.

Table 3. Process for Competency Enhancement/Development

The following steps apply to the nursing process for the purpose of enhancing or developing one’s own nursing competencies. The steps include:

  • Assessment of one’s own competencies
  • Diagnosis of competency gaps, i.e., competencies in need of further refining or development
  • Establish competency goal or goals, e.g., timeframe within which competency will be more fully enhanced or developed
  • Create plan to achieve competency goal
  • Implement competency goal enhancement/development plan
  • Establish an on-going program to evaluate self-progress, attainment of competency benchmark, and increasing mastery of the competency

Note: Tools used to achieve new competencies include continuing education, professional reading, attendance at lectures, TED talks, seeking input and guidance from respected consumers, peers, colleagues, current or past mentors as well as methods using newer technologies, e.g., videotaping and analysis of performance in practice.

Professional Development

Most registered nurses will meet the standard for culturally congruent practice with its associated competencies through the lifelong process of professional development. Nurses gain relevant new information from research, critical reflection, colleagues, and consumers served, and then apply this knowledge to practice. The process requires ever-expanding self-awareness, continuous judgment of current competence, actions for personal and professional growth, and periodic use of evidence-based assessment tools and methods for critical appraisal. This process begins with the novice student and continues throughout the registered nurse’s professional life.

In the Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health, Recommendation 6 states that nurses should “engage in lifelong learning” (Institute of Medicine, 2010, p. S-11). An essential element of professional nursing practice, lifelong learning takes place via formal education, clinical training, self-directed study and observation, and continuing education. Therefore, nurses seek, and advocate for, educational opportunities designed to integrate culturally congruent principles into their care for diverse consumers and populations.

Tailored instruction for nursing colleagues creates the opportunity to educate one another on culturally-specific interventions that improve consumer outcomes of nursing care. Nurses, who generally have had a graduate education, develop and present educational programs to advance culturally congruent healthcare for nurses and colleagues across healthcare professions (Steelman, 2014). Nurses benefit from professional conferences to learn more about culturally congruent care designed to reduce health disparities and improve equitable care, especially with the growing awareness of the social determinants of health (Phillips & Malone, 2014). Tailored instruction for nursing colleagues creates the opportunity to educate one another on culturally-specific interventions that improve consumer outcomes of nursing care.

Self-Assessment

Self-assessment requires awareness of one’s own cultural assumptions, values, and beliefs, as well as one’s own conscious and unconscious (implicit) biases. Validated self-assessment tools are available to the public, including the Implicit Association Test (IAT) used in numerous studies to rate social and racial implicit bias. Haider published three studies using the IAT paired with clinical vignettes: one with medical students (Haider et al., 2011), one with registered nurses (Haider et al., 2015a), and one with acute care physicians (Haider et al., 2015b). Although all groups had implicit biases according to the IAT scores, the nurses and acute care physicians did not reflect their implicit biases in clinical care responses. Self-assessment using IAT and other tools available in the literature can result in negative self-perception and embarrassment, yet the literature shows the importance of doing so in order to help reduce disparities in healthcare (Staats, 2014; Staats, Capatosto, Wright, & Contractor, 2015).

The first step in self-assessment is to conduct a personal inventory through critical reflection to become aware of biases that may inadvertently affect clinical decisions and care practices. Reflective thinking permits persons to examine actions on evaluations and to inquire critically about their worldview and assumptions in specific situations (Teekman, 2000). “Reflection is an integral part of growth and development, as well as the provision of quality nursing care” (Rosenkoetter & Rosenkoetter, 2005, p. 17). As a component of reflection, self-awareness enables each individual to analyze personal feelings (Atkins & Murphy, 1993). Class or group exercises in critical reflection include identification of one’s own values that may be in conflict with the values of others. Beyond awareness of biases, it is important that nurses critically reflect on their own religious beliefs, personality traits, and skills related to emotional and social intelligence so as to be able to deliver nursing care tailored to the cultural preferences of the consumer—not necessarily those of the nurse (Rhodes, Morris, & Lazenby, 2011).

Implementing Culturally Congruent Practice through the Nursing Process

In the NSSP (ANA, 2015a), the concept of culture is included in many passages. For example, culture is mentioned in the first six standards—assessment, diagnosis, outcomes identification, planning, implementation (which includes coordination of care, health teaching, and health promotion), and finally, evaluation of practice. Standard 8 further expands and explicates the concept of culture by providing explicit competencies for nurses to demonstrate in order to provide culturally congruent care.

