Nurses have gifts and talents perfectly designed to serve God (Romans 12:6-8). We come from different places, families, cultures, and educational backgrounds. We have different life experiences. One advantage arising from these differences is the opportunity to share multiple perspectives, allowing for a more holistic approach to each patient situation. In contrast, even though nurses may share a mutual faith, our differences can lead to conflict. Being cognizant of this, acknowledging these dissimilarities, and working together beyond these differences can bring the joy of collaboration and like-mindedness that benefits both nurses and patients.
Nurses are called to care for others, often under challenging circumstances, and to advocate for those who cannot do so themselves. Life may be compared to an iceberg (Figure 1); people see our actions and hear our words, but a significant part of our lives, which involves character development, remains unseen. The journey through life requires effort and faith to cultivate humility that guides our behaviors and actions in alignment with our faith.
OUR INCREASING DIVERSITY
By 2044, it is estimated that the population of the United States will be a "majority-minority" with no racial/ethnic group making up 50% or more of the overall population (Colby & Ortman, 2015). In 2045, half of the population is projected to be non-Hispanic White; 25% Hispanic; 13% Black; 8% Asian; and 4% multiracial (Frey, 2018). Structural inequities, disparities in social determinants of health, and resulting health inequities will increase healthcare demands by racial/ethnic minorities. The increased healthcare demands to manage chronic health conditions will challenge the health system's resources and clinicians' ability to provide quality and efficient care. Therefore, healthcare providers, especially nurses, need to be well equipped to care for and work with diverse populations. In the past, the nursing profession focused on developing competencies to interact with patients from different cultures. However, as the United States becomes more diverse culturally, the concept of cultural competence as a framework to care for and work with an ethnically diverse population may not be the best approach (Foronda, 2020; Foronda et al., 2016).
To provide the best-quality patient care, we must examine our own character and beliefs and those of our patients and treat patients as we would want to be treated (Adelstein, 2015). Personal barriers may prevent nurses from providing effective patient care. These barriers may be perceived or actual and include language, income (socioeconomic status), literacy, and occupation (Adelstein, 2015). For example, statements from persons who sound different than ourselves (e.g., have accents or speak English as a second language) may trigger bias in some persons because, compared with native speakers, nonnative speakers often are perceived as less credible (Lev-Ari, 2015).
The purpose of this article is to provide strategies that can facilitate character development to promote interpersonal relationships in nursing practice. Cultural humility, conscientious practice, and trust building in the context of the changing demographic landscape in the United States are discussed.
EXAMINING CULTURALLY SENSITIVE CARE
Nurses should consider cultural humility, conscientious practice, and establishing trust as important strategies to promote a healthy work environment, increase awareness of healthcare disparities, and provide culturally sensitive care to the changing demographics of the U.S. population. These strategies can help promote positive changes in nursing care that align with Christian values.
CULTURAL HUMILITY
Cultural humility emphasizes the application of humility and the interpersonal attributes of self-reflection, critique, partnership-building, and lifelong learning (Foronda et al., 2016; Lobos & Reyes, 2019; Tervalon & Murray-Garcia, 1998; Vega et al., 2016). Cultural humility was derived from the cultural competence literature and its development is generally a lifelong learning process. The concept of cultural competence-the notion that an individual from another culture is knowledgeable in another person's culture, having interacted or memorized facts from that person's culture-is problematic (Yeung et al., 2018). One problem with the concept of cultural competence is the potential for overgeneralization and stereotyping of persons from other cultures.
Persons or healthcare professionals who consider themselves culturally competent may presume they know what is best for their patients. However, not everyone from a specific culture adheres to all aspects of that culture's beliefs and practices. Moreover, because people are diverse, it becomes impossible to learn and retain enough facts from any given culture to be considered "culturally competent."
Although cultural humility might be new to some, it should not be a new concept to Christians because its core principle, humility, is a quality of the Christian life. Philippians 2:3-4 advises us to be self-aware and selfless and to imitate Christ's humility: "Do nothing out of selfish ambition or vain conceit. Rather, in humility value others above yourselves, not looking to your own interests but each of you to the interests of the others" (NIV). Humility, in this sense, is defined as the act of critically and continuously developing our trust in and reverent fear of Christ while emulating his nature in our daily lives. Features of humility include "modesty in behavior, attitude or spirit; showing patience, gentleness and moderation about one's abilities and values" (Lobos & Reyes, 2019). We must realistically appraise our strengths and weaknesses to make improvements and put the needs of other persons before our own needs. We are encouraged to "put on compassionate hearts, kindness, humility, meekness, and patience" (Colossians 3:12, ESV).
Specific to the healthcare setting, cultural humility is defined as the "ability to maintain an interpersonal stance that is open in relation to aspects of cultural identity that are most important to the patient" (Yeung et al., 2018, p. 555). Others have defined humility as being keen on reserving one's ideologies, truth, or personal and national narratives and making space within themselves for others (Dwiwardani & Waters, 2015). When these two definitions are combined, cultural humility is the willingness to learn from another person either within or outside one's own culture, acknowledging that person as the author and owner of his or her life experiences (Lobos & Reyes, 2019). This minimizes one's cultural superiority over another and embraces humility. The attributes of cultural humility are intended to promote cross-cultural interactions and include awareness, egoless, openness, supportive interactions, and self-reflection (Foronda et al., 2016). Cultural humility has a critical implication in promoting diversity for its framework of valuing each person's cultural and educational backgrounds, including life experiences (Hughes et al., 2020).
For example, in our interactions with patients, it is essential to use plain language and vocabulary familiar to them (Trudeau, 2016). Although this strategy is often associated with health literacy, it also comes from a place of humility. Features of humility include thinking of others before ourselves, putting the needs of other persons before ours, and being modest in our "behavior, attitude or spirit; showing patience, gentleness and moderation about [our] abilities and values" (Lobos & Reyes, 2019). In our interactions with patients, we must acknowledge that patients are the experts of their experiences and culture-a tenet of cultural humility (Adelstein, 2015).
Cultural humility involves the continued use of self-reflection and critique in relationships with persons around us to help address [health] inequities in the milieu of a subjective and fluid culture (Fisher-Borne et al., 2015). Additionally, cultural humility involves lifelong learning and partnership building. Self-reflection and critique are skills that involve developing an inner awareness of one's thoughts, sensations, judgments, and perceptions. Mastering an honest appraisal of one's self requires practice and focus. For example, when taking care of a patient with diabetes who has an infected foot wound, the nurse uses self-reflection and critique to provide nonjudgmental care, disregarding the circumstances surrounding the patient's condition, and instead focuses on necessary tasks or responsibilities and how the patient is treated. The nurse is also cognizant of the social or cultural influences that may have led to the patient's current situation. Understanding and practicing conscientiously, with honesty and integrity, and with cultural humility facilitates one's personal character development and promotes positive personal interactions during care delivery and establishment of meaningful work relationships (See Sidebar: Case Study).
Through the practice of cultural humility, healthcare providers consider implicit biases, self-understanding, and interpersonal sensitivity, while cultivating an appreciation for the patient's culture, gender, or race (Stubbe, 2020). Cultural humility also has been shown to impact organizations; it is associated with higher hospital safety levels and better handoffs (Hook et al., 2016).
Foronda et al. (2016), in their concept analysis of cultural humility, provided a detailed example of how nurses can engage in cultural humility while practicing. As nurses, we can learn from patients when we listen to their experiences and life stories in our interactions and, by practicing cultural humility, understand patients. Similarly, we can admit when we do not know enough about a subject (e.g., culture) and are willing to learn from the patient, the expert of his or her experience and culture. Additionally, through self-critique, we reflect on and evaluate our beliefs and attitudes during our interactions with patients to determine whether these beliefs, attitudes, and actions are self-serving or promote the patient's well-being and whether there are areas for improvement.
Practicing cultural humility can ensure that a message is communicated in a culturally acceptable manner and demonstrates respect for persons and their culture. Paul discusses the importance of being able to relate to other people in 1 Corinthians 9:22: "To the weak I became weak, that I might win the weak: I have become all things to all people, that by all means I might save some" (ESV). Communicating within the cultural context is important for ensuring that our messages are culturally appropriate and clearly understood (Reina & Reina, 2015).
