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Introduction   

When we talk about culture, we often dive right into how to respectfully care for patients who are different than we are. However, let’s start with a different perspective. Imagine you are transferring to another nursing department/unit in your workplace. What might you expect during the orientation training period? Perhaps learning about the new patient population and their care needs? Maybe identifying where all the supplies and equipment are located? How about getting to know your new boss?

While not always a popular topic during orientation training, acclimating to the culture of the new department/unit is equally important. Many nurses are familiar with the workplace culture, but how might you describe it to someone who doesn’t work at your organization? If a workplace can have a culture, how do we truly define culture? How does this relate to patients?

As of January 1, 2025, all nurses in Illinois (LPN, RN, and APRN) are required to obtain continuing education (CE) training on Cultural Competency. This course will explore the expansive nature of culture and explain how you can use your understanding of culture to be culturally competent as a nurse practicing in Illinois. First, the course will outline the new CE requirement.

Illinois Cultural Competency Continuing Education Requirement

The State of Illinois now requires nurses and other registered/licensed health professionals to engage in continuing education on the topic of Cultural Competency to practice within the state as of January 1, 2025. This section will define terminology within the new law and detail the training requirements.

New Law Terminology

As you continue to read through this section, refer to the definition of the following terms as outlined in the new law: (1) Cultural Competency, (2) Health Professional, and (3) Statutorily Mandated Topics [7].

• Cultural Competency

According to the State of Illinois, cultural competency is “a set of integrated attitudes, knowledge, and skills that enables a health care professional or organization to care effectively for patients from diverse cultures, groups, and communities” [7].

• Health Professional

The new law applies to health care professionals in the state of Illinois, including nurses, medical providers, dentists, pharmacists, clinical psychologists, physical and occupational therapists, respiratory therapists, speech-language pathologists and audiologists, social workers, counselors, behavioral analysts, and nursing home administrators.

• Statutorily Mandated Topics

According to the State of Illinois, statutorily mandated topics are “continuing education training as specified by statute” [7]. These are CE topics in which you must receive training to renew your Illinois nursing license and practice within the state. Examples include Implicit Bias Awareness, Sexual Harassment Prevention, and now, Cultural Competency.

New Law Summary

The new law (Public Act 103-0531) is divided into two parts (Section 2105-370 and Section 2105-375) [7]. Part one details the new training requirements. Part two describes how often the new training must occur. 

• Section 2105-370: “Continuing Education; Cultural Competency”

For healthcare professional license or registration renewals occurring on or after January 1, 2025, a healthcare professional who has continuing education requirements must complete at least a one-hour course in training on cultural competency. A healthcare professional may count this one hour for completion of this course toward meeting the minimum credit hours required for continuing education.

• Section 2105-375: “Limitation on Specific Statutorily Mandated Training Requirements”

Notwithstanding any other provision of law, for health care professional license or registration renewals occurring on or after January 1, 2025, a health care professional whose license or registration renewal occurs every 2 years must complete all statutorily mandated topics within 3 renewal periods.

• • Illinois RN and APRN license renewals occur every 2 years, expiring May 31 of each even-numbered year [8]
  • Illinois LPN license renewal occurs every 2 years, expiring January 31 of each odd-numbered year [8]

Therefore, all nurses in Illinois must complete the Cultural Competency continuing education requirement within 3 renewal periods (or once every 6 years).

What is Culture?

Reflect on the word “culture.” What crosses your mind? Do you think of educational background? How about employment status? While it may be easy for some to think culture only refers to an individual’s ethnic/racial background, culture encompasses much more. Culture is defined as “a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group” [3].