Providing culturally congruent care involves applying knowledge of how culture influences one’s health beliefs, health practices, and communication patterns at each stage of the nursing process. Cultural assessment of the consumer occurs in the first stage of the nursing process and is facilitated by a variety of tools. Andrews and Boyle (2015) provide appendices with five types of assessment tools for culturally diverse consumers, including individuals, groups, refugees, and healthcare organizations. Purnell (2013) and Spector (2013) have assessment guides designed for ease of use by the practicing nurse. In addition, Aramburu Alegria (2011) published an assessment tool specifically for use with the LGBT populations. These tools also help identify the levels of acculturation of the client and any effects of discrimination and oppression experiences.

...evaluation should also include a determination of whether the consumers were satisfied with the process and intervention.  With the information gained from these assessment tools, the nurse is able to diagnose potential cross-cultural challenges to providing care and to plan culturally and linguistically appropriate interventions and health teaching programs. Finally, no plan can be complete without evaluation as to whether the intervention was effective in achieving the desired outcome and documenting the process and outcomes. When providing care for culturally diverse consumers, evaluation should also include a determination of whether the consumers were satisfied with the process and intervention. If the intervention is not meaningful or desired, these consumers may not continue with the plan of action and experience negative outcomes.

Culturally Congruent Communication

Effective and respectful communication is essential to nursing practice. Tested tools are available to enhance the efficacy of intercultural communication and also to advance clinical competence. Examples include communication tools for use in the care of patients with sickle cell disease (Tanabe et al., 2013); recognition of pain and its expression in African American, Hispanic, and Caucasian older adults with dementia (Ford, Snow, Herr, & Tripp-Reimer, 2015); and the psychosocial and physical evaluation of transgender clients (Aramburu Alegria, 2011).

Knowledge of cultural customs and values is important in understanding the nuances of the culture and its verbal and nonverbal communication patterns and then in conveying necessary respect. Also, the nurse listens for the consumer’s preferred ways of gathering needed information and takes into account cultural norms for defining the family decision-maker, gender roles, and care of infants and parents. Nurses show genuine caring for consumers in need of nursing care in order to build a trusting relationship with the family (Wiebe & Young, 2015).

Nurses can reduce language barriers by using translators and interpreters and employing nursing skills associated with social and emotional intelligence. For health consumers with hearing impairments, nurses use advanced technology or interpreters skilled in American Sign Language. In choosing written materials, the nurse engages culture-specific consumers in the community to evaluate the materials for readability and cultural appropriateness before distribution. In every possible case, the nurse considers preferences of the health consumer before choosing how to meet communication needs. Nonverbal behaviors also may require sensitivity to cultural practices. For example, the appropriate face-to-face distance between people in conversation varies among groups. The tone and volume of the voice as well as posture are important when communicating with recipients of care and their extended families (Henry, Fuhrel-Forbis, Rogers, &Eggly, 2012).

If nurses build carefully supported, trusting relationships, inadvertent missteps in the cultural space are more likely to be averted or forgiven.  When providers use medical jargon, families may become resistant or even hostile. Wiebe and Young (2015) suggest simple strategies to increase communication and reduce stress. These strategies include answering every question carefully, teaching by demonstration, providing simple explanations, and demonstrating caring relationships for the building of trust. Searching for culture-specific meaning in interactions, terms, and content of conversations will help the nurse provide culturally congruent communication. If nurses build carefully supported, trusting relationships, inadvertent missteps in the cultural space are more likely to be averted or forgiven.

Shared Decision-Making

Shared decision-making highlights patient involvement with treatment decisions, which can lead to better health outcomes (Mead et al., 2013). Mead et al., (2013) examined cancer-related decision-making among underrepresented minority consumers and concluded that, although no one method will fit all, it is essential to include the context of family and community when examining an individual’s preferences and perceptions regarding medical decisions. When consumers share in their health-related decisions, health outcomes are more positive (Cowell, McNaughton, & Ailey, 2000; Cox, et al., 2009). Nurses can share decision-making with these consumers only if nurses themselves have culturally congruent assessment and communication skills. Moreover, nurses need access to validated guidelines (Lipson & Dibble, 2005) when cultural preferences are known along with access to expert cultural consultants who can fill knowledge and skill gaps. For example, in some cultures, the woman is the designated caregiver for the children and needs to be actively involved in all child-related healthcare decisions. In other cultures, the father or the parents together assume this role. Culturally congruent care plans incorporate cultural influences regarding access to care and individual and group health decisions (Hernandez & Wallace, 2014; Lind, Perrine, Li, Scanlon, & Grummer-Strawn, 2014).

