Culture, beliefs, and religion are extremely important in the lives of individuals, their families, and communities. These values can contribute to decisions made in healthcare and influence their subjective beliefs about chronic conditions or associated therapeutic interventions (Shahin et al, 2019). District nurses (DNs) are recognised by an additional qualification in specialist practice and are responsible for the quality of clinical care delivered both individually and as part of the team they lead (The Queens Nursing Institute (QNI), 2014; Bain, 2015). Therefore, DNs require an extensive awareness of culture and beliefs, to establish a sound understanding of how they affect patient experiences within the healthcare system and safeguard high quality care (Galanti, 2014; Bain, 2015). Nevertheless, there is no clear definition of cultural competence, which is recognised as one of the principal foundations of clinical nursing (Sharifi et al, 2019). This article aims to explore cultural competence for the DN in the context of care provision for adult patients and their families.
Background
The UK is evolving in its cultural diversity, and although the terms ‘culture’ and ‘religion’ are closely linked, what they stand for individually, differs. Culture is the body of knowledge in relation to a person's values, norms and beliefs that is learnt through life, although individuals may have the same culture, yet practice different religions (Clark and Phillips, 2010). Religion is the relationship between an individual and the spiritual ideas they regard as holy and worthy, with the religious prayers and meditations directed to the Gods and spirits they believe in (Angelo, 2018). Even among religions, there is diversity between practices (Ives and Kidwell, 2019). Strong beliefs have been connected with an eclectic array of physical and mental health outcomes; however it is suggested that while professionals are positive in their attitude to integrate religious principles into their practice, few incorporate this into their routine assessments (Koenig et al, 2012; Oxhandler and Parrish, 2018). Cultural competence is difficult to define due to the lack of consensus over the meaning of the terms ‘culture’ and ‘competence’. Yet, it is broadly accepted that it refers to the process of safe delivery of care, which holistically meets the patient needs, considering cultural aspects (Oikarainen et al, 2019; Sharifi et al, 2019; Rassouli et al, 2020).
Due to global migration, nurses are caring for patients in increasingly diverse cultural and multilingual settings (Tuohy, 2019). The Office for National Statistics (ONS) (2021) UK census identified an increase in the number of people living in England and Wales belonging to different ethnic groups. The largest increase can be seen in Asian groups from 4.2 million in 2011 to 5.5 million in 2021. Ethnic identity is strongly linked to culture and religion and is a significant predictor of cultural values. With 58 recorded religions in the census, it can be assumed that England and Wales are culturally diverse places to live (Watt, 2014; ONS, 2021). Over 11 million people are aged 65 years or older—a 2.2% increase since the previous census, and are considered as diverse as the rest of the population (ONS, 2021).
It has been identified that equality in culture and religion is vital, and healthcare professionals (HCPs) are expected to be aware of how cultural, spiritual, and religious beliefs impact upon health and wellbeing (National Institute for Health and Care Excellence (NICE), 2016; 2017; NHS England, 2019; UK Government, 2021). The Nursing and Midwifery (NMC) Code of Professional Conduct (2018) states that nurses must treat every patient as an individual, respecting their dignity, never discriminating—irrespective of age, ethnicity, or cultural background. Cultural competence is recognised in the NHS long term plan (2019), from a public health perspective and the standards of proficiency for community nursing specialist practice qualifications, threading throughout the seven platforms (NMC, 2022).
There are many challenges DNs must overcome to ensure their care is truly culturally competent. DNs work within local communities coordinating care for those with complex chronic comorbidities, to reduce unnecessary hospital admissions and enhance quality of life (McCrory, 2019). It is well known that health is determined by numerous factors external to the traditional healthcare environment (Nair and Adetayo, 2019). Measures that seek to improve cultural competence and ethnic diversity can help alleviate healthcare disparities and improve outcomes (Bergeron and Lagacé, 2021).
