Abstract
Background: The necessity of nurses’ cultural awareness in the caring process has been emphasized; however, there is a need to define this concept clearly; so the aim of this study was to clarify the cultural awareness concept in the nursing context.
Methods: in this qualitative study, a concept analysis using 6-steps Rodgers’s evolutionary method (Determining the intended concept and the related terms, selecting the appropriate domain for data gathering, determine attributes, antecedents, and consequences of the concept, data analysis, stating examples and generate a hypothesis) was adopted based on thematic analysis. The articles published in English and Persian language from 2005 to 2019 were searched and then analyzed.
Results: The 6 attributes of cultural awareness include “being a prerequisite to cultural competence, a dynamic and progressive process; having learning potential; being multidimensional; and including self-awareness and awareness about the service user”. Antecedents for cultural awareness consist of global diversity, cultural teaching, developing cultural skills, cultural immersion, and organizations supporting cultural awareness, and researches. Cultural competence or effectiveness, constructive intercultural interaction, and improvement of health outcomes are the consequences of cultural awareness. A definition of cultural awareness was proposed.
Conclusion: In today's global diversity, providing suitable infrastructure (including cultural teaching, development, immersion, and researches) can lead to cultural awareness that is a dynamic multidimensional process of self and service user awareness that causes constructive intercultural interaction, cultural competence, and improvement of health outcomes. So, it is suggested to providing the infrastructures and do more studies related to the development of this concept.
Introduction
Healthcare providers have to deliver care for an increasing number of patients with culturally diverse backgrounds. Cultural challenges are known as a threat to the patients’ safety (1) and the concept of cultural competence as a strategy for providing equal and quality healthcare services for a patient with cultural diversity is interesting (2). Also, during the past decade, the necessity to improve the cultural competence of healthcare providers has been determined.
Cultural competence begins with cultural awareness (3) and the awareness to understand differences and similarities between various cultures is the first step of developing transcultural knowledge (4).
Cultural awareness in a multicultural society, can facilitate communication and reduce the risk of confusion in communication and mistrust between people (5). A lack of cultural awareness has a negative effect on attitudes and preparedness to take care of culturally diverse patients (6). On the other hand, an increased cultural awareness when communicating with different populations is seen as the main factor to overcoming various communication problems (7).
At present, changes in demographic and economic situations, the developing multicultural world, lack of abiding agreements in people’s health condition in diverse ethnic groups and cultural situations resulted in emphasis on cultural awareness in nursing (8). As many nursing textbooks and studies have provided massive information on the necessity of investigating patients from various cultures and topics related to it (3), and considered high emphasis on creating cultural awareness for nurses (8).
Although cultural awareness is essential to improve the quality of communication, efficiency, and patient satisfaction in healthcare (9), challenges for providing culturally competent care were recognized by researchers and clinicians of healthcare systems (10, 11) that may be due to lack of their cultural awareness as the main prerequisite of the cultural competency (3). Also, there are evidences about the lack of the cultural awareness in nursing students, and also, cultural concepts and skills are not integrated in the nursing curricula content in detail (12). In addition, there isn’t a clear definition for this concept and cultural awareness, competence, and sensitivity are used interchangeably and refer to a similar construct (13). One of the main barrier to provide culturally competent care may be the ambiguous understanding of cultural awareness. Thus, clarifying the cultural awareness concept is necessary to improve communication, research and practice in this area.
Among different activities that researchers deal with during the concept analysis process, identifying and determining the intended concept is considered as the first activity (14). Available evidence in the nursing literature shows a lack of a clear definition for the “cultural awareness” concept (13). On the other hand, the “cultural awareness” concept is regarded as one of the main expectations in the nursing field in the comprehensive dimensions, particularly in the globalization issue. Since the current nursing believes that human essence and the phenomena related to it are constantly changing; thus, the elements are dependent on each other and are only interpretable in the context of a collection of background elements; this attitude agrees with Rodgers’s evolutional approach to concept analysis (15). Therefore, the present study was done aiming at clarifying cultural awareness concepts in nursing using Rodgers’s evolutional approach to concept analysis.
Methods
In the present study, Rodgers’s revolutionary approach of concept analysis was used to explore the cultural awareness concept.
