Running head: CULTURAL COMPETENCE IN NURSING

Cultural Competence in Nursing for the Hispanic/Latino Population

Jenna Applebach
Ferris State University

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Abstract
This paper explores the need for cultural competence in nursing for the Hispanic/Latino
population of the United States, which accounts for 17.4% of the total population (CDC, 2015).
Parts of relevant Hispanic/Latino culture related to healthcare are discussed as well as the
relation of health disparities to cultural incompetence and cultural beliefs. This paper also
explores barriers to cultural competence, such as a lack of education, as well as concepts to
improve the quality and safety of nursing practice in relation to culturally competent care for the
Hispanic/Latino population. Finally, implications and consequences of cultural incompetence
regarding the Hispanic/Latino population are discussed.

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Cultural Competence in Nursing for the Hispanic/Latino Population

In 1908, an American named Israel Zangwill coined the term melting pot. What he
meant was that the United States was a melting pot of different peoples and cultures. That may
have been the case a century ago, but in more recent years, the steady influx of immigrants have
remained largely separated according to their ethnicities, races, and cultures (Salam, 2014).
Because of this separation, different cultures within the United States have remained intact.
Therefore, there is a need for cultural competence within the field of nursing in order for nurses
to deliver care of highest quality to their diverse patient population. More specifically, there is a
huge need for culturally competent care for the Hispanic and Latino population, as this group is
currently the largest and fastest-growing ethnic minority in the United States (Aroian, Peters,
Rudner, & Waser, 2012, p.134). The purpose of this paper is to explore why cultural competence
is needed in nursing care for the Hispanic and Latino population.
Latino and Hispanic
Although these two terms are often used interchangeably, they actually have different
definitions. According to Pittman (2015), Latino refers to a person from or having ancestry
from a Latin American country, including Mexico, the island nations of the Caribbean, and South
American countries; it is a term based on geographic location. Hispanic refers to a person who
speaks Spanish as the primary language or is of Spanish-speaking origin (with ties to Spain). For
the sake of simplicity, the terms Hispanic and Latino will be used interchangeably
throughout this document.
Statistics
Currently, there are roughly 55,481,128 people of Hispanic origin living in the United
States. This number accounts for approximately 17.4% of the total population (CDC, 2015). By
2050, that percentage is expected to rise to 30% of the population (Aroian, Peters, Rudner, &

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Waser, 2012, p. 134). It is important to note that, of the 17.4% of Hispanic people, a third of
them are not proficient in English, meaning that they either cannot speak English well or do not
speak it altogether (Krogstad, Stepler, & Lopez, 2015, para. 8).
Nursing Statistics
According to Minority Nurse (2015), only 7.5% of nurses (LPNs and RNs) in the United
States claim to be Hispanic and only 6% of student nurses claim to have a Latino background
(Mayo, Sherrill, Truong, & Nichols, 2014, p. 305). In comparison, 75.4% of nurses identify as
white (Minority Nurse, 2015).
Cultural Tendencies, Beliefs, and Practices
Even though there are many sub-cultures within the Latino culture, as Latinos include
peoples from many different countries of origin, there are commonalities among these cultures
(Aroian, Peters, Rudner, & Waser, 2015, p. 136). Therefore, it is safe to use Latino culture as a
blanket term. More specifically, cultural tendencies, beliefs, and practices related to healthcare
will be discussed.
Physical Closeness
According to Grady (2014), Latinos tend to be a very warm and personable people and a
healthcare worker more than an arms length away may be perceived as cold, indifferent, and
uncaring (p. 26). Physical contact (such as handshaking and hugging) is customary and
important, as it conveys concern and a warm and caring demeanor (Grady, 2014, p. 26).
Health and Illness
Health is perceived as a balance between the physical, emotional, and spiritual being and
illness has religious and spiritual influences (Grady, 2014, p. 27). For instance, illness may be
seen as a punishment from God (Grady, 2014, p. 27). Grady (2014) also stated that family

