Fluent Essays

Please see attached. Chapters 3,5 and 6 are required reading for the week Overview For this discussion, first, read chapters 3, 5, and 6 in your textbook, Transcultural Concepts in Nursing Care, Cultural Competence in Nursing and Cultural Competence or Cultural Humility? Moving Beyond the Debate.  Then, address the following questions:  1. In your own words, define cultural competence. 2. In your own words, define cultural humility. 3. Do you feel culturally competent or culturally humble when taking care of your patients or dealing with families or communities? Why? 4. Choose an example of a time you had to overcome a cultural barrier in your nursing practice. What was the issue? What did you do to overcome the issue? References: · Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references. Words Limits · Initial Post: Minimum 200 words excluding references (approximately one (1) page) Health Promotion Practice January 2020 Vol. 21, No. (1) 142 –145 DOI: 10.1177/1524839919884912 Article reuse guidelines: sagepub.com/journals-permissions © 2019 Society for Public Health Education 142 Invited Commentary Keywords: cultural humility; cultural competence; health disparities; health education W hen public health physician Melanie Tervalon and health educator and clinic administrator Jane Murray-Garcia introduced the concept of cultural humility to the fields of medicine and public health over 30 years ago, they catalyzed fascinating and continuing discourse on whether cultural humility is, in fact, more important than working to become “com- petent” in the cultures of those with whom we work and interact (Tervalon & Murray-Garcia, 1998). They defined cultural humility as “a lifelong commitment to self-evaluation and critique, to redressing power imbal- ances . . . and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations” (p. 123). Furthermore, Tervalon and Murray-Garcia stressed that “culture” should not be limited to dimensions like racial or ethnic identity,but should include, for exam- ple, the culture of the physician or public health profes- sional, which also requires humility in dealing with patients, families, and communities. The concept of cultural humility caught fire in fields including medicine, nursing, public health, community psychology, and social work. Indeed, by 2019, Tervalon and Murray-Garcia’s (1998) original article alone had been cited in over 1,500 peer reviewed articles. A wealth of tools including cultural humility trainings, curricula, and a 2012 videotape by health education professor Vivian Chavez (2012) also emerged and remain fre- quently used in educating both current practitioners and the next generation of professionals in health promotion and related fields. Yet the earlier concept of cultural competence con- tinues to have a far larger following. Selig, Tropiano, and Greene-Moton (2006) quoted a landmark definition from the U.S. Department of Health & Human Services Health Resources & Services Administration (original source no longer online): Cultural competence comprises behaviors, atti- tudes, and policies that can come together on a con- tinuum that will ensure that a system, agency, program, or individual can function effectively and appropriately in diverse cultural interaction and set- tings. It ensures an understanding, appreciation, and respect of cultural differences and similarities within, among and between groups. (p. 249S) Developed by social workers and counseling psychol- ogists in the early 1980s (Gallegos, 1982; Nadan, 2017), cultural competence soon became ubiquitous in the health and health care services literature as well, particu- larly following strong and early support for its importance from leading institutions like the Institute of Medicine (IOM) in two landmark books, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2003a) and Who Will Keep the Public Healthy? (IOM, 2003b). Major health philanthropies, including the 884912HPPXXX10.1177/1524839919884912Health Promotion PracticeGreene-Moton, Minkler / Cultural Competence or Cultural Humility research-article2019 1Community Ethics Review Board, Community-Based Organizations Partners, Flint, MI, USA 2University of California Berkeley, Berkeley, CA, USA Cultural Competence or Cultural Humility? Moving Beyond the Debate Ella Greene-Moton1 Meredith Minkler, DrPH, MPH2 Authors’ Note: Address correspondence to Meredith Minkler, Professor Emerita / Professor in the Graduate Group, Community Health Sciences, School of Public Health, University of California Berkeley, 168 Highland Boulevard, Berkeley, CA 97408, USA; e-mail: [email protected] https://us.sagepub.com/en-us/journals-permissions mailto:[email protected] https://doi.org/10.1177/1524839919884912 http://crossmark.crossref.org/dialog/?doi=10.1177%2F1524839919884912&domain=pdf&date_stamp=2019-11-12 Greene-Moton and Minkler / CUlTURAl COMPETENCE OR CUlTURAl HUMIlITY 143 Robert Wood Johnson Foundation (McGee-Avila, 2018) and the W. K. Kellogg Foundation, and large medical institutions, led by Kaiser Permanente, also took up the call, with Kaiser’s Institute for Culturally Competent Care (Chong, 2002) quickly heralded as a national model. In our personal lives and in our work with communi- ties, health professionals, and students in public health and health care, we see substantial complementarity and synergy between the concepts and practice of cultural humility and cultural competence. We now briefly describe the continuing controversy over the merits of the two concepts and make the case for ending the debate and instead embracing a both/and approach as critical to our thinking, our practice and our lives in communi- ties and societies that are increasingly diverse along multiple dimensions. >>WHy tHe Controversy? As noted earlier, when the concept of cultural compe- tence gained widespread attention in public health and medicine in the 1980s and 1990s, it quickly landed an important place in health promotion and health education practice. Kaiser Permanente’s Institute for Culturally Competent Care created and widely distributed easily accessed manuals on culturally competent care with and for use by health professionals with five diverse racial/ ethnic and other groups (e.g., lesbian, gay, bisexual, and transgender populations; people with disabilities). Trainings in cultural competence and special sessions at the annual meetings of organizations, including the Society for Public Health Education and the American Public Health Association, were among the many ways in which concept dissemination and implementation spread. Within academic public health, the first university class in this area “Cultural