Culture is an identity and can be expressed in many ways, including [3]: 

• Ethnic/Racial Background 
• Language(s) Spoken 
• Religion and Spiritual Beliefs 
• Gender Identity 
• Socioeconomic Status 
• Age 
• Sexual Orientation 
• Geography 
• Educational Background 
• Life Experiences 
• Living Situation 
• Employment Status 
• Immigration Status 
• Ability/Disability

We can belong to many cultures at once. For this reason, when we ask someone about their culture, the answer can be quite complex. We might have multiple ways in which we culturally identify ourselves and this can change over time as culture is not fixed [3]. Your cultural identity can be ever-evolving. For example, you may adopt other groups’ beliefs or practices over time.

Ethnic/racial background, language, and religious/spiritual beliefs are often primarily associated with culture but as you can see, culture is expansive. Culture can also encompass occupations, hobbies, and interests (although these are often associated with the term subculture – a smaller group within a culture, like the “nursing culture”) [3]. Earlier we talked about workplace culture. This refers to the way you and your peers think and behave at work. Your current workplace culture may have existed for many years before your employment; therefore, these thoughts and behaviors may have been passed down.

As nurses, to truly grasp the concept of Cultural Competency, we must first understand the various expressions of culture so we can ensure our attitudes and behaviors are respectful of all aspects of a patient’s cultural identity. Reflect on the following case scenario.

Case Scenario 

A patient comes to the emergency room with an infected leg wound infection. The patient identifies themselves as part of the nomad community and shares they have been staying in hostels, renting rooms, and staying with family and friends over the past four years. The patient states they have a freelance virtual job, like to travel, and prefers not to have a home of their own. They are currently renting a room in a stranger’s home. The patient developed a chronic wound in the right leg caused by a spider bite that recently became infected. They state, “My room has a spider infestation and isn’t as clean, but it works for me right now.”

Cultural Sensitivity and Cultural Humility

Cultural Competency starts with cultural sensitivity and cultural humility – one is an awareness, and the other is an attitude.

Cultural Sensitivity

First, we must be aware that cultural differences exist in the first place. Then we must know that culture can affect the way we think and behave. The American Nurses Association defines cultural sensitivity as “being aware that cultural differences and similarities exist and affect values, learning, preferences and behaviors” [2][5]. This awareness helps us understand why a patient may respond to care in a particular way.  

For example, a patient may refuse a medical treatment based on a spiritual belief, such as holistic healing. If the nurse is aware that spirituality can play a significant role in a patient’s medical decision-making, the nurse may be more likely to respect the patient’s choice. Cultural sensitivity allows the nurse to respect the patient’s right to autonomy (the right to make their own medical decisions regardless of the nurse’s beliefs).  

Cultural sensitivity also involves how you communicate with patients/families from diverse cultural backgrounds. While your communication (both verbal and body language) may be reflective of your cultural background, it may be considered offensive to some patients. In this case, it’s less about changing who you are and more about being aware that your communication may be insensitive. When communication is not culturally sensitive, the risk of miscommunication increases which may result in adverse events or poor adherence to treatment [Brooks].

Cultural Humility

You may be familiar with some aspects of a patient’s cultural identity, such as sexual orientation, based on past encounters with patients who shared the same identity, personal study about sexual orientations, or personal experiences you may have had outside of the workplace. While knowledge is power, cultural humility is the acknowledgment that you do not know everything about a patient’s culture. 

The American Nurses Association defines cultural humility as “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process” [2][5].  

As mentioned earlier, a patient may hold certain cultural beliefs but adopt other groups’ beliefs and practices as well. You may be unaware of the patient’s evolving cultural beliefs as they are unique to each patient. Additionally, your patient may hold many other cultural identities that you may be unfamiliar with. Culture isn’t a one-size-fits-all all. Think back on the example of the patient who culturally identifies as a nomad. How much do you know about the nomad community? What questions might you have for the patient about their lifestyle? What parts of nomadism are interesting or confusing to you? How might a nurse’s lack of cultural humility influence the care they provide to patients who identify as nomads?

Cultural sensitivity and cultural humility are foundational to cultural competency as a nurse. Knowing everything there is to know about a patient’s culture is not necessary to become culturally competent. Cultural competency is a life-long process and simply being willing to learn and evaluate your own culture and biases is key.