CONSCIENTIOUS PRACTICE
Above and beyond humility and cultural humility, as Christians, we should demonstrate conscientiousness in our practice and care of others. Conscientious practice has been extensively addressed in medical journals and articles, but not in nursing literature. This topic thus needs further development in both nursing practice and research (Kaldjian, 2014). Historically, the ancient Greek perspective of conscience was based on the human experience of inner pain that is universal and against human nature (Kaldjian, 2014). Conscience, according to Vithoulkas and Muresanu (2014), is the inherent ability of a human being to perceive what is right and what is wrong. God created humankind in his own image (Genesis 1:27), expressed in the Latin as imago Dei, made to be a reflection of God, unlike any other created beings. In a person who knows God as Savior and Lord, the conscience should be a direct reflection of the imago Dei, where a person mirrors and lives by the moral truth, purity, wisdom, and holiness of God (Cherry, 2017).
For nurses, the conscience encompasses professional conscience, individual conscience, and integrity. Integrity involves both clinical and personal integrity (Dworkowitz, 2013). Just as David asked God in Psalm 86:11 to "unite my heart to fear your name" (ESV), as we practice, we need to ensure that our clinical and personal integrity work together because conscience involves an undivided self and heart. In effect, this is an integration of moral beliefs, values, and actions (Dworkowitz, 2013).
Nursing is both an art and a science. We practice holistic care by integrating critical thinking and addressing patients' physical, psychological (including behavioral), spiritual, and social needs. As conscientious nurses, we need to distinguish between our conscience and ethical judgments concerning specific clinical situations and ultimately ensure that our practice unites conscience and integrity in accordance with biblical principles. For example, we realize that a patient with a new chronic disease diagnosis who keeps giving reasons why he cannot be discharged from inpatient care is not bellicose about his situation. Instead, the patient's actions may be because he needs both support from family and friends and a reinforcement of his faith for inner strength to manage his condition, prevent worsening of his health and bring healing. The nurse can reinforce a patient's faith in healing by providing personalized, faith-based resources for daily use and identify persons (including family or faith leaders such as a chaplain, rabbi, or priest) from whom patients can draw on for strength or support.
ESTABLISHING TRUST
Establishing trust with patients is critical in building successful relationships. A trusting relationship is also an essential element with cultural humility and conscientious practice. Nurses should avoid behaviors that have been reported to diminish patients' trust in nurses, including failing to do required or requested tasks promptly or adequately, show up when called or needed, have the professional equipment for the test, misusing available equipment, or being reckless and indifferent to pain needs among others (Ozaras & Abaan, 2018).
Trust is built incrementally and is a complicated and multidimensional concept with many interpretations (Reina & Reina, 2015). The Reina Trust and Betrayal model is a framework often used in nursing practice and research (Rushton et al., 2007; Rushton et al., 2010). According to this model, trust has three dimensions: character, communication, and competence (Reina & Reina, 2015). Each dimension of trust includes recommended trust-building behaviors. Trust of character involves honoring others' expectations, boundaries, and perspectives as valid (Reina & Reina, 2015)). This reflects the apostle Paul's admonition: "Therefore, having put away falsehood, let each one of you speak the truth with his neighbor" (Ephesians 4:25, ESV). Trust of character may be demonstrated through conscientious behaviors aligned with nurses' individual and professional values. Trust of communication within the Reina Trust Model relates to creating an environment of openness and transparency that leads to a sense of community and shared purpose (Reina & Reina, 2015). Finally, Reina & Reina (2015) state that trust of capability involves the competence to manage demands and expectations placed on a nurse by others.
There are, however, no uniform approaches to engaging in cultural humility and conscientious practice in nursing. As nurses, we should consider the following practices during clinical encounters. First, we should practice self-reflection and question our beliefs surrounding the patient, their family, or culture. For example, we should avoid assuming that all patients wearing headwraps are Muslim. Second, we should always ask patients about their goals or priorities for their care, including learning about their religious beliefs and spiritual care needs. Third, we should listen attentively with our entire bodies (being aware of body language and nonverbal communication). For example, if a patient refuses a treatment regimen, we should listen to his or her personal or cultural reasons for decline declining that treatment and identify feasible alternatives, if possible. Finally, we should continuously build trust and maintain truthful, open, and honest communication with patients and their families. For example, we should not provide false information or lie even when it might appear to benefit the patient or his or her family.