Competence to Eliminate Health Disparities,” was offered in 2002 in the University of Michigan, Flint’s Department of Public Health and Health Education (Selig et al., 2006), and soon was being offered three times per year to a total of 200 students annually. The course quickly became required for all undergraduate and graduate public health students, including those in premed and health administration, and remains a popular elective, as well, for students in biol- ogy, social work, and other fields (S. Selig, personal com- munication, May 19, 2019). The University of Michigan Flint course was followed by numerous others, as well as modules and intensive trainings in public health and medical schools, nursing, and ancillary health and social professions across and beyond the United States. Thousands of articles, book chapters, and Web resources on cultural competence in health promotion and related fields also were, and continue to be, developed to serve a wide range of stakeholders. For example, the Office of Minority Health (see https://minorityhealth.hhs.gov/) has been providing online education in cultural competence through the Think Cultural Health initiative since 2004, offering courses and continuing education for a variety of professions. The courses are free and include content designed for (1) disaster and emergency personnel, (2) nurses, (3) oral health professionals, (4) physicians, nurse practitioners, and physician assistants, (5) promotores de salud, and—new in 2019—(6) behavioral health profes- sionals (U.S. Department of Health and Human Services, Office of Minority Health, 2019). Yet, despite its wide dissemination and use in educa- tion and practice, the notion of cultural competence has continued to cause some uneasiness, in part because of the growing understanding that we cannot ever be truly competent in another’s culture (Chavez, 2018; Isaacson, 2014; Minkler, Pies, & Hyde, 2012; Murray-Garcia & Tervalon, 2014), making the term itself misleading. The word “competence” also was described as problematic by some individuals and communities for whom it implies a top-down approach, with one entity (often including some highly educated and privileged mem- bers of a given racial or other group) deciding what con- tent should be included and which benchmarks or criteria should be used to assess competence for their group(s). Cultural competence also is described by some as too binary a construct, implying that if one is not culturally competent, he or she is implicitly incompe- tent, and perhaps not equipped to interact professionally with members of particular groups (Chavez, 2012, 2018). As illustrated above, however, many describe cultural competence in extremely positive terms, with the IOM naming it one of eight new content areas (along with infor- matics and genomics) in which all schools of public health should be offering training (IOM, 2003b). Furthermore, scholars have argued that the more nuanced understand- ing of culturally competent public health professionals can itself contribute to individual and community control over and participation in decision making (Cerezo, Galceran, Soriano, & Moral, 2014; Taylor-Ritzler et  al., 2008). Finally, in his recent and in-depth reflective anal- ysis of the concepts of cultural humility and cultural com- petence, Danso (2018) argues that cultural competence already incorporates the concept of cultural humility, stressing as it does “the need to question one’s assump- tions, beliefs and biases,” and other tenets at the heart of cultural humility and antioppressive practice such as “respect for difference, reducing power differentials, building partnerships, and learning from clients” (Danso, 2018, p. 415; see also Ben-Ari & Strier, 2010). In our view, and as Isaacson (2014) and others note as well, cultural competence is not something we https://minorityhealth.hhs.gov/ 144 HEAlTH PROMOTION PRACTICE / January 2020 achieve or fail to achieve but rather a reminder to con- tinue to strive to know more about communities of all types with which we work or interact. Together with the concept and embodied practice of deep cultural humil- ity, it provides health educators and other public health professionals with some of our most important tools in working with diverse individuals, groups, and commu- nities in today’s complex world. Below we provide examples from our own lives and/or public health prac- tice, in which the need for both cultural competence and cultural humility was powerfully experienced. >>ella Greene-Moton As a community leader and longtime partner in pub- lic health, who is also an African American woman, my personal struggle with the notion of cultural competence or cultural humility stems from the constant pushback from many of my academic partners on the subject. Too often, academics (and especially those from the domi- nant culture) have embraced cultural humility as the more important and contemporary of the two concepts— as if a choice must be made between them. Yet for many community members and partners, and particularly those who are people of color, perceptions that academ- ics, regardless of race/ethnicity or other identities, often fail to take the time up front to really learn about the cultural realities of groups with whom they will be work- ing sometimes has caused misunderstandings and dis- trust, holding partnerships back from reaching their full potential. Because of such experiences, I firmly believe that cultural humility/cultural competence is not an either/or but rather a both/and. I accept cultural humility to be the ability to maintain an interpersonal stance that is other-oriented (or open to others) while accepting cul- tural competence as the ability to interact effectively with people of different cultures—more of a learned/taught condition. I pride myself on being able to claim both— competence and humility—recognizing both as a lifelong journey, without an end point. I believe cultural humility is a spiritual attribute, drawing from the ability to be humble and couched in a state of selflessness, while cul- tural competence hinges on a deliberate engagement in cultural knowledge transfer. >>MereditH Minkler As a White woman and longtime professor and com- munity-engaged researcher and activist, my need for both cultural competence and cultural humility—and the broader understanding of culture that both terms suggest—was epitomized recently in a gathering of thou- sands of public health professionals. As is my habit, when asked to stand for the national anthem, I “took a knee,” in symbolic protest of the inequitable treatment of Black and Brown people in our criminal justice system and