In shared decision-making, nurses introduce the sharing process, provide information, ascertain preferences, and discuss options to adapt a usual procedure or process, such as screening, treatment, comfort measures, and visitation, among others. Because the consumer may prefer not to make decisions, and urgency for care may preclude choosing, the extent of sharing will vary. 'Tailoring care' for the consumer requires negotiation to share the decision-making process. For example, a consumer (family) may wish to have an end-of-life religious rite that requires a specially scented candle, which would be dangerous in the presence of oxygen. In such cases, the nurse could negotiate for the scents to be released immediately following death and discontinuation of oxygen. 'Translating care' is the process of engaging the consumer (group, population, or community) in redesigning an evidence-based protocol or program so as to be congruent with their culture. For example, a successful clinic-based Diabetes Prevention Program was adapted for several community-based settings because nurses engaged in shared decision-making with their consumers (Kramer et al., 2009; Williams et al., 2013).

Promoting Access to Care

Nurses constitute a large professional workforce that engages in and leads changes in health policy; they have considerable opportunity and responsibility to advance the initiative that all people have access to healthcare. Policy discussions involve the effects and impact of discrimination, oppression, and often-related social and environmental determinants of health on cultural groups and the resulting health disparities. Nurses advocate for policies that promote health and prevent harm among culturally diverse, underserved, or underrepresented consumers. For example, nurses advocate for all consumers, especially the culturally diverse and underserved, to receive equal access to services, tests, interventions, and health promotion programs. Achieving this goal requires nurses to advocate for sufficient funding for efficient and effective planning, delivery, and maintenance of culturally congruent care.

Culturally Congruent Practice for Graduate-Prepared Nurses and APRNs

Graduate-level nurses, including APRNs and other advanced nurses, are equipped to lead and participate in designing systems of care and organizational policies that reflect respect, equity, and values for diversity and inclusion (ANA, 2015a, p. 70). Using national and international standards of care and evidence-based practice, APRNs can model culturally competent adaptation of these guidelines to different life contexts of individuals, families, and communities in order to achieve the best possible outcomes (Carpiano, 2006). When cultural preferences and norms are incompatible with evidence-based practice, these graduate-level nurses can negotiate a solution based on mutual decision-making.

These nurses are in positions ideally suited to advocate for and lead inter-professional teams to identify the cultural and linguistic needs of the consumer and to design appropriate solutions. Nurse administrators have the authority and the tools to develop recruitment and retention strategies that supply a multicultural workforce for their institutions. Through their positions in health systems, nurse executives and leaders can work with organizational leadership in designing policies and systems to facilitate easier access and the tailoring of high quality care to the special needs of their culturally diverse consumers (Douglas et al., 2014). Moreover, through membership in civic and inter-professional organizations, advanced nurses can develop effective coalitions of cross-cultural partnerships to effect change at the local, national, and international levels (Jenerette et al., 2008). Also, nurse leaders should engage representatives of the cultural groups to participate on institutional committees and assume leadership posts in their healthcare systems to impact their respective populations.

Evaluation of Culturally Congruent Practice

The Standard 8 list of competencies will help to formulate a credible assessment tool by which the nurse can conduct an informal self-evaluation of culturally congruent practice.  Culturally congruent nursing practice spans all types of consumers, healthcare delivery systems, and nursing roles; therefore, practice evaluation ranges from fairly simple to complex. The literature shows the beneficial effects of culturally congruent practice on the skills, behaviors, and self-reported practice of healthcare providers and on patient satisfaction (Beach et al., 2005; Renzaho, Romios, Crock & Sønderlund, 2013). However, there remains a lack of comprehensive tools to measure cultural competency, thus limiting the ability to evaluate this aspect of nursing practice; more research is needed to develop these tools (Purnell, 2016). The Standard 8 list of competencies will help to formulate a credible assessment tool by which the nurse can conduct an informal self-evaluation of culturally congruent practice. Standard 8 adds focus and considerable specificity to culture-related care. Because of the specific competencies for graduate-prepared nurses, including APRNs, the standard also guides nurse executives and policymakers.

Research into Culturally Congruent Practice

The aim of research related to culturally congruent practice is to eliminate racial and ethnic health disparities among all populations. Registered nurses from all areas can identify research questions to improve culturally congruent care, and nurses with advanced degrees can evaluate the tools, instruments, and services for culturally diverse populations. These nurses can assess whether evidence-based guidelines of practice for the general population are relevant to specific culturally diverse consumers. Nurse researchers design and clinically test new interventions for culturally diverse consumers to improve the healthcare experience and health outcomes.