Communication
Cross-cultural disparities in health include poor socio-economic status, poverty, low levels of health literacy and language barriers (Bergeron and Lagacé, 2021). For the DN, the ability to communicate effectively with patients from various cultures is crucial for understanding and delivering optimal care. The use of enhanced communication skills when interacting with individuals from different cultures and religions, can assure patient's wishes are followed and a patient-centred plan of care is devised. Communication and therapeutic practice is reinforced by the DNs’ professional responsibility to consider their own beliefs, culture or religion before trying to understand that of others (Ferwerda, 2017). Self-reflection can support the advancement of the DN and their teams in cross-cultural awareness by regulating their personal biases and possible judgemental thoughts. This can also help teams consider the process of cultural adaption, whereby health messages are adjusted to include accurate information, which is relevant and understandable to users from diverse populations (Tan et al, 2020).
It can be a challenge for DNs who provide holistic care to patient groups with lower levels of health literacy and language barriers, which is often performed in home environments and in isolation. Salavati et al (2019) expressed the importance of appointing an independent interpreter when faced with language barriers to overcome the challenges of cross-cultural communication. Kang et al's (2019) community-based study of asylum seekers and refugees highlighted dominant themes within their qualitative study. Language barriers, poor health literacy and inadequate interpretation services, among other issues, illustrated the damaging consequences of poor healthcare and emphasised lesser outcomes for those with marginalised complex needs. It is therefore imperative that DNs are familiar with language services and are able to educate others on how to access such services to improve outcomes.
HCPs require knowledge of different cultures and beliefs, which are to be respected at all times (NICE, 2016; NMC, 2018). Markey and Okantey (2019) advocated a nurturing values-based learning approach to develop culturally competent care within community nursing teams. This can be supported by the NHS England's (2016) 6Cs: strategy for care, outlining compassion, courage, communication, competence and commitment, as a collection of nursing values, which can unify nursing practice (Baillie, 2017). The Care Quality Commission (2022) issued guidance on ‘culturally appropriate care’, which relates not only to the values of person-centred care, dignity, respect and integrity, but also the need for consent. The commission directs practitioners to communicate with sensitivity when dealing with cultural identity and tradition, and be responsive to principles determined by cultural heritage. Health literacy is interrelated to this as it refers to the interpersonal factors that affect an individual's ability to acquire, comprehend and use information about health or health services (Batterham et al, 2016). When carrying out holistic assessments, a greater awareness of health literacy from DNs and their teams can enhance shared decision-making. Research demonstrates that at all levels of health literacy, communicative, functional, and critical skills are required to engage with HCPs (Muscat et al, 2021).
Disparities
It is acknowledged that some health conditions and inequalities adversely affect one ethnic group more than another. According to Galanti (2014), infants born to African-American women are 1.5–3 times more likely to die than those born to women of other races/ethnicities. Hispanic women are more than 1.5 times as likely to be diagnosed with cervical cancer than any other ethnic group (Galanti, 2014). The King's Fund (2023) identified that in the UK, prostate cancer mortality is higher among Black males and lung cancer among Bangladeshi males; yet, there is a lower cancer mortality rate among ethnic minority groups in comparison to white groups. They also acknowledge that while the modes of diseases and their presentations may differ between ethnicities, so may their therapeutic needs. It is therefore important for the DN to understand the wider public health issues and that these statistics differ across cultural and ethnic groups. Another pertinent example is type 2 diabetes (T2DM) which is more prevalent in Asian and Black ethnic groups, and is associated with a considerable disease burden (Pham et al, 2019). T2DM-related cases contribute to a substantial portion of a DN caseload, and DNs have a significant role in the optimisation of treatment regimens for this population. As such, they must increase cultural awareness (Irons, 2022).
Conversely, the COVID-19 pandemic directly exposed ethnic health inequalities, which were evident by the disproportionate effect of the disease on Black, Asian, and minority ethnic communities. It was understood to be caused by a multifaceted interaction of social and biological factors, causing increased exposure to COVID-19, coupled with reduced protection, which resulted in a greater severity of illness in comparison to other communities (Patel and Hanif, 2022).