society at large. Two military officers, both African American and one in dreadlocks, stood beside me, and I assumed, naively, that they’d join me and others in mak- ing this gesture. But when they both stood ramrod straight, hands over their hearts, I realized that my lack of both cultural competence and cultural humility had caused me to misread this situation completely. Having more cultural humility, for example, would have helped me recognize immediately my own biases and stereo- typic beliefs, for example, that being a Black man (and especially one wearing dreadlocks) would trump being a member of the military in a situation like this one. But my lack of cultural competence—in part, about the mil- itary—compounded my ignorance and prejudices. When later that day I met with a small and diverse group of young public health professionals, I related this story and was immediately set straight. One of the women explained that she, too, was in the military, and in her experience getting on your knees (even when getting up from push-ups!) conveyed weakness. Another remarked that in her Baptist community, kneeling is a sign of defer- ence to God. And a Muslim woman commented that in her faith, getting on one’s knees was a sign of humility, and thus may have been appropriate in this context—but she was not sure. In short, my gesture of solidarity with Black and Brown people too often denied justice at the hands of the law was seen in very different ways by this small group. It was a reminder of how much I need to learn about many cultures, including military culture. And while I continue to “take a knee” when the national anthem is played, I no longer presume to know how this gesture is being interpreted by others. >>sUMMary In sum, and particularly in the troubling contexts of our time characterized by increasingly virulent racism and a weakening of civil and human rights both nationally and globally, we believe it imperative to find a road around the false choice between cultural humility and cultural com- petence. As we have argued, both concepts grew out of increasing recognition of the need for public health, med- ical, social work, and other professionals to reflect on and address our own biases and actively seek to understand and address the cultural or social realities of the diverse individuals, groups, and communities with whom we and our groups and organizations interact. Furthermore, and while typically focused on building understanding and bridging differences based on race/ ethnicity, both cultural humility and cultural competence Greene-Moton and Minkler / CUlTURAl COMPETENCE OR CUlTURAl HUMIlITY 145 also have been profitably used to encourage self-reflection and reflective practice with respect to ability/disability, sexual orientation and gender identity, and numerous other dimensions too often characterized by inequitable power, privilege, and injustice that affect health and well- being. Both concepts increasingly have stressed the need to challenge the institutions and systems in which we live and work that may, wittingly or unwittingly, enable these injustices to remain. Finally, as we pursue the path of “both/and,” we can more effectively partner across a wide range of barriers and divides to work collectively toward racial, social, and health equity and the more just and habitable society and planet on which our work and our future depend. referenCes Ben-Ari, A., & Strier, R. (2010). Rethinking cultural competence: What can we learn from levinas? British Journal of Social Work, 40, 2155-2167. Cerezo, P. G., Galceran, M. S., Soriano, M. G., & Moral, J. l. (2014). Design and evaluation of an educational course in cultural compe- tence for nursing. Procedia-Social and Behavioral Sciences, 132, 262-268. Chavez, V. (2012). Cultural humility: People, principles and prac- tice [Video file]. Retrieved from http://www.ces4health.info/find- products/view-product.aspx?code=XT4NJRJP Chavez, V. (2018). Cultural humility: Reflections and relevance for CBPR. In N. Wallerstein, B. Duran, J. Oetzel, & M. Minkler (Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 357-362). San Francisco, CA: Jossey-Bass. Chong, N. (2002). A model for the nation’s health care industry: Kaiser Permanente’s institute for culturally competent care. The Permanente Journal, 6, 366-381. Danso, R. (2018). Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts. Journal of Social Work, 18, 410-430. Gallegos, J. S. (1982). The ethnic competence model for social work education. In B. W. White (Ed.), Color in a white society (pp. 1-9). Silver Spring, MD: National Association of Social Workers. Institute of Medicine. (2003a). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Institute of Medicine. (2003b). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies Press. Isaacson, M. (2014). Clarifying concepts: Cultural humility or com- petency. Journal of Professional Nursing, 30, 251-258. McGee-Avila, J. (2018, June 21). Practicing cultural humility to transform health care [Web log post]. Retrieved from https://www. rwjf.org/en/blog/2018/06/practicing-cultural-humility-to-trans- form-healthcare.html Minkler, M., Pies, C., & Hyde, C. A. (2012). Ethical issues in com- munity organizing and capacity building. In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 110-129). New Brunswick, NJ: Rutgers University Press. Murray-Garcia, J., & Tervalon, M. (2014). The concept of cultural humility. Health Affairs, 33(7), 1303. Nadan, Y. (2017). Rethinking “cultural competence” in interna- tional social work. International Social Work, 60(1), 74-83. Selig, S., Tropiano, E., & Greene-Moton, E. (2006). Teaching cultural competence to reduce health disparities. Health Promotion Practice, 7(3 Suppl.), 247S-255S. doi:10.1177/1524839906288697 Taylor-Ritzler, T., Balcazar, F., Dimpfl, S., Suarez-Balcazar, Y., Willis, C., & Schiff, R. (2008). Cultural competence training with organizations serving people with disabilities from diverse cultural backgrounds. Journal of Vocational Rehabilitation, 29(2), 77-91. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125. U.S. Department of Health & Human Services, Office of Minority Health. (2019). Think cultural health: Education. Retrieved from https://thinkculturalhealth.hhs.gov/education http://www.ces4health.info/find-products/view-product.aspx?code=XT4NJRJP http://www.ces4health.info/find-products/view-product.aspx?code=XT4NJRJP https://www.rwjf.org/en/blog/2018/06/practicing-cultural-humility-to-transform-healthcare.html https://www.rwjf.org/en/blog/2018/06/practicing-cultural-humility-to-transform-healthcare.html https://www.rwjf.org/en/blog/2018/06/practicing-cultural-humility-to-transform-healthcare.html https://thinkculturalhealth.hhs.gov/education International Journal of Nursing Studies 99 (2019) 103386 Cultural competence in nursing: A concept analysis Najmeh Sharifia, Mohsen Adib-Hajbagheryb,*, Maryam Najafic a PhD. Candidate of Nursing, Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran b Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran c Candidate of English Language Teaching, Department of English Language, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran A R T I C L E I N F O Article history: Received 5 January 2019 Received in revised form 25 July 2019 Accepted 25 July 2019 Keywords: Cultural competence Concept analysis Nursing A B S T R A C T Background: Cultural competence is one of the principal foundations of clinical nursing. It has not yet been clearly defined and analysed and there are different views regarding this issue. Objective: Analyzing the concept of cultural competence in nursing. Design: A concept analysis. Data Sources: The literature was searched using electronic databases including PubMed, ScienceDirect, Scopus, ProQuest, Google Scholar, CINAHL, Wiley, Ovid, Magiran, and SID with no date limitation. Any quantitative or qualitative studies published in English or Persian, which were focused on cultural competence in nursing were included in the study. Review methods: Walker and Avant’s strategy for concept analysis was used. The attributes, antecedents, consequences, and uses of the concept were identified. Results: A total of 43 articles were included. The six defining attributes of cultural competence were cultural awareness, cultural knowledge, cultural sensitivity, cultural skill, cultural proficiency, and dynamicity. Antecedents included cultural diversity, cultural encounter and interaction, cultural desire, cultural humility, general humanistic competencies, educational preparation, and organizational support. The consequences of cultural competence were also identified: those related to care receivers, those related to care providers, and health-related consequences. Conclusion: A theoretical definition and a conceptual model of cultural competence were developed. The attributes, antecedents, and consequences of cultural competence identified in this study can be used in nursing education, research, and managerial and organizational planning. © 2019 Published by Elsevier Ltd. What is already known about the topic? � Reduction in health care inequalities, enhancing patients' trust in healthcare systems and cultural safety are among the main Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns � Cultural competence is one of the principal foundations of clinical nursing. � Cultural competence is affected by the immediate financial, political, social, historical, and cultural context. � There are many different definitions of cultural competence. What this paper adds � Cultural competence is the dynamic process of acquiring the ability to provide effective, safe, and quality care to the patients through considering their different cultural aspects. * Corresponding author. E-mail addresses: [email protected] (N. Sharifi), [email protected] (M. Adib-Hajbaghery), [email protected] (M. Najafi). http://dx.doi.org/10.1016/j.ijnurstu.2019.103386 0020-7489/© 2019 Published by Elsevier Ltd. consequences of cultural competence. � The nursing education system and healthcare organizations have significant roles in improving nurses' cultural competence. 1. Introduction Globalization and international migrations have caused cultural diversity in societies and hence, nurses in different societies have patients with different cultures and different cultural needs (Alizadeh and Chavan, 2016; Sharma et al., 2009). Cultural diversity can be a major barrier to effective care delivery. Nurses’ lack of knowledge and skills about how to effectively deal with patients from different cultures may impair their relationships with them and result in inequality in care delivery. Consequently, cultural competence has become an international demand (Alizadeh and Chavan, 2016; Taylor, 2005). http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2019.103386&domain=pdf mailto:[email protected] mailto:[email protected] mailto:[email protected] http://dx.doi.org/10.1016/j.ijnurstu.2019.103386 http://dx.doi.org/10.1016/j.ijnurstu.2019.103386 http://www.sciencedirect.com/science/journal/00207489 www.elsevier.com/ijns Box 1. Electronic search strategy in PubMed. Cultural competency [Title/Abstract] AND nursing[Title/ Abstract]. Culturally competent care [Title/Abstract] AND nursing[Title/ Abstract]. Transcultural nursing [Title/Abstract]. 2 N. Sharifi et al. / International Journal of Nursing Studies 99 (2019) 103386 The importance of cultural competence in nursing was recognised two decades ago. Then, many studies were carried out and several nursing theories were developed to address this concept. Nonetheless, many ambiguities still surround this concept (Cai, 2016; Suh, 2004). The term cultural competence consists of the words culture and competence. Some studies focused on the word competence and defined cultural competence as a spectrum or a process, while some studies focused on the word culture and referred to the methods for developing cultural competence. For instance, Campinha-Bacote (2002) focused on the word compe- tence and defined cultural competence as a process which encompasses the five components of cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire On the other hand, Leininger (2002) defined cultural competence based on the different dimensions of culture, including values, health beliefs, religion, and philosophy. Some studies also interchangeably used cultural congruence, culturally congruent care, culturally competent care, and congruent care to refer to the cultural competence concept (Andrews and Boyle, 2008). Despite the crucial importance of nurses’ cultural competence in care delivery, there is no clear guideline for the clinical application of this concept (Campinha-Bacote, 2002). Concept analysis studies can help develop applicable guidelines for concept application through identifying the attributes, antecedents, and consequences of concepts (Walker and Avant, 2010). Different concept analysis studies have been conducted so far regarding the concept of cultural competence (Burchum, 2002; Cai, 2016; Dudas, 2012; Smith, 1998; Suh, 2004; Zander, 2007). They provided contradictory results and did not cover all aspects of the concept. Most of these studies dealt with the effects of nurses’ cultural competence on healthcare organizations, but did not address the roles of healthcare organizations and education in its develop- ment. Since cultural competence is affected by the immediate financial, political, social, historical, and cultural context (Jirwe et al., 2006) and its semantic framework changes over time, more studies are required to analyse the current views on the concept. The present study was conducted to bridge these gaps. The aim of the study was to analyse the concept of cultural competence and provide an in-depth understanding of its different key compo- nents. Such understanding can help nurses deliver more culturally congruent care and thereby, improve care outcomes. 