Lincoln University College, Wisma Lincoln, No. 12-18, Jalan SS 6/12, 47301 Petaling Jaya, Selangor Darul Ehsan, Malaysia
*Corresponding Author’s Email: christinamojini@gmail.com
Keywords: Cultural Awareness; Culture Competence; Elder Care; Newly Graduate Nurses
In today's globalized society, the Nordic countries have experienced a notable increase in immigration, necessitating a greater emphasis on intercultural communication, particularly in professions with interactions across diverse cultural backgrounds (Hemberg & Vilander, 2017). Within healthcare, nurses regularly encounter patients from various cultural backgrounds, making intercultural care a fundamental aspect of their practice. The multicultural nature of contemporary society introduces new challenges and demands for cultural competence in healthcare delivery. Cultural competence, as defined by Berger (1998), is recognized as a potential strategy to improve quality and address disparities in healthcare, particularly regarding race or ethnicity. Moreover, intercultural care is defined as a foundational element of the nurse-patient relationship, especially when individuals come from differing cultural backgrounds (Wikberg, 2021).
Within the healthcare realm, cultural competence is defined by an awareness of how social and cultural elements impact patients' health beliefs and behaviors. Global health crises have profound implications for social, economic and political affairs, affecting human connectivity and increasing vulnerability within families, homes, and societies (Jonathan & Gates, 2024). It involves addressing these influences at different levels within healthcare systems to ensure the delivery of high-quality care (Betancourt & Green, 2010; Betancourt et al., 2018). Cultural competence is recognized as a multifaceted concept, comprising components such as cultural sensitivity, attitudes, awareness, and knowledge and skills (Shen, 2015; Tao et al., 2022; Alizadeh & Chavan, 2016; Kaihlanen et al., 2019). Card (2017) defines the aging phase as beginning at 65 years old and beyond, categorizing this demographic into distinct groups: individuals aged 65–74 years are considered younger older adults, those aged 75–84 years are classified as advanced older adults, and those aged 85 and older are designated as very advanced older adults (Aslan et al., 2024). Aging is a complex process involving psychological, social, and physical dimensions, leading to various changes such as reduced cognitive abilities, decreased productivity, impaired attention, and weakened short-term memory (Marzo et al., 2023; Aktaş & Bakan, 2021). Foster & Walker, 2021; Sayın Kasar & Karadakovan, 2017). Gerontology, the scientific study of aging, characterizes old age as the regular alterations occurring in living organisms or adult individuals as they progress in chronological age, influenced by environmental conditions (Aslan et al., 2024). Gerontological nursing provides specialized care for older adults, addressing their physical, psychosocial, spiritual, and other needs to enhance their well-being and quality of life (Wyman et al., 2019).
The demographic shift towards an aging population (Berger et al., 2022) highlights the increasing demand for specialized nurses trained to comprehend the unique care needs of older individuals. This expertise is crucial not only in hospital settings but also in facilities and programs dedicated to the care and rehabilitation of older adults. By leveraging this expertise, it becomes feasible to maintain current levels of functioning, enhance health outcomes, and assess individuals holistically, considering their physical, psychological, social, and cultural dimensions (Savas et al., 2023; Değer et al., 2019; Kaya & Caydam (2019). Nurses possessing the necessary knowledge, skills, and positive attitudes play a pivotal role in meeting the intricate health and social requirements of older individuals (Tate et al., 2023).
Providing personalized care demands, a thorough understanding of the numerous factors influencing intercultural interactions. These factors encompass cultural background, socioeconomic status, education level, and family dynamics. Rather than isolating culture, it should be perceived as an integral component of an individual's intricate identity. This perspective acknowledges the intersection of culture with various facets of a person's life, influencing their values, beliefs, preferences, and behaviours. By appreciating the complexity of each patient's uniqueness, healthcare providers can tailor care plans that are sensitive and adaptable to their specific needs and circumstances (Broom et al., 2019; Burke et al., 2023). Nurses must recognize that caregiving is a multifaceted endeavour, characterized by a web of events, actions, interactions, feedback, and opportunities constituting the phenomenon at hand. Approaching this responsibility entails understanding its intricacy, surpassing mere knowledge about care. It involves integrating conscious reflection and critically restructuring acquired knowledge and experiences (James et al., 2021). It is essential for nursing personnel to gain knowledge about aging and geriatric care, nurses who lack sufficient theoretical understanding and practical experience in this area may be hesitant to care for older adults after graduation (Söylemez et al., 2018; Baysal & Yildiz 2021; Soleimani & Yarahmadi, 2023).Thus, familiarity with aging, effective communication skills with older individuals, and maintaining high professional values promote positive attitudes towards working in geriatric care (Venables et al., 2023).