 The main inclusion criteria for the final analysis was the literature published in English and Persian language from 2005 to 2019 and having a context of nursing, health, and sociology sciences. Also, literatures that weren’t in the fields of nursing, health, or sciences sociology were excluded. The literatures were reviewed to retrieve published theses, articles, books, and scientific websites in English and Persian between 2005 and 2019. All types of documents using keywords related to cultural awareness phenomenon. The search terms were “culture”, “awareness”, “cultural awareness”, “cultural competence”, and “cultural sensitivity” which were searched in topic, abstract, and keywords of the texts in different nursing, health, and sociology disciplines. The sources used for searching in this study were international databases include Scopus, PubMed, and ProQuest, and the local databases include SID and Iranmedex. To clarify the cultural awareness concept in the nursing context, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) as a principal database for nursing was searched. In addition, the Google scholar database and various valid dictionaries were searched to clarify the cultural awareness concept generally. Table 1 shows selected articles for the analysis in this study.

In sum, from 140 English texts being reviewed and their abstracts investigated, 38 which included the key terms of the present work that is cultural awareness in the topic and other parts of the texts and were accessible as full text were selected and investigated. Figure 1 shows flow diagram for systematic literature review.Data were analyzed using thematic analysis according to Rodgers’ evolutionary approach (Table 2). For this purpose, all the articles were read carefully and the appropriate contents were included in the following categories; attributes, antecedents, consequences, related concepts, surrogate terms, and definitions for cultural awareness concept guided the inquiry into the literature. The validating of the findings of this study was provided through using valid literature and also team analyses and review of the findings by the team members.

Results
The results are presented under the headings of definitions, attributes, related concepts, antecedents, and consequences of cultural awareness concept were investigated, and then sample examples, hypotheses, and analytical reasons were stated for more developments of the concept.
A. Cultural awareness definition
Cultural awareness is defined as a culture determinant process and as a phenomenon for investigation of individual biases and emotions contrasting with various cultures and exploring personal professional and cultural background (16). Cultural awareness in the study done by Sue and Sue (2012) is explained as awareness of orientations, personal values, presupposed imaginations, personal limitations, and hypotheses about human behavior that is combined with active efforts to comprehend service users’ global attitude from different cultures and without negative judgments (17). Giddens et al. (2012) believe that cultural awareness is a self-evaluating process, person’s bias toward other cultures as well as awareness of obstacles for cultural caring (18). Leininger’s “sunrise” model has a vital role in health R10 to the theory of cultural caring diversity theory and globalization (19). Leininger defines a culturally aware nurse as:
• Conscious introducing of a truth affecting the culture dominating the nurse-service user’s communications.
• Asking each patient about their cultural priorities and performances clearly and emphatically.
• Integrating the service user’s cultural, environmental, social, and personal needs with the caring plan as much as possible.
• Respecting and appreciating cultural diversity and effort to increase knowledge and sensitivity related to this requisite nursing concern (20).
B. Attributes
Identifying attributes of the concept is the first part and the heart of concept analysis which results in a realistic definition of it (21, 22).
Precise investigation of texts shows that the cultural awareness concept has several characteristics: being a prerequisite to cultural competence, a dynamic and progressive process; being multidimensional; and including self-awareness and awareness about the service user.
B.1. A prerequisite to cultural competence
Cultural competence begins with cultural awareness. Cultural awareness is regarded as an incipient investigation process for individual culture and determining how it affects the person’s thinking about other cultures. With more investigation, one finds the opportunity of comparing and contrasting his own culture with that of others; therefore, he can gain the competence of accepting people from different cultures (23).
B.2.  A dynamic, progressing process
Cultural awareness has a dynamic and progressing nature (24): different levels of cultural awareness help to understand cultural differences. In the first level, people are only aware of ways for doing things in their way and believe that their way is the only working method (territorial or parochial level). In the second level, people are aware of others’ ways of doing things, but they still believe their own ways are the best (Ethnocentric stage). In the third stage, people are aware of their own way of doing things, but they opt for the best way based on the situation (Synergistic stage). In the fourth stage, which is the last one people from diverse cultural backgrounds try to create one single culture with common concepts (Participatory Third culture stage) (25).
B.3.  Multidimensional matter
Cultural awareness is a multidimensional matter which consists of five subsets: public education, taking care of the patient, behavior comfort (the comfort level experienced when meeting people of various cultures), research-related issues, and cognitive awareness. Cultural awareness is learnable through dimensions of cultural knowledge, skill, and competence (24).
B.4.  Including self-consciousness and awareness of service user realms
Quappe and Cantatore (2005) define cultural awareness as the ability of understanding the values, beliefs, and personal attitudes of people of one’s own culture besides that of other cultures. Cultural awareness is the basis of communications and includes the ability to look back on ourselves as well as our cultural values, beliefs, and perceptions (25). So, it seems healthcare providers must be aware of the contrast between their background and that of the patient.
C. Surrogate concepts
Through reviewing the literature, it was identified that the terms cultural competence, cultural sensitivity, cultural responsiveness, multiculturalism, multicultural awareness, and cultural knowledge were used as substitute words for cultural awareness (8, 26, 27). However, some of them were distinguished from cultural awareness in some texts.