2. Methods 2.1. Concept analysis method This concept analysis was conducted using the Walker and Avant’s (2010) eight-step method. This method was used because it is one of the most easiest and understandable methods for concept analysis, particularly for beginners. The eight steps of this method are: 1) Selecting a concept; 2) Determining the aims or purposes of analysis; 3) Identifying all uses of the concept; 4) Determining the defining attributes of the concept; 5) Construct- ing a model case; 6) Constructing borderline, contrary, invented, and illegitimate cases; 7) Identifying antecedents and consequen- ces; and 8) Defining empirical references (Walker and Avant, 2010). 2.2. Selecting the concept Nursing care requires paying attention to patients’ culture. Nurses’ lack of cultural competence can impair nurse-patient relationship and results in negative health outcomes such as loss of screening opportunities, diagnostic errors, adverse drug inter- actions, and even early death (Kim-Godwin et al., 2001; Brach and Fraserirector, 2000). Due to the ambiguities surrounding the concept of cultural competence, this concept was selected for analysis. 2.3. Data sources We searched several online databases including PubMed, ScienceDirect, Scopus, ProQuest, Google Scholar, CINAHL, Wiley, Ovid, Magiran, and SID. Search keywords were “cultural compe- tency”, “culturally competent care”, “transcultural nursing”, and “nursing”. These keywords were searched in the title, abstract, and keyword section of the studies. The search protocol was not limited to any date, and the Boolean operator “AND” was used to combine search results (Box 1). Any quantitative or qualitative studies published in English or Persian, which were focused on cultural competence in nursing were included in the study. Primarily, 5505 studies were found. After excluding duplicates, 3147 studies remained. We assessed the titles of the studies and excluded book reviews, letters to the editor, irrelevant studies, and studies published in languages other than English or Persian. Abstracts of the remaining studies were read, and studies were included in the final analysis if they had referred to at least one of the following items: attributes, antecedents, consequences, definitions, contrib- uting factors, and measurement techniques of cultural compe- tence. Subsequently, 43 studies in the area of nursing or health sciences were included and analysed (Fig. 1, Appendix 1). Data on the definitions of cultural competence and its attributes, ante- cedents, consequences, contributing factors, and measurement methods were extracted from the included studies. 3. Results 3.1. Uses of the concept The concept of cultural competence includes the two sub- concepts of culture and competence. Merriam-Webster’s dictio- nary (2016) defines culture as “the customary beliefs, social forms, and material traits of a racial, religious, or social group” and also “the characteristic features of everyday existence (such as diversions or a way of life) shared by people in a place or time”. The definition of this word in the Oxford dictionary (2004) is “the ideas, customs, and social behaviour of a particular people or society”. Persian dictionaries such as Moein(1999) and Dehkhoda (1998) also define culture as the science, manner, cognition, education, wisdom, choices, and literary and scientific literature of a group of people. Competence, the other sub-concept, is defined in Merriam-Webster’s dictionary (2016) as “the quality or state of being competent”, while its medical definition in this dictionary is “the quality or state of being functionally adequate” (Merriam- Webster, 2016). The Oxford dictionary (2004) also defines competence as “the ability to do something successfully and efficiently. The definitions for competence in Persian dictionaries include being qualified, meritorious, and befitted (Dehkhoda, 1998; Moein, 1999). The words ability, capability, capacity, competency, and faculty are synonyms for the word competence (Marriam-Webster, 2016). 3.1.1. Cultural competence in nursing In the nursing literature, culture is defined as the learned paradigm shared by a group. Culture affects values, beliefs, rituals, Fig. 1. Flowchart of the study selection process of the concept analysis. N. Sharifi et al. / International Journal of Nursing Studies 99 (2019) 103386 3 and behaviours and is reflected in language, dress, food, materials, and social institutions of a group (Purnell, 2002). Benner, a nursing theorist, defines competence as the ability to work to obtain the desired outcomes under the various conditions of the real world (Alligood, 2014). The term cultural competence was first used by Cross (1989) as a set of appropriate behaviours, attitudes, and policies which come together in an organization or among professionals and enables the organization or the professionals to work in cross-cultural situations. Leininger (1996) refers to culturally competent nursing care as the creative, sensitive, and meaningful culture-based use of health and care knowledge to coordinate the needs and the usual ways of living among individuals or groups. The ultimate goal of this type of care is meaningful health and well-being or effective coping with illnesses, disorders, and death. The definitions for cultural competence have greatly been affected by the level of importance of its two sub-concepts, i.e. culture and competence. Definitions which focus more on the competence sub-concept mainly refer to attributes such as knowledge, attitude, and skill (Campinha-Bacote, 2002; Cross, 1989) while definitions which focus more on the culture sub-concept include dimensions such as cultural values, religion, and health beliefs (Leininger, 2002; Giger and Davidhizar, 2002). Some scholars consider cultural competence and its acquisition as an ongoing and evolutionary process rather than an endpoint and hence, define it as an ongoing process through which health care providers continuously attempt to acquire the ability to work in different cultural societies and to provide effective services in the client’s cultural context)Campinha-Bacote, 2002; Suh, 2004). Smith (1998) and Burchum (2002) also define cultural competence as the process of developing nurses’ cultural awareness, knowl- edge, skill, integrity, and sensitivity which empower them to work in transcultural situations. In some definitions, cultural competence is merely a set of components. For instance, Purnell and Paulanka (2003) define it as cultural self-awareness, knowledge, and understanding of client’s culture, respect for cultural differences, openness to cultural encounter, and culture-based adaptation of care. Others also added components such as cultural awareness, skill (Zander, 2007), and sensitivity to issues related to culture, race, and gender (AAN, 1992). 