The current research into culturally congruent nursing to improve healthcare is sparse, and findings are not usually conclusive. One nurse-driven program of research focuses on underrepresented minorities facing health disparities that put them at greater risk for chronic illnesses and mortality (Conn, Chan, Banks, Ruppar, & Schraff, 2014a). For example, minority populations often have higher rates of medication noncompliance (Conn, Enriquez, Ruppar, & Chan, 2014b), which improved after providers used culturally relevant strategies. However, across such studies examined with meta-analyses, health outcomes did not significantly improve (Conn et al., 2014b). Similar meta-analytic studies of physical activity interventions showed improvement when underrepresented minority members were involved in delivering the project to those in their communities (Conn et al., 2014a). More research on culturally congruent interventions is needed for understanding the effectiveness of these interventions. Standard 8 can help nurses at all levels so as to advance research to improve outcomes for culturally diverse consumers.

Conclusion: A Call to Action

The demand for culturally congruent practice in Standard 8 and accompanying competencies prevails in clinical, educational, and research settings. Within quality-focused practice settings, nurses take the opportunity to learn about the cultures of the consumers for whom they provide care and support. Nurse managers are advised to use standard onboarding, continuing education, and annual reviews to advance individual and unit development for culturally congruent practices. Development sessions could include such topics as ways to understand diverse, non-verbal communication patterns, how to negotiate culturally conflicting situations, and how and when to access language services when consumers have limited English proficiency. It is important that quality healthcare systems serving diverse populations pay attention to providing appropriate language services that include provision of interpreters and translators, especially for all informed-consent processes, consumer-rights documents, and consumer-education materials.

Educational institutions should incorporate cultural content throughout all nursing curricula, including specialties. In addition, nursing programs striving to be culturally competent will want to recruit and then support 'underrepresented in nursing' minority faculty and students. Professional organizations and regulatory bodies are strongly encouraged to disseminate rapidly the new Standard 8 and its competencies to larger audiences through poster and podium presentations, publications, and social media.

Nurse researchers are encouraged to build substantial research programs beyond descriptive investigations. The essential next step is to design and test interventions that have meaning for populations from different cultures and improve their health and quality of life. Because this step requires sample sizes large enough to support meaningful conclusions, nurses and supporters need to advocate for more funding for these studies at the national level. Such research can help to eliminate the dismal inequities seen in diverse-consumer health outcomes.

By implementing Standard 8 and its accompanying competencies, nurses will RAISE the bar... and make important contributions toward reducing racial and ethnic disparities in both health outcomes and healthcare services. By implementing the standard, culturally competent nurses will increasingly serve as role models for novice clinicians, colleagues, and consumers and as leaders of change. The new standard for culturally congruent practice sets the bar for registered nurses' educational, legal, and societal accountability. Cultural congruence is part of the fabric of nursing practice because of the social contract between the profession and society; and the new Standard 8 advances all of nursing practice within the contract. By implementing Standard 8 and its accompanying competencies, nurses will RAISE the bar (See Figure below) and make important contributions toward reducing racial and ethnic disparities in both health outcomes and healthcare services.

Readers can use the Call to Action strategies listed in the Box to guide their own plan to advance culturally congruent nursing practice.

Figure. Call to Action

We call to action all registered nurses to

RAISE the bar by:

Reading Nursing: Scope and Standards of Practice, Third Edition (ANA, 2015)

Assessing the document and contemplating what it means to you and your practice

Integrating the scope and standards into practice by developing culturally congruent care in every situation and setting

Sharing the word and encouraging other nurses to integrate the scope and standards into practice

Excelling in using knowledge and conducting and applying research to achieve the highest quality, evidence-based care.

Nursing Scope and Standards Revision Workgroup (2015), P 19. Reprinted with permission.

By implementing Standard 8 and its accompanying competencies, nurses can make an important contribution toward reducing racial and ethnic disparities in both health outcomes and healthcare services.

Acknowledgment

The authors acknowledge Amanda Chapman Howard, MSN, RN, College of Nursing at Augusta University PhD student, who contributed to the final preparation of this manuscript for publication.

Authors

Lucy Marion, PhD, RN, FAAN, FAANP
Email: lumarion@augusta.edu

Lucy Marion, PhD, RN, FAAN, FAANP, Dean of the College of Nursing at Augusta University, has taught nursing research and practice at all levels. Over 30 years, she worked to develop national nursing standards, including coauthoring the first American Nurses Association nurse practitioner scope and standards and the current nursing scope and practice standards. Her NIH and other funded research evaluates health behavior change interventions designed by nurse practitioners for persons and groups from challenging walks of life. As a family nurse practitioner, she cared for people who were at highest risk due to poverty, racial discrimination, homelessness, immigration, abuse, and mental and other illnesses.