Cultural Demographics in Illinois

As discussed, part of cultural sensitivity is having an awareness of the existence of diverse cultures. To provide culturally sensitive care to patients, nurses must be aware of the various cultures that exist in their area of practice.

Let’s take a look at some cultural demographics in Illinois.

Ethnic/Racial Background [16]:

• White – 76%  
• Hispanic or Latinx – 19%  
• Black or African American – 15%  
• Asian – 6%  
• American Indian and Alaska Native – 1%

Ancestry [15]: 

• German – 17%  
• Irish – 11%  
• English – 7%  
• Polish – 6%  
• Italian – 5%  
• French (except Basque) – 1% 
• Sub-Saharan African – 1%  
• Scottish – 1% 
• Norwegian – 1%

Language(s) Spoken [15]: 

• English – 76% 
• Spanish – 14% 
• Other Indo-European languages – 6% 
• Asian and Pacific Islander languages – 3%  
• Other languages – 1%

Religion and Spiritual Beliefs [11]:

• Feel a sense of spiritual peace and well-being at least several times a year – 80% 
• Feel a sense of wonder about the universe at least several times a year – 73% 
• Participate in meditation at least several times a year – 53% 
• Christian – 71% 
• Agnostic – 4% 
• Atheist – 3% 
• Jewish – 2% 
• Muslim – 1% 
• Buddhist – 1% 
• Hindu – 1%

Age [15][16]: 

• Under age 5 – 5% 
• 5 to 14 years old – 12% 
• 15 to 17 years old – 4%  
• 18 and older – 78%  
• 65 and older – 17%

Sex/Gender [16]: 

• Assigned female at birth – 51% 
• Assigned male at birth – 49%

Sexual Orientation [10]:

• Adult residents who identify as LGBTQ* (Lesbian, Gay, Bisexual, Transgender, Queer) – 4%

Educational Background [15]:

• High school – 25% 
• Some college, no degree – 19% 
• Associates degree – 8% 
• Bachelor’s degree – 23% 
• Graduate or professional degree – 16%

Living Situation [15][16]: 

• Married couple family household – 45% 
• Female householder, no spouse present – 29% 
• Male householder, no spouse present – 19% 
• In poverty – 12%  
• Moved from a different state – 2% 
• Moved from abroad – 1%

Civilian/Veteran Status [15]:

• Veteran – 5%

Employment Status [12][15]:

• Private-owned company workers – 68% 
• Local, state, and federal workers – 13%  
• Private not-for-profit workers – 10%  
• Self-employed – 9%  
• Unemployed – 5%

Ability/Disability [6][15]:

• Have a disability – 12% 
• Have a disability under age 65 – 7%  
• Ambulatory difficulty – 6% 
• Cognitive difficulty – 5% 
• Hearing difficulty – 3% 
• Self-care difficulty – 3% 
• Vision difficulty – 2%

*The “Q” in LGBTQ can also include those who are “questioning.” Additionally, sometimes a “+” is added at the end to include other orientations [3]

As you can see from the statistics, the State of Illinois is culturally diverse. The world as a whole is becoming increasingly diverse. All nurses must be equipped with the tools necessary to provide culturally sensitive care that respects the dignity and human rights of all patients. The first right of the Patient Bill of Rights is the “right to considerate and respectful care” [3].

The Code of Ethics for Nurses and the Standards of Nursing Practice – both developed by the American Nurses Association – also outline the importance of providing care that is respectful of patients’ cultural differences. This care must be bias-free. This is not optional. It is a requirement as long as you hold a nursing license and practice in your state. This is why Cultural Competency training is so important.