3.1.2. Relevant concepts Relevant concepts are terms similar to the concept of interest which can be differentiated from it through further analysis (Walker and Avant, 2010). The concepts of culturally congruent care and culturally competent care have interchangeably been used with the concept of cultural competence (Andrews and Boyle, 2008), while cross-cultural competence and transcultural nursing are concepts related to the concept of cultural competence. Culturally congruent care: Leininger(2002) defines culturally congruent care as helping, supporting, facilitating, or empowering cognition-based actions or decisions, which are congruent with the cultural values, beliefs, and lifestyle of individuals, groups, or organizations. Culturally competent care: It is defined as the creative, sensitive, and meaningful culture-based use of health and care knowledge to coordinate the needs and the usual ways of living of individuals or groups for acquiring meaningful health and well-being or coping with illnesses, disorders, and death (Alligood, 2014). Cross-cultural competence: It is the ability of effective perfor- mance in another culture. This ability requires the comparison or the encounter of two or more cultures. Cross-cultural competence facilitates the development of cultural competence (Cai, 2016). Transcultural nursing: It focuses on competencies for holistic cultural care and helps individuals or groups maintain or restore health and cope with disability, death, or other human conditions in an appropriate and beneficial cultural way (Williamson and Harrison, 2010). 3.2. The defining attributes of cultural competence The core of concept analysis is to determine the defining attributes of the concept, i.e. a group of attributes which have the strongest relationship with the concept and allows analyser to obtain a deep insight. These attributes differentiate the intended concept from similar or related concepts (Walker and Avant, 2010). The most common defining attributes of cultural competence are cultural awareness, cultural knowledge, cultural sensitivity, cultural skill, cultural proficiency, and dynamicity. 3.2.1. Cultural awareness Cultural awareness is to understand the effects of one’s own culture. It helps individuals assess their biases and prejudices and 4 N. Sharifi et al. / International Journal of Nursing Studies 99 (2019) 103386 forms a basis for valuing others’ beliefs and values; it can be used to identify the similarities and the differences of other cultures with one’s own culture (Leonard and Plotnikoff, 2000; Zander, 2007). Without cultural awareness, individuals may impose the beliefs, values, and behavioural patterns of their own culture to people from other cultures (Campinha-Bacote, 2002). 3.2.2. Cultural knowledge Cultural knowledge is continuous information acquisition about different cultures. It includes the learning of conceptual and theoretical frameworks, which help data processing. Cultural knowledge is the basis for cultural understanding (Kim-Godwin et al., 2001). To acquire cultural knowledge, health care providers need to integrate their knowledge about health-related beliefs, cultural values, incidence and prevalence of illnesses, and treatment effectiveness. Knowledge of such issues helps health care providers understand how patients think and behave during their illnesses, and which maters should be noticed while making caring decisions for patients from different ethnic groups (Campinha-Bacote, 2002). 3.2.3. Cultural sensitivity Cultural sensitivity is to value, respect, and admire cultural diversity. The characteristics of cultural sensitivity are knowledge, attention, understanding, respect, and optimization of interven- tions based on patients’ cultural needs (Jirwe et al., 2009; Foronda, 2008). It is an attempt to understand the world of others without racism glasses (Guidry, 2000). Cultural sensitivity helps nurses understand how patients’ attitudes and viewpoints affect their behaviours and care-seeking patterns (Burchum, 2002). 3.2.4. Cultural skill Cultural skill is the ability to establish effective communication with individuals from other cultures. This ability is the consider- ation of different beliefs, values, and methods in planning and providing care (Balcazar et al., 2009; Cai et al., 2017). 3.2.5. Cultural proficiency Cultural proficiency refers to the acquisition and the transfer of new knowledge through conducting researches using culturally sensitive therapeutic approaches. It reflects the commitment for change. Acquiring new cultural knowledge and skills and sharing them through articles, educational programs and other methods are indicative of cultural proficiency (Cross, 1989). 3.2.6. Dynamicity Dynamicity implies that instead of being a culturally competent nurse, a nurse is becoming culturally competent through frequent encounters with different patients (Capell et al., 2007; Dunn, 2002). 3.3. Cases According to Walker and Avant, cases help further clarify concepts. Model, borderline, related, and contrary cases are provided in the following section. 