Marilyn (Marty) Douglas, PhD, RN, FAAN
Email: martydoug@comcast.net

Marilyn “Marty” Douglas, PhD, RN, FAAN, is an Associate Clinical Professor (currently Volunteer status) in the School of Nursing at the University of California, San Francisco (UCSF). Dr. Douglas earned her doctorate in International and Cross Cultural Nursing from UCSF and an MSN in Cardiovascular Nursing from the Catholic University of America. She served as a Peace Corps Volunteer in Colómbia, South America (1970-1972), leading to a heightened sensitivity to the influence of culture on healthcare beliefs and practices. She served as president of the Transcultural Nursing Society, followed by 15 years as the Editor-in-Chief of the Journal of Transcultural Nursing. As a member of the American Academy of Nursing, she chaired a task force of the Expert Panel on Global Nursing and Health to develop Standards of Practice for Culturally Competent Nursing Care.

Mary Ann Lavin, ScD, FNI, FAAN
Email: lavinma@slu.edu

Mary Ann Lavin, ScD, APRN, FNI, FAAN is a Charter Fellow of the American Academy of Nursing and of NANDA-International. She is a retired nurse practitioner, with doctorate and master’s of science degrees from Harvard School of Public Health and bachelor's and master's degrees in nursing from Saint Louis University. Dr. Lavin is an Associate Professor Emerita at Saint Louis University where she taught doctor of nursing practice students, served as founding director of clinical services at Casa de Salud, and as principal investigator of a federal Office of Rural Health Policy outreach demonstration grant in Washington County, Missouri.

Nancy Barr, RN, MN
Email: nbarr@kumc.edu

Nancy K. Barr, RN, MSN is a Clinical Assistant Professor at the University of Kansas School of Nursing. She received her diploma at St. Mary’s Hospital of Nursing, her BSN at Avila University, and her MN at the University of Kansas School of Nursing. She is a long standing member of the Missouri Nurses Association (MONA) and has previously served as president of this organization. She is also a member of the American Association of Critical Care Nurses, the Emergency Nurses Association, Sigma Theta Tau, and the Missouri Action Coalition. Her research interests include professional nursing care documentation, nursing students and their preceptors, and nursing in older adults. She is a delegate in the American Nurses Association and a current member of the workgroup for the Revision of Standards and Scope of Practice for the organization.

Shena Gazaway, MSN, RN
Email: sgazaway@augusta.edu

Shena Gazaway, MSN, RN is the Assistant BSN Program Director at the Augusta University College of Nursing Athens campus. She is a past Jonas Nurse Leaders Scholar (2014-2016), and her research interest lies in the area of professional socialization. As a community health nurse, she has cared for individuals of various ages, socioeconomic status, and cultural backgrounds.

Elizabeth (Libby) Thomas, MEd, RN, NCSN-E, FNASN
Email: libbythomas@msn.com

Elizabeth L. Thomas, MEd, RN, NCSN-E, FNASN is a national certified school nurse-emerita and fellow of the National Academy of School Nursing. She worked with Dean Marion as her Jonas Scholar student and my volunteer experience with the Georgia Nurses Association. Mrs. Thomas led the workgroup charged with production of the third edition of Nursing: Scope and Standards of Practice, published by ANA in 2015. Previously, she chaired and edited School Nursing: Scope and Standards, 2005 and 2011, co-published by ANA and the National Association of School Nurses (NASN) and was a member of the ANA Committee on Practice Standards and a steering committee member for the publication of the Code of Ethics for School Nurses with Interpretive Statements for Nurses. A consultant in school health, Mrs. Thomas, manages and provides professional development for the Delaware Comprehensive Induction Program for School Nurses.

Carol Bickford, PhD, RN-BC, CPHIMS, FAAN
Email: carol.bickford@ana.org

Carol J. Bickford, PhD, RN-BC, CPHIMS, FHIMSS, FAAN, Senior Policy Advisor, American Nurses Association Department of Nursing Practice and Work Environment, directs ANA’s scope and standards of practice program. Her portfolio includes development and revision of nursing scope and standards of practice documents, consultation services to specialty nursing organizations seeking ANA recognition, workgroup support, and document development. Dr. Bickford was an integral member, contributor, and facilitator of the initial nursing scope and standards revision workgroup and the subsequent smaller group creating this discussion about the new professional performance standard addressing culturally congruent practice.