Cultural Competency

Now that we have defined culture, reviewed cultural demographics in the State of Illinois, and outlined your responsibility in providing culturally sensitive care, we can bring it all together and apply cultural competency to practice in everyday interactions with patients/families. As mentioned earlier, the State of Illinois defines cultural competency as “a set of integrated attitudes, knowledge, and skills that enables a health care professional or organization to care effectively for patients from diverse cultures, groups, and communities.” Essentially, cultural competency is a skill. Just as you may be competent in starting an IV or placing a urinary catheter, you can be competent in effectively caring for patients from diverse cultural backgrounds.

In this section we will discuss:

• Cultural Influences on Care 
• Culturally Safe Environments 
• Cultural Negotiation 
• Benefits of Cultural Competency

You can also apply the skills you learn in this section to your interactions with your peers/coworkers from diverse cultural backgrounds.

How Culture Influences Care

As aforementioned, cultural sensitivity is an understanding that cultural differences exist and can affect our thoughts and behaviors.

The following are ways a patient’s cultural background may influence their decisions about medical care or treatment [3]:

• Perception of Illness

This may include beliefs about the cause of illness, how diseases are healed or treated, and pain perception.

• Necessity and Type of Medical Care

This can include beliefs about holistic care / alternative medicine versus contemporary medicine, religious restrictions, the necessity of health insurance, or mistrust of the medical field.

• Patient Spokesperson

This might include beliefs about who can speak on behalf of the patient or become the durable power of attorney (i.e., only the patient’s spouse). This can also include the level of family involvement.

• Nutritional Habits

This can include the type of meal (i.e., Kosher, Vegetarian, Vegan, Fasting, etc.), times to eat meals, who prepares the meal, or how the food is prepared (i.e. Halal foods).

Learning about various health-related cultural beliefs can be motivated by cultural knowledge and/or cultural desire. Cultural knowledge refers to the process of seeking out information about cultural health beliefs/values to understand patients better [3]. Cultural desire refers to the internal motivation and commitment to develop cultural awareness [3]. Familiarity with various cultural beliefs surrounding medical care and treatment is highly beneficial as a nurse as it can help you develop and strengthen your level of cultural sensitivity. However, what happens when a patient’s cultural beliefs interfere with care? Reflect on the following case scenario.

Case Scenario

A patient on the medical-surgical unit is recovering from diabetic ketoacidosis. During the assessment, the patient tells the nurse they prefer to eat their own home-prepared meals because the hospital does not have culturally diverse food options on the menu. They state that they asked their family to bring in home-cooked meals instead. The patient describes the type of foods they eat at home, which are very high in carbohydrates. The nurse recognizes the patient’s home-cooked meals do not align with the diet ordered by the provider (carbohydrate-controlled) and may interfere with the patient’s healing process.

To address the scenario, the nurse should:

1. Inquire. Ask the patient if they understand the importance of consuming the ordered diet and how not doing so can negatively affect their health.
2. Teach. Teach the patient about their disease process, the benefits of consuming a carbohydrate-controlled diet, and the risks associated with consuming a high-carbohydrate diet. Patients may not be entirely aware of how their actions may affect their health, so nurses should ensure patients are provided basic education on how to manage their disease effectively. The nurse should also include the family in the teaching session and employ the teach-back method to ensure everyone understands the information.
3. Inform. Speak to the provider about the issue. The provider may speak with the patient as well or consult a specialist, such as a dietician/nutritionist or diabetic educator, to come up with a plan that works best. The nurse should also be aware that a patient’s cultural beliefs can influence their perception of authority figures (note: this awareness is part of cultural sensitivity). The patient may trust advice from a provider over a nurse. The nurse should involve a supervisor and/or ethics committee/representative if needed.
4. Respect. If the patient still chooses against the ordered diet and the nurse has ensured the patient truly understands the benefits and risks of their decision, the nurse should respect the patient’s decision, document the situation, and involve the appropriate team members to keep the patient safe (i.e., delegate to unlicensed assistive personnel to notify the nurse if family members bring in outside food).

Culturally Safe Environments

Part of cultural competency is creating a safe space for patients to share their cultural beliefs without feeling judged. This is referred to as a “culturally safe environment” [3]. In the example above, the nurse can create a culturally safe environment in the inquiry step. Inquiring about the patient’s background, preferences, beliefs, and values surrounding medical care/treatment can make patients feel comfortable sharing as it displays curiosity, interest, and/or concern. Standardized patient admission forms and the patient assessment area of the electronic medical record may include culturally specific questions that can guide the nurse’s inquiry.

Creating a culturally safe environment also involves evaluating your own cultural beliefs and potential biases so that you do not judge patients based on cultural differences. Bias is a human trait stemming from an individual’s personal experiences and need to make sense of the world [14]. It involves both stereotypes (categorizing others by age, gender, ethnicity/race, etc.) and attitudes (positive or negative feelings directed towards others) [14]. You may be aware (explicit) or unaware (implicit) of the biases you may have.

Nurses can challenge themselves by engaging in cultural encounters. A cultural encounter is a process in which you directly engage in face-to-face cultural interactions with patients from culturally diverse backgrounds to change your existing beliefs about a cultural group [3]. This is a self-motivated action to prevent possible stereotyping as biases can inhibit your ability to provide culturally sensitive care.

Cultural Negotiation

Cultural negotiation is the process of coming to a mutual agreement on how to deal with competing interests of the care/treatment plan and the patient’s cultural needs [3]. In the example above, cultural negotiation may occur during the teaching and inform steps. The nurse should attempt to accommodate the patient as much as possible while ensuring the accommodations do not significantly alter the care/treatment plan [3].

Keep in mind that cultural negotiation is a collaborative process. Teamwork between the nurse, the patient, the provider, a supervisor, a dietician/nutritionist, and an ethics committee/representative (if needed) are key. The solution may be to ask the dietary department (with the support of a dietician) to prepare special meals that follow diet order although these food items aren’t listed on the menu. Another solution may be to allow the patient’s family to only bring certain types of home-cooked food items that comply with the diet order, but the food must be brought to the nurse first for confirmation before the patient can consume it. The goal is to “meet the patient halfway” so to speak.

Benefits of Cultural Competency

Now that we have discussed how to apply cultural competency to practice in nursing, we will conclude the course by recognizing your efforts and contributions. Facing your own biases and being open to learning about other cultures is not always an easy task. Your efforts to provide culturally sensitive care increase patient satisfaction and can make them feel considered and respected [4]. This is great, but whether you realize it or not you are making an even greater contribution to patients.

Culturally sensitive care contributes to positive patient outcomes and reduced health disparities [3][4]. Health disparities occur when socially disadvantaged groups experience preventable differences in the burden of disease, injury, violence, or opportunities related to unequal distribution of social, political, economic, and environmental resources [13]. These social disadvantages are based on factors such as poverty, inadequate access to health care, or educational inequalities [13].

Cultural competency is also beneficial for the delivery of high-quality care in today’s diverse complex healthcare system [9]. Culturally sensitive care is by definition a facet of high-quality care. In 2011, the Institute of Medicine (IOM), now the National Academy of Medicine, outlined six domains of quality healthcare.

Health systems nationwide use this six-domain guide as a model to determine if the care they provide is of the highest quality possible. The sixth domain of the IOM’s Six Domains of Healthcare Quality identifies equitable care as high-quality care. The IOM’s definition of equitable care is “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” [1].

In summary, the benefits of cultural competency include: 

• Patient satisfaction 
• Positive patient outcomes 
• Reduced health disparities 
• Provision of high-quality care

Conclusion

Cultural Competency training has been shown to improve the knowledge and attitudes of health professionals [9]. Hopefully, this course has broadened your understanding of culture and provided you with tips and tools to challenge your own potential biases, strengthen your level of cultural competence, and effectively care for the residents of Illinois and any other region in which you practice.

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