3.3.1. Model case Model case is an example of the use of the concept that demonstrates all its defining attributes and helps better articulate the meaning of the concept (Walker and Avant, 2010). Mr. X, an emergency department nurse, was assigned to admit and care for a woman with type II diabetes mellitus. The patient had referred to the emergency department with her husband due to dyspnea and chest pain. During his first communication with the patient, Mr. X noticed that the patient and her husband are Kurdish and barely speak Persian. Based on his previous experiences, Mr. X remembered that Kurdish people greatly value receiving care from same-gender health care providers. The patient’s husband also requested medical visit by a female doctor. In coordination with the head nurse, Mr. X delegated care delivery responsibility to a female nurse, called for a female doctor, and started to perform tasks related to laboratory tests and medical consultations. Then, he provided the doctor with data about the patient’s conditions and emphasized the cultural differences between the patient and health care providers. He also asked a Kurdish colleague to refer to the emergency department to help him establish proper commu- nication with the patient and obtain more information about her values, beliefs, and culture. After that, he provided the collected data to his other colleagues and asked the nursing supervisor to assign care delivery to the patient to Kurdish nurses. Mr. X can be considered as a nurse with adequate cultural competence who exhibits all dimensions of cultural competence in his relationship with a patient of a different culture. He was aware of the differences between his culture and the culture of the patient. When patient’s husband made a request for medical visit by a female doctor, Mr. X immediately understood patient’s sensitivity in this area and called for a female doctor based on his cultural sensitivity and skill in care delivery. Moreover, he called for a Kurdish colleague to refer to the emergency department in order to obtain more detailed information about the patient’s conditions. Thereby, he improved his cultural knowledge. He also showed cultural proficiency through providing patient-related data to his colleagues. His attempts for providing culturally congruent care reflect his cultural competence and the dynamicity of the process of its development. 3.3.2. Borderline case Borderline cases are those examples that contain most defining attributes of the concept (Walker and Avant, 2010). Mrs. Y was assigned to admit and care for a young woman referred with her husband to the emergency department with the complaint of abdominal pain. The patient was sitting with restlessness and discomfort on a chair next to her bed and was waiting for the doctor. Her husband requested medical visit by a female doctor and hence, Mrs. Y noticed patient’s and her husband’s sensitivity over same-gender medical visit. After taking a brief history and monitoring vital signs, Mrs. Y went to doctor’s room, hopelessly returned, and respectfully said, “I respect your request and understand your sensitivity; but there is no female doctor in the emergency department”. Patient’s husband sadly said that they do not allow medical visit by a male doctor, thanked Mrs. Y, refused consent for medical treatment, and left the emergency department. In this case, Mrs. Y was culturally aware of the patient’s values and showed her cultural sensitivity through respecting the request of the patient’s husband for a medical visit by a physician of the same gender; but, she did not attempt to persuade the patient and her husband to be visited by the only male physician in the department. The process of care was consequently disrupted and the patient left the hospital without receiving proper care. 3.3.3. Related case Related cases are instances that are related to the concept, but do not contain all its defining attributes (Walker and Avant, 2010). Mrs. Z, an emergency nurse, was responsible for care delivery to a 50- year-old diabetic woman referred with her husband to the emergency department with chest pain and dyspnea. The patient just spoke Arabic. Mrs. Z, who just spoke Persian, attempted to communicate with the patient and her husband. Because of her inability to understand Arabic, Mrs. Z just treated the patient’s and her husband’s words with a smile and head N. Sharifi et al. / International Journal of Nursing Studies 99 (2019) 103386 5 nodding and used body language to provide her own explan- ations. Whenever she referred to the patient to perform care- related activities, she responded to the patient’s questions by a smile and saying that she could not understand her language. Thus, the patient became silent. Although Mrs. Z attempted to respectfully treat the patient and provide all routine care services, she was unable to establish effective communication with her and provide culturally congru- ent care to her due to the language barrier. Mrs. Z had no adequate knowledge about the patient’s culture and did not make a great effort to communicate with her. Her practice is indicative of her limited cultural sensitivity and cultural skill. 3.3.4. Contrary case Contrary case is an example of what the concept is not (Walker and Avant, 2010). Mrs. K was assigned to admit a diabetic woman with chest pain and dyspnea. In her first encounter with the patient, she noticed that the patient’s culture and language are different from hers. She was unfamiliar with the patient’s culture and language and hence, preferred to avoid communication with the patient, perform admission, provide the patient with routine care services, and inform her senior nurse about her inability to communicate with the patient due to the language barrier. Mrs. K is a good example of a nurse who lacks cultural competence. She did not have any of the characteristics of cultural competence and expressed her inability to provide care to a patient from a different culture. 3.4. Antecedents of cultural competence Antecedents are events which happen before the intended concept (Walker and Avant, 2010). The antecedents of the concept of cultural competence are cultural diversity, cultural encounter and interaction, cultural desire, cultural humility, general human- istic competencies, educational preparation, and organizational support. 3.4.1. Cultural diversity Differences among patients respecting skin colour, race, ethnicity, nationality, socioeconomic status, educational level, employment, and religion result in cultural diversity. Cultural diversity, in turn, creates different health-related attitudes and expectations. The fulfillment of such expectations requires nurses with cultural competence (Schim et al., 2007; Dudas, 2012). 3.4.2. Cultural encounter and interaction Cultural encounter refers to interpersonal contacts and relationships among people from different cultures (Brach and Fraserirector, 2000). Nurses cannot acquire cultural competence merely through self-study or other mental activities; rather, they need to develop their direct personal and professional interactions with patients from different cultures in order to correct their own beliefs about different cultures and avoid prejudicial behaviours (Kardong-Edgren and Campinha-Bacote, 2008; Khezerloo and Mokhtari, 2016). 3.4.3. Cultural desire Cultural desire is an internal request for being culturally competent. Cultural desire is indicative of real eagerness for being open and flexible to others, accepting differences, and learning from others (Henderson et al., 2018). 