References

American Geriatrics Society Ethics Committee. (2015). American geriatrics society care of lesbian, gay, bisexual, and transgender older adults position statement. Journal of the American Geriatrics Society, 63(3), 423-426. doi:10.1111/jgs.13297

American Geriatrics Society Ethnogeriatrics Committee. (2016). Achieving high-quality multicultural geriatric care. Journal of the American Geriatrics Society, 64(2), 255-260. doi:10.1111/jgs.13924

American Nurses Association (ANA). (2003). Nursing's social policy statement (2nd ed.). Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2015a) Nursing: Scope and standards of practice (3rd ed.). Silver Springs, MD: Nursesbooks.org.

American Nurses Association (ANA). (2015b) Code of ethics for nurses with interpretive statements. Silver Springs, MD: Nursesbooks.org.

Andrews, M. M., & Boyle, J.S. (2015). Transcultural concepts in nursing care. (7th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams, & Wilkins.

Aramburu Alegria, C. (2011). Transgender identity and health care: Implications for psychosocial and physical evaluation. Journal of the American Academy of Nurse Practitioners, 23(4), 175-182. doi: 10.1111/j.1745-7599.2010.00595.x

Atkins, S., & Murphy, K. (1993). Reflection: A review of the literature. Journal of Advanced Nursing, 18, 1188-1192.

Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., ... & Powe, N. R. (2005). Cultural competency: A systematic review of health care provider educational interventions. Medical Care, 43(4), 356.

Bond, M.L., Cason, C.L., & Baxley, S.M. (2015). Institutional support for diverse populations: Perceptions of Hispanic and African American students and program faculty. Journal of Nursing Education, 40(3), 134-139. doi: 10.1097/NNE.0000000000000126

Campinha-Bacote, J. (2011). Coming to know cultural competency: Anevolutionary process. International Journal for Human Caring, 15(3), 42-48.

Carpiano, R. M. (2006). Toward a neighborhood resource-based theory of social control for health: Can Bourdieu and sociology help? Social Science & Medicine, 62, 165-175.

Conn, V., Chan, K., Banks, J., Ruppar, T., & Scharff, J. (2014a). Cultural relevance of physical activity intervention research with underrepresented populations. The International Quarterly of Community Health Education, 34, 391-414. PMCID: PMC4388245

Conn, V., Enriquez, M., Ruppar, T., & Chan, K. (2014b). Cultural relevance in medication adherence interventions with underrepresented adults: Systematic review and meta-analysis of outcomes. Preventive Medicine, 69, 239-247. PMCID: PMC4312199

Cox, C.L., Oeffinger, K., Montgomery, M., Hudson, M.M., Leisenring, W., Whitton, J., Robinson, L. (2009). Determinants of mammography screening participation in adult childhood cancer survivors: Results from the childhood cancer survivor study. Oncology Nursing Forum, 36(3), 335-344.

Cowell, J.M., McNaughton, D.B., & Ailey, S. (2000). Development and evaluation of a Mexican immigrant family support program. The Journal of School Nursing, 16(5), 32-39.

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care: Volume 1. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center.

Douglas, M. K., & Pacquiao, D. F. (Eds.). (2010). Core curriculum in transcultural nursing and health care [Supplement]. Journal of Transcultural Nursing, 21 (Suppl. 1: 395-515).

Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J, … Purnell, L. (2014), Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-121. doi:10.1177/1043659614520998

Ford, B., Snow, A.L., Herr, K. & Tripp-Reimer, T. (2015). Ethnic differences in nonverbal pain behaviors observed in older adults with dementia. Pain Management Nursing 16(5) 692-700. doi:10.1016/j.pmn.2015.03.003.

Giger, J.N, & Davidhizar, R.E. (2008). Transcultural nursing: Assessment and intervention. (5th ed.). St. Louis, MO: Mosby/Elsevier.

Haider, A. H., Sexton, J., & Sriram, N. (2011). Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. Journal of the American Medical Association, 306, 942-951. doi:10.1001/jama.2011.1248

Haider, A. H., Schneider, E. B., Sriram, N., Scott, V. K., Swoboda, S. M., Zogg, C. K., … Cooper, L. A. (2015a). Unconscious race and class biases among Registered Nurses: Vignette-based study using implicit association testing. Journal of the American College of Surgeons, 220, 1077-1086.e3. doi:10.1016/j.jamcollsurg.2015.01.065.