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participation is essential in order to overcome an illness and two curative measures may include
the use of curanderos and herbal remedies (p. 27). According to Grady, a curandero is a folk
healer and is often a family elder. It is also important to note that herbal remedies tend to have a
negative impact when used with Western medicines and that both the use of curanderos and
herbal remedies tends to be much more prevalent among the older Latino generation (p. 27).
Other Beliefs and Practices
A study carried out by Aroian, Peters, Rudner, and Waser (2012) indicated that Hispanic
people tend to have a common belief of fatalism, where health outcomes are influenced by fate
and that there is nothing one can do to change these outcomes (p. 139). Aroian, Peters, Rudner,
and Waser also found that healthcare is typically sought only if a Latino is on his or her
deathbed and that being overweight is perceived as being healthy, acceptable, and sometimes,
preferable (p. 139).
Health Disparities
A combination of the underrepresentation of Latino nurses, health-related cultural beliefs
and practices, and cultural incompetence in the field of healthcare has led to a plethora of health
disparities in comparison to the non-Hispanic white population of the United States.
According to Families USA (2014), Hispanic women are 45% more likely to be
diagnosed with cervical cancer and are 40% more likely to die of cervical cancer. Hispanic
people are also 15% more likely to be obese and 65% more likely to have diabetes. The Centers
for Disease Control and Prevention (2015) indicate that 30.4% of Latinos do not have health
insurance as compared to only 12.7% of the non-Hispanic white population.
Cultural Competence in Nursing

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Health disparities exist in part because of a lack of resources and education in the Latino
population, but more importantly, because of a lack of cultural competence within the healthcare
system. Being able to deliver proper care to the Latino population has direct ties to being
knowledgeable about their health-related cultural beliefs and practices as well as being able to
communicate with them in their native language.
Cultural Competence
The National Center for Cultural Competence at Georgetown University (1989) defines
cultural competence as a set of congruent behaviors, attitudes, and policies that come
together in a system, agency or among professionals and enable that system, agency or those
professions to work effectively in cross-cultural situations (para. 3).
Culturally Competent Care
According to Larsen and Reif (2011), culturally competent care [is defined as] the
attitudes, knowledge, and skills necessary for providing quality care to diverse populations (p.
350).
Josepha Campinha-Bacotes model and conceptual guide to cultural competence lists five
essential and interdependent concepts for achieving proficiency in culturally competent care.
These concepts include having cultural desire, cultural awareness, cultural knowledge, cultural
skill, and engaging in cultural encounters (Grady, 2014, p. 27). Grady (2014) defines cultural
desire as a wanting to advance ones personal cultural competence. Cultural awareness involves
examining ones own cultural influences and biases. Cultural knowledge is defined as advancing
ones knowledge on a specific culture or cultures. Cultural skill is the ability to perform a
cultural assessment in a culturally-appropriate way. Finally, cultural encounters involves
engaging in communication with people of different ethnicities and cultural backgrounds (p. 27).

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Examples: Importance of Cultural Competence

When cultural beliefs and practices are taken into consideration and culturally competent
care is delivered, health disparities among the Hispanic population as compared to the nonHispanic white population may decrease.
Language. When nurses and other healthcare workers are aware that about one third of
Latinos are not proficient in English (Krogstad, Stepler, & Lopez, 2015, para. 8), they can make
an effort to speak Spanish themselves or employ interpreters to communicate effectively with
their patients. This language barrier is huge, and misunderstandings have potential to lead to
health disparities.
Physical closeness. When nurses and other healthcare workers are aware that Latinos
tend to favor physical closeness and touch during communication (Grady, 2014, p. 26), they may
employ these behaviors in order to foster positive relationships with their patients. In return, their
Latino patients may continue to seek needed health care in the future, leading to decreased health
disparities.
Herbal remedies. A final example may be that when nurses are aware of the fact that
many Latinos (especially those of the older generation) prefer to use herbal remedies over
Western medicines (Grady, 2014, p. 27), they would know to question about this use during
assessments. In doing so, they could determine whether or not they would need to consult with a
physician over the potential negative impact of using an herbal remedy simultaneously with a
Western medication.
Hypertension Prevention Study
A great example of a culturally competent teaching intervention for nurses can be found
in a qualitative study carried out in 2012 to determine the hypertension (HTN) prevention beliefs