3.4.4. Cultural humility Cultural humility is a process which consists of openness,- self-awareness, egolessness, and self-criticism after voluntary interactions with people from different cultures. This capability results in mutual empowerment, respect, collaboration, ideal care, and lifelong learning about patients from different cultures (Steefel, 2016; Foronda et al., 2016). 3.4.5. General humanistic competencies Nurses need to have a series of general competencies, which are necessary for nursing practice in all cultures and contexts. Positive personality characteristics, humanistic attitude, empathy, kind- ness, and respect are essential prerequisites to provide care to all patients irrespective of their cultural backgrounds. After develop- ing such competencies, nurses need to develop cultural compe- tence for working with patients from a specific culture (Dreher and Macnaughton, 2002; Jirwe et al., 2006). 3.4.6. Educational preparation The ability to provide effective care in a culturally diverse society requires culture-based nursing education (Heidari et al., 2013). Participation in workshops and courses on cultural competence can develop nurses’ cultural knowledge, insight, and skill (Wells, 2000; Beach et al., 2005). Nurses with limited educational preparation for dealing with cultural diversity avoid contact with patients from different cultures (Songwathana and Sriratanaprapat, 2009). A key prerequisite to educational prepara- tion for culturally congruent care is the cultural competence of nursing instructors, which in turn depends on their ability to be good role models and to successfully teach nursing students from different cultures (Starr et al., 2011; Mousavi Bazaz and Karimi Moonaghi, 2014). 3.4.7. Organizational support The delivery of culturally congruent care and the fulfillment of the needs of ethnic minorities cause challenges that cannot be managed without the support of healthcare organizations (Taylor, 2005). Healthcare organizations need to modify their philosophy, mission, goal, and vision and provide nurses with the necessary tools, recourses, and motives to care for patients from different cultures (Chrisman, 2007; Werner and DeSimone, 2006; Taylor and Alfred, 2010). 3.5. Consequences of cultural competence Consequences of a concept are events that happen due to … RUBRIC: DISCUSSION BOARD (30 pts) Last updated: 02/02/2017 © 2017 School of Nursing - Ohio University Page 1 of 1 NOTE: No direct quotes are allowed in the discussion board posts. *Peer-reviewed references include professional journals (i.e. Nursing Education Perspectives, Journal of Professional Nursing, etc. – see library tab on how to access these from database searches), professional organizations (NLN, CDC, AACN, ADA, etc.) applicable to population and practice area, along with clinical practice guidelines (CPGs - National Guideline Clearinghouse). All references must be no older than five years (unless making a specific point using a seminal piece of information) References not acceptable (not inclusive) are UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases. **Since it is difficult to edit the APA reference in the Blackboard discussion area, you can copy and paste APA references from your Word document to the Blackboard discussion area and points will not be deducted because of format changes in spacing. Criteria Levels of Achievement Meets Expectations Needs Improvement Unsatisfactory Characteristics of initial post 10 to 10 Points  Provided response with rationale.  The post is substantive and reflects careful consideration of the literature.  Examples from the student’s practice/experience are provided to illustrate the discussion concepts.  Addressed all required elements of the discussion prompt.  Well organized and easy to read. 3 to 9 Points  Provided response missing either substantive rationale, consideration of the literature, or examples from the student’s practice/experience to illustrate the discussion concepts.  Addresses all or most of required elements.  Somewhat organized, but may be difficult to follow. 0 to 2 Points  Provided response with minimal rationale.  Does not demonstrate thought and provides no supporting details or examples.  Provides a general summary of required elements. Support for initial post 5 to 5 Points  Cited minimum of two references: at least one (1) from required course materials to support rationale AND one (1) from peer-reviewed* references from supplemental materials or independent study on the topic to support responses.  The initial post is a minimum of 200 words excluding references. 2 to 4 Points  Missing one (1) required course reference AND/OR one (1) peer-reviewed reference to validate response.  Post has at least 200 words. 0 to 1 Points  Missing 1 or more of the correct type (course or peer-reviewed) or number of references to support response.  Post is less than 200 words or there’s no post. Responses to Peers 10 to 10 Points  Responses to colleagues demonstrated insight and critical review of the colleagues’ posts and stimulate further discussion  Responded to a minimum of two (2) peers and included a minimum of one (1) peer-reviewed* or course materials reference per response.  Responses are a minimum of 100 words and are posted on different days of the discussion period by the due date. 4 to 9 Points  Responses to colleagues are cursory, do not stimulate further discussion and paragraph could have been more substantial.  Responses missing one of the following: o insight/critical review of colleague’s post, o OR respond to at least two peers, o OR a peer reviewed*or course materials reference per response  Responses are a minimum or less than 100 words and posts were on the same date as initial post. 0 to 3 Points  Responses to colleagues lack critical, in depth thought and do not add value to the discussion.  Responses are missing two or more of the following: o insight/critical review of colleagues’ post o AND/OR response to at least two peers o AND/OR a peer reviewed* reference per response.  Responses are less than 100 words, posted same day as initial post. APA format*; Spelling/ Grammar/ Punctuation 5 to 5 Points  APA format** is used for in-text citations and reference list.  Posts contain grammatically correct sentences without any spelling errors. 2 to 4 Points  APA format is missing either in-text or at end of the reference list.  Posts contain some grammatically correct sentences with few spelling errors. 0 to 1 Points  Not APA formatted OR APA format of references has errors both in-text and at end of reference list.  Post is grammatically incorrect.