Haider, A. H., Schneider, E. B., Sriram, N., Dossick, D.S., Scott V.K., Swoboda, S.M., … Freischlag, J.A. (2015b). Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions. Journal of the American Medical Association Surgical, 150(5), 457-464. doi:10.1001/jamasurg.2014.4038

Henry, S. G., Fuhrel-Forbis, A., Rogers, M. A., & Eggly, S. (2012). Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis. Patient education and counseling, 86(3), 297-315. doi:10.1016/j.pec.2011.07.006

Hernandez, C.M., & Wallace, D. (2014). A profile of Mexican-born women who adhere to national cervical cancer screening recommendations. Journal of Community Health Nursing, 31(3), 157-166. doi:10.1080/07370016.2014.926678

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R1

Jeffreys, M. R. (2010). A model to guide cultural competence education. In M.R. Jeffreys (Ed.) Teaching cultural competence in nursing and health care: Inquiry, action, and innovation. (2nd ed., pp. 45-59). New York, NY: Springer Publishing Company.

Jenerette, C. M., Funk, M., Ruff, C., Grey, M., Adderley-Kelly, B., & McCorkle, R. (2008). Models of inter-institutional collaboration to build research capacity for reducing health disparities. Nursing Outlook, 56(1), 16-24.

Kamen, C. S., Smith-Stoner, M., Heckler, C. E., Flannery, M., & Margolies, L. (2015). Social support, self-rated health, and lesbian, gay, bisexual, and transgender identity disclosure to cancer care providers. Oncology Nursing Forum, 42(1), 44-51. doi:10.1188/15.ONF.44-51

Kramer, M.K., Kriska, A.M., Venditti, E.M., Miller, R.G., Brooks, M.M., Burke, L.E., … Orchard, T.O. (2009). Translating the diabetes prevention program: A comprehensive model for prevention training and program delivery. American Journal of Preventive Medicine, 37(6):505-511. doi: 10.1016/j.amepre.2009.07.020.

Koch, J., Everett, B., Phillips, J., & Davidson, P. M. (2015). Is there a relationship between the diversity characteristics of nursing students and their clinical placement experiences? A literature review. Collegian, 22(3), 307-318. doi:10.1016/j.colegn.2014.03.007

Leininger, M.M. (1970).Nursing and anthropology: Two worlds to blend. New York: John Wiley & Sons.

Leininger, M.M, & McFarland, M.R. (2002). Transcultural nursing: Concepts, theories, research and practice. New York, NY: McGraw-Hill Education.

Lind, J.N., Perrine, C.G., Li, R., Scanlon, K.S., Grummer-Strawn, L.M. (2014). Racial disparities in access to maternity care practices that support breastfeeding - United States, 2011. Morbidity and Mortality Weekly Report, 63(33), 725-728.

Lipson, J. G., & Dibble, S. L., Eds. (2005). Culture and clinical care. San Francisco, CA: UCSF Nursing Press.

McFarland, M. R., & Wehbe-Alamah, H. B. (2015). The theory of culture care diversity and universality. In M. R. McFarland and H. B. Wehbe‐Alamah (Eds.), Leininger's culture care diversity and universality: A world wide nursing theory. (3rd ed., pp. 1-31). Burlington, MA: Jones and Bartlett Learning.

Mead, E. L., Doorenbos, A. Z., Javid, S. H., Haozous, E. A., Alvord, L. A., Flum, D. R., & Morris, A. M. (2013). Shared decision-making for cancer care among racial and ethnic minorities: A systematic review. American Journal of Public Health, 103(12), e15-e29. doi:10.2105/AJPH.2013.301631

Médicins Sans Frontières. (2016). Obstacle course to Europe: A policy-made humanitarian crisis at EU borders. (pp. 1–58, Rep.). Retrieved from http://www.msf.org/article/migration-european-policies-dramatically-worsened-so-called-2015-%E2%80%9Crefugee-crisis%E2%80%9D

Messias, D. K., McEwen, M. M., & Clark, L. (2015). The impact and implications of undocumented immigration on individual and collective health in the United States. Nursing Outlook, 63(1), 86-94. doi:10.1016/j.outlook.2014.11.004

Morales, L., Pilet, J. B., & Ruedin, D. (2015). The gap between public preferences and policies on immigration: A comparative examination of the effect of politicisation on policy congruence. Journal of Ethnic and Migration Studies, 41(9), 1495-1516. doi:10.1080/1369183X.2015.1021598

Nursing Scope and Standards Revision Workgroup. (2015). Issues up close: Announcing ANA’s Nursing: Scope and Standards of Practice, 3rd Ed., American Nurse Today, 10(7), 18-19.