Cultural competence is widely recognized as a multi-dimensional construct, often encompassing a person's cultural sensitivity or attitudes, cultural awareness, and cultural knowledge and skills (Alizadeh & Chavan, 2016; Shen, 2015). Within the healthcare context, cultural competence is defined as an understanding of how social and cultural factors impact patients' health beliefs and behaviors and how these factors are addressed across various levels of healthcare delivery systems to ensure the provision of quality healthcare.
Competence is defined as the functional capability and capacity to integrate knowledge and skills into contextual practices specific to attitudes and values, and it is recognized as a core component of occupational standards. It is also defined as personal skills developed through vocational education and training and includes observable behaviors in occupational practice and unobservable characteristics, capacities, dispositions, attitudes, and values. (Fukada, 2018.). According to James et al. (2021), cultural competence (CC) is an ongoing process in which healthcare professionals strive to achieve the capacity and readiness to effectively operate within the cultural context of families, individuals, or communities (Campinha-Bacote (2002). This process involves integrating various elements informed by the theoretical framework guiding our actions.
Competence, as delineated by Fukada (2018), encompasses more than just knowledge and skills; it extends to the practical ability and aptitude to apply these elements within specific contexts while integrating attitudes and values. This definition positions competence as a fundamental aspect of occupational standards, reflecting the personal skills honed through vocational education and training. These skills manifest not only in observable behaviors in professional practice but also in underlying characteristics, capacities, dispositions, attitudes, and values. In essence, competence encompasses a holistic approach that goes beyond mere technical proficiency to include the broader spectrum of qualities essential for effective performance in a given role or profession.
According to Papadopoulos et al. (2022) & Blessing et al., (2024), culture encompasses the collective ways of life of a group, including their beliefs, values, ideas, language, communication styles, norms, and practices. These cultural elements are expressed through various means, such as customs, art, music, clothing, and etiquette. Culture plays a significant role in shaping people's lifestyles, personal identities, and interactions with others, both within and outside their cultural community. Furthermore, Papadopoulos et al. (2022) define cultural competence as the responsibility of professionals to advocate for underserved populations based on their ethnicity, ensuring their right to receive proper treatment without prejudice regarding their ancestry. Additionally, cultural competence involves empowering individuals to actively participate in healthcare decisions (Blessing & Potter, 2024).
Cultural competence in nursing involves integrating culture-specific knowledge into patient care and implementing culturally appropriate interventions that are acceptable to both healthcare providers and patients (Lowe-Archibald, 2009). Nursing's diversity can positively impact healthcare by addressing cultural dimensions of health needs and reducing health inequalities (Young-Guo, 2020). Increasing ethnic and cultural diversity in nursing can also alleviate the nursing shortage, reflecting and embracing cultural diversity in its practices (Young-Guo, 2020). Language barriers, socio-economic conditions, religious values, and cultural practices can pose significant obstacles to delivering high-quality care to an increasingly diverse patient population, contributing to disparities in healthcare delivery. Improving cultural competencies is highlighted as part of the solution to reducing these disparities (Majda et al.,(2021).
Currently, the topic of multiculturalism is gaining increasing relevance due to the development of the society, driven by globalisation and increased migration (Mihu, Marques & Pontifice Sousa, 2024). Cultural awareness, as described by Majda et al. (2021), is the capability of healthcare personnel to comprehend and address the distinctive cultural needs of individuals. It encompasses the recognition and understanding of the cultural differences and similarities that exist between individuals and groups. Richardson et al., 2024. This involves being conscious of one's own cultural background, beliefs, values, and biases while also being open to learning about and respecting the cultural perspectives of others (Shepherd, 2019; Kerrigan et al., 2024). Culturally aware healthcare professionals are crucial in various contexts, including healthcare, education, business, and social interactions, as they promote empathy, inclusivity, effective communication, and collaboration across diverse cultural settings (Sharifi et al., 2019).
Qualitative methodology was selected for its ability to provide a thorough understanding of the phenomena under study, considering participants' circumstances and cultural context. This approach allows for the exploration of nuances and complexities through techniques like interviews and textual analysis, revealing rich insights into lived experiences and perspectives.
This study was conducted using semi-structured interviews with registered nurses employed in private healthcare settings. Purposeful sampling ensured diversity in participants' demographics, including age, gender, ethnicity, and geographical location. The study included 10 participants, consisting of 7 females and 3 males, who were registered nurses currently working at a private aged care center and had graduated from a private nursing college and expressed willingness to take part in the interviews. Data collection was led by the author with assistance from a nursing sister and a senior nurse, utilizing semi-structured interviews to explore nurses' perspectives on cultural competence, experiences in providing care to patients from diverse cultural backgrounds, perceived challenges, and strategies to enhance cultural awareness. The research took place from January 10th to February 5th, 2020, at a private nursing home in Kota Kinabalu. The majority of the residents were Chinese, followed by Sino/Kadazan, Kadazan, Bruneian, Bajau, Indian, and Filipino. The primary languages spoken, besides their mother tongues, were Bahasa Malaysia and English. Participants received thorough verbal and written explanations regarding the study's objectives. Before the interviews, participants confirmed their willingness to participate by providing written consent. They were assured of their right to withdraw from the study at any time without explanation. Additionally, participants were guaranteed confidentiality and anonymity, and the research adhered to ethical standards for studies involving human subjects. Approval and clearance for the study were granted by the management.
The data analysis followed Braun and Clarke’s (2006) six-step thematic analysis. Initially, relevant quotes were identified from each paper and noted openly for initial concepts. These were then collated into a dataset for preliminary open coding, aided by a color-coding system to identify patterns. Reflection and discussion led to the development of broader themes, which were defined, labeled, and critically reviewed for accuracy, verifying the themes. To enhance credibility, trustworthiness, and rigor, various strategies were implemented. Member checking ensured the accuracy and alignment of findings with participants' experiences. Peer debriefing facilitated discussions with colleagues to validate interpretations and ensure the thoroughness of analysis. Triangulation of data sources involved incorporating multiple participant perspectives through diverse data collection methods, enriching the findings' credibility. These practices collectively fortified the validity and reliability of the study's outcomes. Currently, many studies have been conducted focusing on the influence of functional status, physical activity, and quality of life among older adults (Hussein, Khalip & Hashim, 2022).
Ethical clearance for this study was obtained from the management of Kanaan Nursing Home, Comfort Aged Care Group PLT, Malaysia with reference no. CACC/2020/G/03on 10thJanuary, 2020.
All participants unanimously expressed their preference for working with seniors in aging care facilities. They are keenly aware of aging trends, noting that older adults are living longer due to improved healthcare services, socioeconomic factors, and advancements in technology. They emphasized the importance of management understanding the growing diversity among elderly individuals (Yava, 2023) and the need for staff to learn basic spoken languages to facilitate effective communication and mutual understanding in daily tasks (Ashipala & Matundu, 2023).
Table 1: Enhancing Cultural Awareness a Qualitative Exploration of Nurses' Perspectives on Application of Cultural Competence in Elder Care
Emerging Theme and Sub-Themes during the Thematic Analysis | |
Theme | Sub-Theme |
Theoretical knowledge | Translating knowledge into practice |
Effective communication | Building rapport |
Self-achievement | |
Enhance comprehension | |
Preferred language | |
Consistent and ongoing interactions | Build familiarity and trust |
Treating individuals with respect | Providing care |
Being attentive | |
Implementing theoretical understanding in real-world situations can be challenging, especially when faced with language barriers. In such instances, resorting to non-verbal communication methods like gestures and body language becomes necessary (Gerchow et al., 2021). Practitioners' positive efforts to ensure patients' understanding were evident, which was viewed as crucial for establishing trust (Green et al., 2018).
Applying my knowledge into practice is challenging due to language barrier, sometimes I have to use signs and body language …. (P2)
The participant articulated that the knowledge acquired throughout their nursing training has proven invaluable in acclimating to their current work environment. They expressed confidence in their ability to continue honing their skills through consistent practice and dedication, foreseeing opportunities for further improvement and growth in their professional capacity.
I feel that the knowledge I have gained has assisted me in adjusting to my current workplace. With time, I believe I can further assimilate and enhance my skills…(P3)
Building rapport is essential when providing personalized care to elderly clients and their caregivers from diverse cultural backgrounds. It demands sensitivity and a profound comprehension of the cultural aspects shaping their health beliefs and behaviors. Healthcare providers must tailor care plans to match cultural preferences, values, and practices while also addressing individual needs and circumstances. By doing so, they ensure that care is delivered in a manner that respects cultural norms. This approach nurtures a sense of closeness between nurses and clients, thereby enriching the quality of care provided (Dijkman et al., 2022).
I realised the importance of building rapport with elderly clients and their family members, creates a common line of communication which make it much easier get cooperation when performing caregiving task that requires it…. (P13)
Maintaining open and clear communication with elderly clients from diverse cultural backgrounds fosters mutual understanding and ensures clarity regarding their expectations in line with their cultural norms. This involves employing various strategies to enhance comprehension, such as using simpler language, offering additional context or examples, breaking down complex concepts into smaller parts, and utilizing visual aids to illustrate key points (Ashipal & Matundu, 2023; Arnold & Boggs, 2022).
When leading simple exercises, I frequently use straightforward language that everyone can understand, ensuring cooperation and active participation until the activity ends, this approach results in everyone clapping their hands and smiling happily(P12).
Self-achievement" refers to the sense of personal fulfillment or accomplishment that an individual experiences when they successfully attain their goals, realize their potential, or overcome challenges. Kaledio & Favour (2024). It involves a sense of satisfaction, pride, and confidence in one's abilities and accomplishments. It is often associated with feelings of happiness, fulfillment, and a sense of purpose in life.
I find satisfaction in my ability to communicate efficiently and effectively with clients and their primary caregivers…. (P5)
Integrating technology resources for interpretation enables healthcare providers to communicate efficiently with patients and their families, overcoming language barriers and ensuring the delivery of high-quality care (Kiblinger et al., 2023; Rojas et al., 2023).
I use a translator app on my smartphone to comprehend words spoken by the client, particularly because my proficiency in Chinese is limited…. (P8)
After a follow-up review, if the client's primary caregiver requests medical updates in their preferred language, the nursing sister acknowledges the management's request and provides the report in written form along with a brief summary. This approach is adopted in response to the emphasis placed by resident stakeholders on the significance of this timeframe for ensuring effective communication (Rojas et al., 2023; Moss et al., 2020; Mukhalalati et al., 2023).
If the client's primary caregiver requests medical updates in their preferred language, I consult with the nursing sister for guidance… (P7)
Delivering individualized care to clients and their caregivers from diverse cultural backgrounds
requires a deep understanding of the cultural factors influencing their health beliefs and behaviours. It involves tailoring care plans to align with cultural preferences, values, and practices, while also considering each individual's unique needs and circumstances. This approach ensures that care is provided respectfully and in accordance with cultural norms, fostering trust between healthcare providers and patients (Rassouli, et al., 2020). The sense of comfort and ease experienced can be attributed to ongoing interaction, increasing familiarity, and the gradual development of trust over time,
Despite being Kadazan, I often find a sense of closeness when interacting with people from other races. In such instances, there is a feeling of comfort and ease, which I attribute to continuous interaction, growing familiarity, and the development of trust over time…. (P10)
Effective individualized care requires recognition of various factors influencing intercultural encounters, including culture, socioeconomic status, education, and family dynamics. Instead of isolating culture, it should be viewed as an integral aspect of a patient's multifaceted identity. This perspective enables tailored care that acknowledges and respects each patient's unique background and requirements (Broom et al., 2019).
Treating clients and their caregivers, of different cultural background while performing individualise care …. (P11)
Being attentive involves actively listening to the needs and concerns of elderly clients, observing their non-verbal cues, and responding with empathy and sensitivity. It requires taking the time to understand their cultural background, values, and beliefs, which can vary significantly among different groups. By demonstrating genuine interest and respect, healthcare providers can establish trust and rapport with elderly clients, fostering a supportive and caring environment for effective communication and quality care (Tuohy, 2019; López- Hernández, 2021).
I observed that elderly clients often require healthcare providers to actively listen to their needs and concerns attentively. Typically, when they need assistance or have a request, elderly clients will call for nurses to come closer to gain their attention…. (P13)
The diversity within healthcare teams is typically seen as beneficial for delivering high-quality care, but it can also place extra demands on culturally diverse patients and their primary caregivers, potentially impacting their overall well-being and the experiences of healthcare professionals (McCleskey & Cain, 2019; Burke et al., 2023; Ashipala & Matundu, 2023). Cultural competence is vital for delivering patient-centered care, which focuses on effective communication (Rassouli et al., 2020), personalized attention to individual needs, and respecting patients' rights. It entails understanding cultural nuances in communication, catering to diverse cultural requirements, and honoring patients' cultural identities and rights. Integrating cultural competence into patient care ensures the delivery of tailored and respectful services, leading to better patient outcomes and satisfaction.
The linguistic challenges faced by nurses worldwide involve multiple elements, including cultural differences, the utilization of interpreters, and the implementation of nursing techniques and resources, all of which have substantial effects on the delivery, standard, and results of care. Patients' preferences for language, particularly when they contrast with the official language of a country, are highlighted as crucial social risk factors and determinants of health (Gerchow, 2021). A study by de Voogd et al. (2021) highlights the challenges healthcare practitioners face when they lack a common language with their patients. This language barrier can hinder effective communication, leading to misunderstandings that may compromise the quality of care. Patients may struggle to accurately express their symptoms, concerns, or medical history, while healthcare providers may find it challenging to convey crucial information about diagnoses, treatment options, or medication instructions. As a result, both patients and practitioners may experience frustration or anxiety, and there is a heightened risk of errors in diagnosis or treatment. Boucher & Johnson (2021) suggest that improving communication skills and increasing awareness of the various factors influencing communication among nurses, patients, and families could be beneficial (Shepherd, 2019).
Generally, nurses often encounter uncertainty when engaging with patients from unfamiliar cultural backgrounds, as evidenced by studies such as those conducted by Gerchow et al. (2021) and Bloomer et al. (2019). Barriers to delivering care to ethnic minority patients are evident, as nurses report challenges in communication, a lack of culturally appropriate resources, and insufficient education as significant concerns (Joo & Liu, 2020). Therefore, enhancing healthcare practitioners' understanding of cultural aspects related to elder care, along with the development of communication skills and self-reflection, can provide a valuable framework for approaching clinical interactions (Semlali et al., 2020 ; Schembri 2024). Additionally, educating practitioners in moral reasoning could facilitate ethical decision- making, particularly when caring for patients from culturally diverse backgrounds (Markey, 2021). It is also recognized that newly graduated nurses may have limited engagement with elderly care during their training, which can impact their ability to provide culturally sensitive care to elderly patients (Burke et al., 2023).
This study highlights the challenges encountered by newly graduated nurses when caring for clients and their families from diverse cultural backgrounds. Additionally, it presents strategies, such as enhancing cultural awareness, as described by Majda et al. (2021), aimed at addressing these challenges and effectively meeting the needs of older adults. The study's narrow focus on newly graduated registered nurses may restrict the applicability of its findings to a wider range of healthcare professionals. Therefore, future research could replicate the study on a larger scale, including various other healthcare professionals, to enhance the generalizability of the results.
This study focuses on exploring nurses' perceptions and practices regarding cultural competence in their clinical work. It delves into their experiences, obstacles, and approaches to delivering culturally sensitive care to patients from diverse backgrounds. The topic underscores the significance of cultural awareness in healthcare settings and aims to uncover insights that can inform initiatives to enhance nurses' cultural competence, thereby elevating the standard of patient care. Additionally, the study sheds light on the challenges newly graduated nurses encounter when caring for older adults and engaging with culturally diverse family caregivers. It underscores the hurdles posed by language barriers and communication discrepancies rooted in cultural diversity, emphasizing the need for concerted efforts to improve interaction and comprehension. Despite these challenges, nurses demonstrate adaptability by leveraging their skills and utilizing tools such as smartphone apps to navigate unfamiliar scenarios. They embrace a person centered approach to involve family members in the care process. The study also advocates for greater integration of cultural considerations into nursing education to bolster cultural competence and enhance care delivery, particularly in indigenous communities.
The author declared no conflict of interest.
The author expresses heartfelt gratitude to all participants for sharing their valuable views and insights in this study. Special thanks are extended to the healthcare facility for their support and facilitation. Additionally, appreciation is extended to the research assistants and colleagues whose contributions were instrumental in the successful completion of this study.
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