Cultural awareness, competence, and sensitivity are concepts whose definitions are still being completing. Many of them are used interchangeably and refer to a similar construct. In some cases, their definitions are implicit and general instead of being obvious; despite the high emphasis on cultural competence, the terms cultural awareness, sensitivity, or competence have been increasingly used, but they are considered undetermined words (13). So, to clarify the features of the mentioned concepts as substitutes, particularly cultural competence and cultural sensitivity that have appeared as substitute words for cultural awareness in many texts, some definitions for this term are stated here:
C.1. Cultural competence
There are many definitions; however, the key elements are having self-awareness of care providers of personal tendencies, acquiring knowledge about cultural backgrounds of patients and health-related beliefs, respecting different cultural attitudes, and being skillful to be able to use them in intercultural situations effectively (28, 30).
C.2. Cultural sensitivity
Cultural sensitivity is a person’s sensitivity to the significance of cultural differences and others’ different cultural points of view (31, 32). According to the concept analysis done by Foronda (2008), cultural sensitivity is utilizing knowledge, considerations, understanding, respect, and cultural fitting after understanding self-awareness and others as well as facing people or one diverse group (32).
C.3. Multiculturalism
Multiculturalism is being related, reflecting, or adapting to different cultures (33). Multicultural awareness is understanding and sensitivity for other groups’ lifestyles, values, and history more but is not limited to race, ethnicity, gender, cognitive awareness, religious institutes, social and economic condition, physical or mental ability (34).
C.4. Cultural responsiveness
Cultural responsiveness consists of healthcare systems that encounter health-related beliefs and performances, culture and lingual needs of various patients' communities/clients, and respects these principles (35).
D. Related concepts
Related concepts are words that include only a part of relations and applications of the main concept; therefore, they do not possess all the features of the concept under investigation (14).The words that can rather be regarded as words related to cultural awareness include transcultural nursing, cultural skills, cultural knowledge, cultural encountering, cultural tendency, cultural diversity, and assimilation and acculturation (Table 3).

E. Antecedent
Antecedents are under analysis prerequisites of the concept, thus affecting the emergence of the concept (22). These antecedents were determined based on reviewing the literature including global diversity, cultural teaching, developing cultural skills, cultural immersion, and organizations supporting cultural awareness.
E.1. Global diversity
Global diversity demonstrates changing demographic and economic conditions of a multicultural developing world as well as lasting differences in people’s health conditions with various cultural groups and settings (41).
E.2. Cultural teaching
A variety of diverse approaches to teaching cultural variety in texts can be considered as antecedents that are included in all courses related to cultural issues even introducing virtual classes (42). Sermeno (2011) said that “Cultural awareness is more oriented to knowledge acquired by observing, reading, or studying other groups (50).
E.3. Cultural skills development
Cultural skills development including analyzing intercultural similarities and differences (51), admitting attributes of a cultural group (43), awareness of communication method; noting lingual hindrances, service user’s cultural identity, beliefs, and habits; creating mutual interaction, cultural investigation; and considering biases of health care providers are cultural awareness antecedents (44).
E.4. Cultural immersing
Cultural immersing is another cultural awareness antecedent representing an individual’s participation in another culture to the extent that he/she experiences real living in that culture for 24 hours and a noteworthy period (27).
E.5. Organizations Supporting Cultural Awareness
Organizations Supporting Cultural Awareness is organizational benefits to increase the cultural awareness of the personnel and intercultural skills (52).
F. Consequences
A phenomenon expected to appear when a concept happens is called consequence (14).  To name some general cultural awareness results, we can refer to cultural competence or effectiveness, constructive intercultural interaction, and promoting health results:
F.1. cultural competence or effectiveness
One of the consequences of cultural awareness is cultural competence or effectiveness that includes the development of positive attitudes related to people in other racial and ethnic groups (45) and improving caring abilities of the nurses to show theoretical and practical competence in intercultural approach about nursing social health care (51).
F.2. Constructive Intercultural interaction
Constructive Intercultural interaction is another consequence of cultural awareness. Communicating with others, achieving teamwork goals, solving daily routine problems with others, enjoying achievements, and getting help from people around (46, 47) are all examples of intercultural constructive communication.
F.3. improvement of health outcomes
Finally, one important consequence is the improvement of health outcomes, in a way that cultural awareness can lead to increase patient/family satisfaction and improve the quality of best cure for all society members (48, 49), offering global nursing caring services, and facilitating the process of becoming international (46).
G. An appropriate example of the concept
One appropriate way to clarify the concept and its effective applications is a vivid example of the concept that represents all attributes of definitions for the concept extracted from real life, of articles or a condition made up by a nurse or any other person (14). The examples are useful to show the concept practically (14).
Example
One of the members of the Shoshone-Paiute tribe was a woman who had a serious car accident and passed coma resulting in cerebral traumatic damage successfully. She did not have any visitors during the first two weeks; she was hospitalized in the Intensive care unit (ICU). There was very little information about her family. She survived the damage but did not respond to any the environmental stimulants, nor made no effort to monitor her consciousness. At the end of the third week, her mother and aunt came to visit her. She did not have a good attitude toward white people. Healthcare personnel could hardly communicate with them and consequently, they came up with her family request asking to hold a water celebration for the patient’s wellbeing. After the ceremony was done, the patient started to talk and thanked her family for holding the celebration. In this case, the nurse could help the process of recovery for the patient by awareness of the culture of this native service user; hence, she cooperated with her family. Therefore, the best care services in line with the patient’s culture must be provided.
H. Determining Hypotheses and Implications of Concept Analysis
The final stage of concept analysis consists of determining hypotheses and analysis of reasons for better development of the concept that provides the opportunity of discussing the application of the findings derived from the concept analysis (14). Considering this study, the hypotheses for future studies are as follows:
• There is a direct relationship between offering efficient nursing cares in communities with diverse races and the necessity of exploiting cultural awareness.
• Cultural awareness is the primary element and prerequisite for acquiring cultural competence.
• Cultural awareness helps to augment the quality of care services offered to patients, and improve the recovery process and patient and his family’s satisfaction.
Discussion
In the growing world and increase of minorities’ time, cultural awareness is an important need that must be taken into consideration (53) for providing better health results (48, 49). But, cultural awareness lacks clear borders with other related concepts, no study has been done on the analysis of this concept to shed light on it and make its use easier. Since concept analysis is a tool used for clarifying the concept and gives out an idea that distinguishes one concept from other similar concepts (14, 54), in the present study, the researcher worked on analyzing this concept. Based on the findings, the definition of cultural awareness is a logical, purposeful, and lifelong process of self-evaluation of the culture, personal philosophy, and the way it affects the person’s perceptions and actions; it is also sensitivity and awareness of probable personal reactions and biases in the various cultural worlds. Moreover, it is awareness of the culture of other service users and respecting their values, beliefs, and traditions. Cultural awareness is the beginning of cultural competence that is regarded as an important expectation in the nursing field. Also in this study, the attributes of cultural awareness were determined under terms like: a prerequisite to cultural competence, a dynamic progressive process, multidimensional, and including self-consciousness and awareness about service user. Leininger's model was introduced as the most important model related to cultural awareness. Among the antecedents in this study, we can point to cases that are related to global diversity, cultural education, cultural skills development, cultural immersing, and organizations supporting cultural awareness, according to the present project, concept analysis, cultural competence or effectiveness, and constructive intercultural interaction are determined as better health outcomes and general outcomes of cultural awareness.
The limitations of this study were the lack of texts and articles related to the concept under investigation, especially in the nursing field. It is suggested that more conceptual, qualitative, and quantitative studies should be conducted in developing this concept in the field of nursing.
Conclusion
According to this study, in today global diversity, providing suitable infrastructure including cultural teaching, developing cultural skills, cultural immersion, and organizations supporting cultural awareness, and researches can lead to cultural awareness that is a dynamic multidimensional process of self and service user awareness that causes constructive intercultural interaction, cultural competence, and improvement of health outcomes. So, it is suggested to provide the infrastructures and do more studies related to the development of this concept in different fields of nursing.
This concept analysis leads to more clarification, knowledge, and insight and a better understanding of cultural awareness concept among the nurses that can have a positive effect on nurse-patient interactions and providing qualified patients care. Additionally, the findings of this concept analysis can contribute to the development of theories and models common in the nursing field. This study was an effort to begin cultural awareness concept analysis, hoping that putting this concept in the center of discussions between nursing authors and theoreticians strengthens it.
Acknowledgements:
The authors would like to thank the authorities of colleges of nursing and midwifery affiliated with Shiraz University of Medical Sciences.
Funding source:
This research received no specific grant from any funding agency in the public, commercial, or non-for-profit sectors.
Ethical statement:
Not applicable.
Conflict of interest:
None declared
Author contributions
FA.H and CT were responsible for the study conception and design; FA.H performed the data collection; FA.H, CT and BT performed the data analysis; FA.H, CT and BT were responsible for the drafting of the manuscript; FA.H, CT and BT made critical revisions to the paper for important intellectual content.