Obergefell v. Hodges, 576 U. S. __ p. 6, 2015 (June 26, 2015) (Dist. file).

Phillips, J. M., & Malone, B. (2014). Increasing racial/ethnic diversity in nursing to reduce health disparities and achieve health equity. Public Health Reports, 129 (Suppl 2): 45–50.

Purnell, L. (2013). The Purnell Model for cultural competence. In L. Purnell (ed.), Transculturalhealth care: A culturally competent approach. (pp. 15-44). Philadelphia: F.A. Davis Co.

Purnell, L. (2016). Are we really measuring cultural competence?Nursing Science Quarterly, 29(2), 124. doi: 10.1177/0894318416630100

Renzaho, A. M. N., Romios, P., Crock, C., & Sønderlund, A. L. (2013). The effectiveness of cultural competence programs in ethnic minority patient-centered health care—a systematic review of the literature. International Journal for Quality in Health Care, 25(3), 261-269. doi:10.1093/intqhc/mzt006.

Rhodes, M., Morris, A., & Lazenby, R. (2011). Nursing at its best: Competent and caring. OJIN: The Online Journal of Issues in Nursing, 16(2). doi: 10.3912/OJIN.Vol16No02PPT01

Rosenkoetter, M.,& Rosenkoetter, J. (2005).Creativity, reflection and the pedagogy of nursing. In H. Klein (Ed.), Creative Teaching (pp. 13-21). Boston, MA: World Association for Case Method Research & Application (WACRA).

Schuette v. Coalition to Defend Affirmative Action, No. 12-682 (S. Ct. Apr. 22, 2014).

Shively, M., Subramanian, R., Drucker, D., Edgerton, J., McDevitt, J., Farrell, A., & Iwama, J. (2014). Understanding trends in hate crimes against immigrants and Hispanic-Americans (pp. 1-137, Rep.). Washington, DC: National Criminal Justice Reference Service (NCJRS).

Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice Hall.

Staats, C. (2014). State of the science: Implicit bias review 2014. Retrieved from http://kirwaninstitute.osu.edu/wp-content/uploads/2014/03/2014-implicit-bias.pdf.

Staats, C., Capatosto, K., Wright, R.A., & Contractor, D. (2015). State of the science: Implicit bias review 2015. Kirwan Institute for the Study of Race and Ethnicity. Retrieved from http://kirwaninstitute.osu.edu/wp-content/uploads/2015/05/2015-kirwan-implicit-bias.pdf

Steelman, V.M. (2014). Engaging in lifelong learning to lead the way. AORN Journal, 99(5), 557-559. doi: 10.1016/j.aorn.2014.03.001

Tanabe, P., Thornton, V.L., Martinovich, Z., Todd, K.H., Wun, T. & Lyons, J. S. (2013). The emergency department sickle cell assessment of needs and strengths (ED-SCANS): Reliability and validity. Advanced Emergency Nursing Journal, 35(2):143-153. doi:10.1097/TME.0b013e3182, 358ecbd5.

Teekman, B. (2000). Exploring reflective thinking in nursing practice. Journal of Advanced Nursing, 31, 1125-1135.

U.S. Department of Justice Civil Rights Division. (2015). Investigation of the Ferguson Police Department (Rep.). Retrieved from https://www.justice.gov/sites/default/files/opa/press-releases/attachments/2015/03/04/ferguson_police_department_report.pdf

U.S. Department of Justice Office of Public Affairs. (2016). Justice Department Files Lawsuit to Bring Constitutional Policing to Ferguson, Missouri. Retrieved from https://www.justice.gov/opa/pr/justice-department-files-lawsuit-bring-constitutional-policing-ferguson-missouri 

Wiebe, A., & Young, B. (2015). Parent perspectives from a neonatal intensive care unit: A missing piece of the culturally competent care puzzle. Journal of Transcultural Nursing, 22(1), 77-82. doi:10.1177/1043659609360850.

Williams, L., Sattin, R., Dias, J., Garvin, J., Marion, L., Joshua, T., … Narayan, V.K.M. (2013). Design of a cluster-randomized controlled trial of a diabetes prevention program within African-American churches: The fit body and soulsproject. Contemporary Clinical Trials, 34, 336-347. doi:10.1016/j.cct.2013.01.002.


© 2016 OJIN: The Online Journal of Issues in Nursing
Article published November 18, 2016


Related Articles

From: 
Email:  
To: 
Email:  
Subject: 
Message: