cultural competency

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Cultural Awareness Online Continuing Education Course (Est. 1 to 1.25 Contact Hours*) Published March 22, 2006.

By the end of this module, the participant will be able

1. Define cultural competence.
2. Discuss the stages of cultural competence.
3. Differentiate between cultural competence, cultural awareness and cultural sensitivity.
4. Define stereotype, prejudice, ethnic identity and worldview.
3. Explore several tools for cultural self-assessment.
4. Assess and evaluate own level of personal competence.

This is the third module on the Cultural Competency Series.

This course builds on the concepts from Cultural Competency I and Cultural Competency II.  It is recommended that the participant review the concepts introduced in those courses.
The Cultural Competency I course is available here.

Developing Cultural Awareness:
Cultural self-assessment

I. Introduction.

"How does a nurse achieve the requisite knowledge, skills and respect for
differences that lead to cultural competence?
The first step is awareness and an honest exploration of one's own
cultural values, beliefs and prejudices against other cultures.
Humility and self-understanding come first before the study of another  culture. (Leonard 2001) (1)

Central to the concept of cultural competency is that it is a developmental process
that evolves over an extended period. In order to respect and acknowledge
differences, a person needs to know and accept himself or herself as a cultural being.

Self-assessment is not only for individuals, but it also expected of organizations in
which individuals belong.

Conducting cultural self-assessments by individuals and organizations is one of the key elements in achieving cultural competence (1,2,3,4,5).
Both organizations and individuals are at various levels of
awareness, knowledge and skill acquisition along the cultural competence continuum
as self-assessment is an ongoing process, not a one-time occurrence (1,2,3).

In this section, we will review some basic concepts of cultural competency,
and introduce definitions of terminology commonly used in the
discussion of cultural competence.

II. First is a review of the definition of culture.

According to Leininger, the founder of Transcultural Nursing,
culture consists of the learned, shared and transmitted values,
beliefs, norms and lifeways of a particular group that guide their thinking,
decisions, and actions in patterned ways (2).

Elements of cultural competency:

“The culturally competent system would:

  • value diversity
  • have the capacity for cultural self-assessment
  • be conscious of the dynamics inherent when cultures interact;
  • have institutionalized cultural knowledge; and
  • have developed adaptations to diversity." (Terry Cross 1989)(2)

“Practice must be based on accurate perceptions of behavior,
 policies must be impartial, and attitudes must be unbiased.” (Terry Cross et al. 1989.) (2)

 III. Cultural competence terminology

Cultural competence:  "The complex integration of attitudes, knowledge, and skills to facilitate communication and
appropriate interactions between persons of
diverse cultures." (American Academy of Nursing, 1993)

Cultural competence is the ability to work effectively in a multicultural setting. Campinha-Bacote defines cultural competence as "the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of a client" (family, individual or community) (3).

Cultural competence:  “Care that takes into account issues related to diversity, marginalization, and vulnerability due to
culture, race, gender, and sexual orientation. This
care is guided by nursing theories, models, and/or
research”. (National Academy of Nursing expert panel, 1990)

“Cultural awareness is developing an awareness of one's own culture, existence, sensations, thoughts, and environment without letting them have an undue influence on those from other backgrounds.”(Purnell, 2005).

"Cultural awareness is defined as the process of conducting a self-examination of one’s own biases towards other cultures and the in-depth exploration of one’s cultural and professional background." (Campinha-Bacote 2002).

Cultural Sensitivity: Knowing that cultural differences as well as similarities exist, without assigning values, i.e., better or worse, right or wrong, to those cultural differences (National Maternal and Child Health Center on Cultural Competency, 1997).

IV. Background terminology for cultural competency:

Bias: An inclination of temperament or outlook; especially a personal and sometimes
unreasoned judgment (6).

Stereotypes: Overall impressions based on the assumption that all
members of a group possess similar attributes(7).
Stereotypes are the cognitive precursors of prejudice and discrimination (8).

Prejudice: A negative feeling toward a group based on a faulty generalization (9).

Racial identity: Generally refers to physical characteristics of individuals to
include skin color, facial features, hair, etc; used to define race categories
(eg, White, African American, Native American, Asian) (10).

Ethnic identity: refers to how individuals self-identify based not only on
physical characteristics, but on religious background, nationality, and cultural experience (10).

Cultural identity is a broader term: people from multiple ethnic
backgrounds may identify as belonging to the same culture.

Cultural identity:  Any combination of shared historical, linguistic,
and psychological factors that influence the perspectives of different cultural groups (7, 10).

One example would be people from Mexico, Guatemala and Columbia
may identify with the Latin American culture at the same time identifying
with different ethnic cultures.
Leininger refers to the different subcultures within the healthcare system:
the patient's culture, the care-giver's culture, and the healthcare organization are all part
of the larger healthcare system "culture".

Caregivers may have their own ethnic identity, yet self-identify as part of a professional culture,
within a specific department's subculture. For example, an operating room nurse
may have his/her own ethnic identity and still hold a professional identity as an OR nurse,
with a culture that is distinct from a medical-surgical nursing culture.

Values: Ideas held by human individuals or groups about what is desirable, proper, good or bad.

Differing values represent key aspects of variations in human culture.
What individuals value is strongly influenced by the specific culture in which
they happen to live. (8)

Worldview: A framework through which an individual interprets the world and interacts in it.
A collection of beliefs about life and the universe held by an individual or a group (11)

Almost everything that we experience is shaped by the perceptions provided by our
view of the world.  Culture filters what we see and what we perceive. Culture determines the generally accepted definitions of social reality (11)

For example, the predominant Technological Worldview of most Western countries, that technology would be able to solve  most human disease and illnesses, might be in contrast to a holistic worldview of other cultures.

V. Cultural competence: a journey

According to the Campinha-Bacote model, cultural competency is
not an end-result to be achieved, but a continuous process of life-long

learning and desire, to achieve the ability to work effectively within the cultural context of the client.

The Papadopoulos, Tilki and Taylor Model for Developing Cultural Competence
describes a four-stage model that starts with cultural awareness, to the acquisition
of cultural knowledge, to the development of cultural sensitivity and cultural competence (4).

Developing cultural awareness requires  self-humility, self-understanding,
and self-acceptance of one's own cultural identity. It requires "a life-long
life-long commitment to self-evaluation and self-critique...(3)".

Self-awareness must not only be intellectual, it must be emotional
or heart-felt to be effective (11). It requires recognition of one's biases and
prejudices, and recognizing the limits of one's competence (12).

Source: Papadopoulos, Tilki and Taylor Model (

  cultural competency model


“Cultural identity development is a major determinant of...client
attitudes toward the self, others of the same group,
and the dominant group”.

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(1)  Leonard, B. (May 31, 2001)  "Quality Nursing Care Celebrates Diversity" Online Journal of Issues in Nursing. Vol. #6 No. #2, Manuscript 3.
(2) Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System  of Care: Volume I. CASSP Technical Assistance Center, Georgetown University Child Development Center. Washington, DC; 1989.
(3) 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(2), 117-125.
(4)Sue, D., Ivey,A. Pederson, P. et al (1996). A Theory of Multicultural Counseling  and Therapy. Baltimore, MS: Brooks/Cole Publishing CO. cited in


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