Gender disparities can raise a variety of challenges for the DN; from a clinical perspective, many patients express preferences for male or female only staff members when intimate procedures are carried out. Some religions and cultures simply forbid this from happening; for example, those of Middle Eastern origin will never allow a male physician to examine a woman (Galanti, 2014). This can prove challenging in emergency situations or when managing a complex DN caseload, where the allocated HCP who is trained for an intervention is of an opposing gender. DNs needs to work collaboratively with other teams and services to ensure all is done to meet a patient's needs and wishes. Burns (2015) demonstrates that a collaborative approach to the healthcare a patient receives can dramatically enhance their experience. However, resource constraints, difficulties with safe staffing and complex caseloads can inhibit cultural competence, as DNs battle against a diminishing workforce and have an increasing number of visits (The King's Fund, 2016; QNI, 2016).
Nutrition
It is important to develop cultural competence to understand patients’ and families’ views on healthcare and treatments. An illustration of this is healthy nutrition. Food plays a central role in maintaining a healthy life, aiding the healing process and recovery from associated chronic illnesses such as cancers and long-term conditions, often placing a considerable burden on health populations and health care systems (Vasiloglou et al, 2019). Therefore, it may become a challenge when nursing a patient whose culture forbids them from eating certain foods, or from even eating at all. Arbit et al (2017) recognised the powerful correlation between the health and moral factors in food behaviours and consumption choices, which were not always positive. DNs will experience detrimental food behaviours in practice, with some cultures indulging in or excluding certain food group,s depriving them of vital nutrients, resulting in negative health outcomes. Certain communities actively encourage the consumption of food and drink that is detrimental to health as it is seen in their culture as being ‘sacred’. This was identified by Mogre et al's (2019) qualitative study focusing on barriers to T2DM in an African population. They found a belief in ‘spiritual forces’ prevented some individuals engaging in positive dietary practices. Poverty and insufficient access to a seasonal variety of foods also proved a barrier to managing T2DM. This population does not directly mirror that of the UK but raises matters that DNs could experience with regard to diabetic control, malnutrition and associated poverty contributing to food insecurity, the prevalence of which is higher than previously thought within the UK (Power et al, 2018). The Hindu culture use food as one way to determine social ‘ranking’, with the colour of some foods regarded as higher in status and therefore, not being available to all (Sharma, 2012; Galanti, 2014). Some foods are ultra-processed or modified to change their colour for many reasons, but this reduces their nutritional value and plays some part in disease development (Helman, 2000; Srour, 2019). The DN needs to be mindful of such belief systems, offering support and education but also respecting the patient's individuality and working with them to achieve the desired outcome. If the DN identifies decisions as medically ‘unwise’, they must provide all necessary information and assess the individual's capacity to consent, while respecting a patient's wishes and autonomy (Legislation UK, 2005).
Pain
It is extensively documented that Western countries are in acceptance of using pain medication to manage symptoms, alleviate pain and promote comfort. However, Griffiths et al (2015) explains that some cultures believe the illnesses or symptoms they are experiencing are a punishment from God due to sins in a past life. This can result in patients refusing treatment or medication. Pain management, blood infusions, fluids, antibiotics, and cardiopulmonary resuscitation (CPR) may be viewed very differently from one culture to another. Enduring pain or other uncomfortable symptoms can often be seen as necessary as a sign of overcoming the disease; more so, responses to pain relief and other analgesics can vary due to gender or genetic variations (Clark and Phillips, 2010; Packiasabapathy and Sadhasivam, 2018). Chinese communities have strong beliefs about the effectiveness of Chinese herbal medicine. Considerations are also required for those practising the Indian and holistic form of Ayurvedic medicine, which is thought to strengthen the individual and is used as a complement to Western medicine (Hansson and Stensson, 2022). In addition to these, non-conventional therapies (NCT) such as acupuncture, phytotherapy, naturopathy, and osteopathy are emerging and nurses must be attentive to these developments (Feijó et al, 2018).
Shahin et al (2019) stated that when asked if any alternative treatments or home remedies are being used, individuals often deny any use due to embarrassment. Chen et al (2015) highlighted that culturally, there is more of a widespread acceptance of both western and Chinese herbal medicine. However, drug interactions are a danger. Disclosure of medications and interactions with prescribed medications can pose a challenge for the DN regardless of cultural background and even more so when patients are in the home environment with access to other drugs, legal or otherwise.
End-of-life care
End-of-life care is a challenging time for patients and their families (Ohr et al, 2016). DNs often require the knowledge and understanding of different cultures and religions in relation to death and the associated rituals or spiritual processes that take place. Clark and Phillips (2010) explained that some cultures discourage speaking about death, which creates issues for emergency health care planning, ‘Do Not Attempt Resuscitation’ (DNAR) discussions and patients’ expressing their own wishes at the end of life. The DN is required to work collaboratively with other services and the patient's GP, and ensure all appropriate multidisciplinary team (MDT) referrals are made to help support these processes. Utilisation of a designated social prescriber may provide additional facilities and support for the patient, particularly when providing anticipatory care or even family support. NHS England (2022) indicated that social prescribing can improve the lives of people with long-term conditions, people who need support with their mental health, people who are lonely or isolated and others who have complex social and cultural needs.
Gordon (2015) echoed the need for cultural anticipatory care, noting that Orthodox Jewish rituals begin as death draws near. Both the family and dying patient take part in religious farewell rites until the body has ‘passed’; it is then prepared immediately for burial. Furthermore, according to Loike et al (2010), the Orthodox Jewish religion requires the appointment of a Rabbi by the family when a patient is nearing end of life, and they are involved in decisions made, even the withdrawal of treatment. Some religions challenge withdrawal of medical interventions to shorten a life—including the withdrawal of fluids, medications and cardiopulmonary resuscitation (Gordon, 2015). It is important that the DN recognises these issues for future practice, working collaboratively with safeguarding teams to ensure decisions made are in the patient's best interests, when they are no longer able to decide (NICE, 2020). Issues are also raised regarding Verification of Expected Death (VoED), with some religions preferring it to be carried out in a timelier manner, to organise the death certificate and funeral arrangements. VoED requires communication alongside the family and MDT prior to death to ensure a respectful experience and delays in this process can cause additional anxiety and stress (Hospice UK, 2022). Scenarios such as these involve the DN having difficult conversations with the patient, family, and religious clergy. A good understanding of religions is required, along with well-developed communication skills.
Conclusions
This article identified how cultural and diverse communities can influence the role of the DN and the care they deliver. It is vitally important that the DN and community nursing teams are utilised as a resource to promote and safeguard patient-centred healthcare. Gaps in knowledge may exist in the practices and beliefs of the individuals that are cared for, due in part to the evolving demographics of the communities served. Targeted education for cultural development, therapeutic communication, the provision of cultural resources and the use of reflective practice, can support DNs to enhance the care they already provide to such diverse groups.
Key points
- Therapeutic communication is a key factor in developing culturally competent relationships
- Health inequalities are prevalent within many cultural and minority groups, affecting the quality of health care delivered
- District nurses (DNs) are ideally placed to promote cultural competence within the community nursing team
- DNs should explore their own beliefs and those of others to facilitate new learning around culture, beliefs, and religion
CPD reflective questions
- Reflect on your own experiences and knowledge of cultures, religions, or beliefs and how they have impacted your clinical practice
- Does your geographical area of service delivery feature a prevalent population that identify with a prominent culture or religion?
- Do some of the examples in the article highlight educational needs you may have with cultural competence and how can you develop this individually and as a team?