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of Hispanic people as well cultural factors that may lead to HTN. According to Aroian, Peters,
Rudner, and Waser (2012), HTN affects one in four Hispanics in the United States and more than
30% have pre-HTN (p. 134). In their study, 17 participants of varying Hispanic backgrounds
answered 10 questions regarding behavioral beliefs, normative beliefs, and control beliefs about
HTN (Aroian, Peters, Rudner, & Waser, 2012, pp. 135-136).
Findings
Though not all results of the research questionnaire will be covered, several key findings
include the fact that many Hispanics felt they did not have time to exercise, they valued social
interaction over exercise (with the exception of dancing), and had hot emotions that could lead
to increased stress (Aroian, Peters, Rudner, & Waser, 2012, pp. 137-138).
Time. Many of the Hispanics interviewed felt that their lives were more hurried and busy
in the United States compared to their countries of origin. They said that Americans tend to work
more and, in order for Hispanics to prove that they are an ideal minority, they felt the need to
work more jobs and longer hours. Therefore, they felt they did not have much time to exercise to
decrease the risk of developing HTN (Aroian, Peters, Rudner, & Waser, 2012, p. 138).
Social interaction. Spending time with family and friends is very important to Hispanics
and many of the interviewees explained that exercise should never take away from family time.
Exercise is acceptable only if it is done in moderation and does detract from time for social
interaction (Aroian, Peters, Rudner, & Waser, 2012, p. 138). Several interviewees went on to
explain that dancing is an acceptable form of exercise, as music and dancing during get-togethers
is common and is a part of our culture (Aroian, Peters, Rudner, & Waser, 2012, p. 138).
Hot emotions. Finally, hot emotions were explained as intense reactions to certain
situations and that Hispanics are emotional and get worked up easily. They said that these

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intense emotions and reactions could lead to stress, which is a common precursor to HTN
(Aroian, Peters, Rudner, & Waser, 2012, p. 137).
Implications: Culturally Competent Education
Since several Hispanics said that dancing is a large part of their culture and that it is an
acceptable form of exercise, nurses can teach their Hispanic patients that dancing is a great way
to help prevent HTN. Not only that, but dancing also challenges the three barriers to HTN
prevention mentioned in the previous section. It solves the not-enough-time issue because time
for social interaction is occurring simultaneously and it allows Hispanics to blow off the steam
from their hot emotions. Nurses can encourage their Hispanic patients to attend dance sessions
or have get-togethers with dancing involved.
Barriers to Cultural Competence
Cultural competence in nursing is obviously important, but it is also important to explore
potential barriers to achieving proficiency in cultural competence. These barriers include a
racially and ethnically-homogenous nursing workforce, living in a racially and ethnicallyhomogenous society, not knowing the Spanish language, the concept of ethnocentrism, a lack of
education, no desire to learn about culture, and unconscious biases.
Homogenous Nursing and Homogenous Society
The vast majority of nurses in the United States identify as white (75.4%) and only 7.5%
identify as Latino (Minority Nurse, 2015). If most nurses do not work alongside Latino nurses,
they cannot observe the caring actions of Latino nurses toward their Latino patients. Therefore,
there remains a degree of ignorance regarding culturally competent care, as no learning is
occurring. Many areas of the United States also remain mostly white, so there is a lack of