CONCLUSION
As Christian nurses, we have the potential to significantly impact others. As we work toward improving patients' health outcomes and educating the next generation of nurses, we must be cognizant of hurdles that impact our practice. We work in challenging environments that sometimes involve poor communication and team dynamics. Our society is facing rapidly changing demographics. Represented by an iceberg image, most of the work to overcome these challenges begins below the water-in our hearts and characters-and is expressed above the water, visibly, in our actions.
Confronting the challenges of the diversity of personal characteristics and experiences is difficult. Cultural humility has been suggested as a way of tackling this (Hughes et al., 2020). However, cultural humility alone is not enough, especially for those striving to live by their faith. We must be conscientious, able to intrinsically assess and judge our actions, ensuring conformity to the Word of God. Cultural humility and conscientious practice inherently involve internal beliefs and processes that are different for each nurse. Many nurses can engage in these behaviors without practicing cultural humility or engaging in conscientious practice. However, as Christians, living out our values and beliefs requires that the source of our behaviors and character reflect Christ. This congruence between what we believe and practice is essential for us to provide quality patient care and live rewarding lives as children of God.
Acknowledgment
RT is supported by the Strategically Focused Research Network Award from the American Heart Association: 17SFRN33590069 and was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health under award number T32DK062707. MN was supported by the Robert Wood Johnson Foundation Health Policy Research Scholar program, the National Institute on Aging (NIA# 1F31AG057166-01), and now by the Robert L. Kane Endowed Chair in Long-Term Care and Aging at the University of Minnesota School of Public Health.
Sidebar: Case Study
Kirsten, a white, non-Hispanic home health nurse, arrived for a home visit with a Hispanic family. Kirsten had not yet met the family, but she had reviewed information in the chart and knew the primary purpose for this visit was to evaluate Mr. Garcia's left great toe for a flare-up of gout. Mr. Garcia also had a history of hypertension and diabetes. Kirsten planned to do some education with the family on healthy eating using the DASH (Dietary Approach to Hypertension) diet during this visit.
When Kirsten arrived, Mr. Garcia was sitting in a chair with his feet resting on a towel on the floor, ready for the nurse's visit. Kirsten introduced herself and began to examine the affected big toe. She was surprised to observe what appeared to be a large amount of loose flesh hanging off the gouty toe. The loose flesh looked pale and had poor color. At that moment, Mrs. Garcia entered the room and gasped, "Oh no! I am sorry. I meant to take that bacon off before you got here!" Kirsten smiled in relief and inquired about the cultural practice of wrapping a toe with gout in raw bacon. Mrs. Garcia shyly replied that it was a folk remedy; their belief was that the saltiness of the raw bacon would draw out infection and promote healing. Mrs. Garcia had seen the nurse's confusion when looking at the toe encased in the raw bacon. Both Mrs. Garcia and Kirsten laughed as Mrs. Garcia unwrapped the bacon from Mr. Garcia's toe to allow for a closer examination.
When Kirsten acknowledged this cultural practice, she was nonjudgmental and applied cultural humility appropriately, which opened the opportunity for further conversation. Indeed, Kirsten was humbled that she didn't know of this common practice for the treatment of gout, and she later reflected on her own beliefs and attitudes regarding culturally specific home remedies and how these could be incorporated within her plan of care.
Kirsten learned that it was acceptable to ask about unique practices and the beliefs behind them. Certainly, the application of raw bacon to a gouty toe was a lesson in cultural humility for this nurse, but her affirming reaction to this practice opened the opportunity for Mr. and Mrs. Garcia to share their culture in a safe environment. Also, after their mutually respectful sharing, the Garcias were more open to Kirsten's discussion about diabetes and hypertension.
-Kristen L. Mauk, PhD, DNP, RN, CRRN, GCNS-BC, GNP-BC, FARN, FAAN
JCN Senior Editor
Web Resources
* Nurses Christian Fellowship Internationalhttps://ncfi.org
* Samaritan's Pursehttps://samaritanspurse.org
* Transcultural Nursing Societyhttps://tcns.org/
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