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experience with Latino patients and, therefore, little chance for using culturally competent care
in nursing practice.
Spanish Language
According to Burgen (2015), there are 41 million native Spanish-speakers in the United
States, making it the second-largest Spanish-speaking country in the world (Mexico is the
largest) (para. 1-2). It can be assumed that the majority of American nurses do not know Spanish,
making language a barrier to cultural competence. If nurses cannot communicate with their
Hispanic patients, how will they learn about their unique culture and provide the best care
possible?
Ethnocentrism
The Merriam-Webster Dictionary (2015) defines ethnocentrism as having or based on
the idea that your own group or culture is better or more important than others. Therefore, it can
be inferred that if a nurse is ethnocentric, he or she will not be willing to learn about and accept
the cultural beliefs of his or her patient(s) and cultural incompetence will persist.
Lack of Education and Lack of Desire to Learn
Cultural incompetence stems from ignorance, and if nurses are not receiving external
education on different cultures, how can they be expected to practice culturally competent care?
Also, if there is a lack of desire to learn about a new culture, it is obvious that cultural
incompetence will persist.
Unconscious Biases
Everyone has a bias about something and many of these biases can be unconscious or, in
other words, an unawareness of ones own biases. Personal biases are barriers to cultural
competence in that we may unintentionally avoid those from a particular culture because we

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have had several bad experiences with members of that culture or have heard or read
something negative related to that culture.
Theory Base
There are a couple of theories relevant to culturally competent care. One is known as the
Cultural Care Theory by Madeleine Leininger and the other is Lev Vygotskys Sociocultural
Theory, which is a theory of psychology.
Cultural Care Theory
Madeleine Leiningers theory suggests that Culturally competent nursing care can only
occur when client beliefs and values are thoughtfully and skillfully incorporated into nursing
care plans (Sitzman & Eichelberger, 2004, p. 97). When nurses use culturally competent care as
a guide, they are able to provide holistic, culturally-based care (Sitzman & Eichelberger, 2004, p.
97). When nurses recognize the value of culturally competent care and incorporate it into
practice, they can initiate positive changes to healthcare practices for a specific cultural group.
This practice of culturally competent care would lead to fewer health disparities in the Latino
population.
Sociocultural Theory
Lev Vygotskys Sociocultural Theory is based on the idea that children acquire the
behaviors and thinking patterns of knowledgeable persons within a culture. Childrens thoughts
and behaviors are further developed through interacting with others in the same culture. Of
course, such thoughts and behaviors vary between cultures (Gallagher, 1999, para. 4). This
psychological theory is linked to culturally competent care in that the nurse is made aware that
culture becomes an innate part of a persons cognition from a very early age. Through this
awareness, the nurse recognizes that patterns of thinking and behaviors are not easily changed.

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Therefore, rather than trying to change the behaviors of a patient, the nurse can adjust her care to
include the cultural needs of her patient. A great example would be the persistent presence of a
Hispanic childs extended family during hospitalization. Family is extremely important to
Hispanic people and, knowing this, the nurse could include family members in the plan of care as
much as possible. To a Latino, the lack of family involvement during hospitalization would be
nearly unthinkable (University of South Florida, n.d.).
ANA Standards
Three standards of the American Nurses Association are highlighted in the concept of
culturally competent care. These include Standard 8 (Education), Standard 10 (Quality of
Practice), and Standard 11 (Communication).
Standard 8: Education
Standard 8 is Education, which, according to the American Nurses Association (2010),
includes the nurses responsibility to attain knowledge and competence that reflects current
nursing practice (p. 49). Nursing is dynamic and always changing, so ongoing education is
important to keep up with current nursing practice (ANA, 2010, p. 49). Cultural competence is a
great example because ongoing education is required, as patient populations are constantly
changing. Nurses need to acquire knowledge, consider personal biases, and share new
knowledge with colleagues regarding Latino patient populations in order to give high-quality
care.
Standard 10: Quality of Practice
Standard 10 is Quality of Practice. The American Nurses Association (2010) states that
The registered nurse contributes to quality of nursing practice [by] identifying aspects of
practice important for quality monitoring (p. 52) The nurse also contributes to quality of

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practice by collecting and analyzing data to monitor the quality and effectiveness of care as well
as identify areas of quality improvement (ANA, 2010, p. 52). The nurse is contributing to quality
of practice when she monitors Latino patient care outcomes and compares this data to other
patient populations to pinpoint disparities. From there, the nurse can adjust care accordingly to
improve quality of care and equalize outcomes. Culturally competent care begins with improving
the quality of practice.
Standard 11: Communication
Standard 11 is Communication and states that The registered nurse communicates
effectively in a variety of formats in all areas of practice (ANA, 2010, p. 54). The nurse assesses
the communication format preferences of her patients and also assesses her own communication
skills with patients (ANA, 2010, p. 54). Proper communication is an essential part of culturally
competent care. The nurse determines whether her Latino patients will need to communicate in
Spanish and calls on the assistance of an interpreter as needed. The nurse also assesses and
adjusts her own communication style to ensure her patients understanding of care interventions.
Recommendations for Quality and Safety Improvement
The three ANA standards mentioned in the previous section, along with the competencies
of the Quality and Safety Education for Nurses (QSEN) project, are connected to quality and
safety improvement. According to Case Western Reserve University (2014), the competencies of
the QSEN project include patient-centered care, teamwork and collaboration, evidence based
practice, quality improvement, safety, and informatics.
Recommendations for Nursing School

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Recommendations for quality and safety improvement for the Latino patient population
should begin at the nursing student level, as nursing students can carry such an improved level of
cultural competence into practice with them as registered nurses.
Spanish Minor. It is recommended that a Spanish Minor be a mandatory part of the
nursing curriculum. It may be difficult to fit Spanish language into nursing curriculums as they
already tend to be packed with courses, but knowing basic Spanish may lead to better cultural
understanding and improved quality of care for future Latino patients.
Cultural immersion. It is recommended that nursing students be given opportunities for
cultural immersion in a Spanish-speaking country through their respective nursing programs.
This method has actually been proven to be the best method for improving cultural competence
and efficacy in culturally competent care (Mayo, Sherrill, Truong, & Nichols, 2014, p. 310).
Standardization of cross-cultural education. Even though cross-cultural education in
nursing schools has been mandatory since 1986, this education is not standardized. Therefore,
nursing students have often displayed less-than-satisfactory levels of cultural competence (Mayo,
Sherrill, Truong, & Nichols, 2014, p.306). With standardization, nursing students would have
similar proficiency levels of Latino cultural competence.
Recommendations for Nurses
Recommendations for quality and safety improvement should continue well into the
nursing career, as evidence based care and nursing practice is constantly changing in order to
lead to culturally congruent care.
Monthly meetings. Monthly language and cultural knowledge meetings should be held
for nurses. Language should cover basic words and phrases that nurses might be able to use to

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communicate with their Latino patients. Cultural education should include health beliefs and
practices of Latino patients. Through these meetings, quality of care could be improved.
Awareness of personal biases. Nurses should become aware of their unconscious biases
toward Latinos through special tests. Once they are aware of such biases, they would be able to
work against them to improve their willingness to learn more about their Latino patients and give
higher-quality care.
Implications, Consequences, and Inferences
According to Mayo, Sherrill, Truong, & Nichols (2014), a lack of understanding of
Latino culture is linked to an increase in negative attitudes toward this population. We can infer
that these negative attitudes would lead to decreased quality of care for the Latino population.
Cultural competence combats this issue.
As evidenced by the information found throughout this document, cultural competence is
extremely important. Without cultural competence, health disparities may worsen due to
ignorance and miscommunication, negative attitudes toward the Latino population may persist
from such ignorance, unawareness of personal biases will negatively impact nursing care,
feelings of ethnocentrism may take over (leading to decreased quality of care), and the vicious
cycle unequal care and health disparities Latinos face will continue indefinitely.
Conclusion
The Hispanic and Latino population of the United States will continue to rise over the
next several decades. With this increase in population, cultural competence in nursing is
absolutely essential for providing high-quality care to these people. Through increased exposure
to Latino patients and cultural immersion, proficiency in culturally competent care may improve,
and with it, health disparities between Latinos and their white counterparts. Cultural competence

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will continue to be a driving force behind quality care and equity of care for Latino and Hispanic
people as well as those from other cultures in the United States.

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