Contributor: Hannah Scranton

Contemporary nursing practice occurs within social and structural contexts that shape both health outcomes and clinical relationships. While cultural competence has been incorporated into U.S. nursing curricula, its emphasis on knowledge acquisition and generalized cultural characteristics is insufficient for preparing nurses to engage with complex, intersecting identities and power dynamics in contemporary practice. Traditional educational models overlook intersectionality, risk reinforcing stereotypes, and inadequately address the historical and structural forces that shape nurse–patient relationships. As nursing practice increasingly occurs within complex adaptive systems, there remains a need for a framework that centers reflexivity, relational power, and ongoing learning—gaps this article addresses through a cultural humility lens.

Moving from “cultural competence” to the Nursing Theory of Complex Adaptive Systems and Cultural Humility

Nursing education in the United States has only recently begun preparing students for practice in an increasingly globalized world (Carmack & Jannat, 2025). The concept of cultural competence was integrated into standardized nursing curricula in 2011 when the American Association of College of Nursing included it in the Core Competencies for Interprofessional Education (Interprofessional Education Collaborative Expert Panel, 2011). Cultural competence in nursing is defined as the “ability to understand, respect, and interact with patients from diverse backgrounds and consider a patient’s individual experiences and beliefs” (Carmack & Jannat, 2025) and depends on the development of a knowledge base of cultural values and practices.

While most nursing textbooks from the last decade offer descriptions of diverse ethnicities, examples intended to broaden perspectives may reinforce conscious and unconscious biases through generalizations; furthermore, textbooks often lack representation of non-ethnic diverse identities and intersectionality of identities (Carmack & Jannat, 2025). Since health education has deep roots in colonialism, it is imperative that nurses become aware of the influence of power in therapeutic relationships (Gondwe et al., 2024). Nurses must understand they are agents of a larger system subject to complex ongoing dynamics shaped by historical power imbalances. However, cultural competence fails to address these limitations and does not encourage nurses to deeply engage with and learn from the plethora of lived experiences and identities we will encounter in clinical practice (Johanson et al., 2024).

How, then, should nurses best prepare for person-centered practice in an interdependent and increasingly multicultural environment?

Pairing the Nursing Theory of Complex Adaptive Systems (NTCASs) with cultural humility may hold the key. NTCASs acknowledges the interconnected nature of healthcare settings where each individual—patient, family member, or healthcare staff—can influence outcomes through unique interactions and adaptation. As a result, nurses are continuously adjusting practices in response to patient needs, policy changes, and technology shift. Cultural humility further enhances this approach by promoting self-awareness, openness, and respectful engagement with every patient. Cultural humility goes beyond a process of accumulating and practicing cultural awareness; it is a “lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities” (Tervalon & Murray-García, 1998).

As complex systems unto themselves, our patients cannot be reduced to a stereotyped interpretation of what we think we know about them. It is only through continually cultivating openness, self-awareness, active listening, supportive interactions and self-reflection that the culturally humble nurse can identify and break down biases that stand in the way of safe and effective care (Foronda et al., 2022). This synergy fosters care that is not only evidence-based and adaptive, but also deeply respectful and aligned with the whole person.

Intercultural experiences build cultural humility

Intercultural experiences provide valuable opportunities for the development of cultural humility and advancing holistic nursing care. When nursing students engage in diverse healthcare settings—whether abroad or through virtual international collaborations—broadens nurses’ awareness of social determinants, resource constraints, and cultural practice shape health and care delivery, fostering meaningful human connections and deepening respect for differences (Andreassen et al., 2025).

Intercultural learning is accessible and multifaceted, from traditional study abroad programs to international experiential learning, to online collaborations such as the Collaborative Online International Learning (COIL) model, students can participate in international exchange, gain insight into global perspectives, and enhance cross-cultural communication skills without physical travel (Cornelius et al., 2025; Casenove, 2023). When combined with ample pre-education, mentoring, and reflection, students who participate in online international collaborative learning can gain a greater sense of responsibility in an interconnected global community (Waddington, 2026).

It is important to understand that international experiences, whether online or in-person, are not a guaranteed pathway to increased cultural humility, nor are they the only pathway. Cultural humility requires a commitment to “redressing and mitigating power imbalances”, which is achieved through becoming lifelong students of those we encounter (Murray-García et al., 2021). Without deliberate openness to learning from others and reflecting on how we can and must contribute to mutually beneficial, non-paternalistic relationships, cross-cultural encounters may only reinforce stereotypes (Waddington, 2026). It is only through ongoing discussion, self-reflection, collaboration, and learning about social determinants of health that nurses can begin to address the inherent biases that continue to shape healthcare. By prioritizing mutuality, ongoing dialogue, and reflective practice within intercultural learning, nurses can address biases and cultivate a deeper competency in cultural humility. This ongoing, practice-based competency not only prepares nurses to serve an increasingly diverse patient population but also strengthens their capacity to contribute to equitable, compassionate care in a diverse workforce and global healthcare landscape (Gondwe et al., 2024).

Ongoing lessons from my DNP project in Guatemala

During my Doctor of Nursing Practice (DNP) training, I conducted a program evaluation for a Community Health Worker (CHW) program focused on noncommunicable disease management in rural Guatemala. Preparatory work included reviewing Guatemala’s sociopolitical history and the growing burden of noncommunicable diseases affecting rural populations. I reviewed literature that highlighted the critical role CHWs play in expanding access to care in underserved communities, particularly because they are members of the same communities they serve and often contribute their work on a voluntary basis (Scott et al., 2018).

However, many aspects of CHW practice extend beyond what can be captured in academic texts, so I traveled to Guatemala and engaged directly with CHWs in their communities to better understand these dynamics. I talked to them, accompanied them during home visits, and gained insight into how they interpret their roles, navigate challenges, and sustain their commitment to improving community health.

Theory, literature and curriculum taught me what CHWs are supposed to do within their communities, but practicing cultural humility—following their lead to understand their community engagement—allowed me to better understand how they built relationships, reflect on their growth, care for their community members, and continue to develop their identity.

Moving forward, we must build cultural humility into the evolving role of the DNP student and advance practice nurse (APN). In 2025, the World Health Organization called for optimizing the role of APNs to better protect vulnerable populations; to achieve this goal, we must consider how global learning and DNP projects can take person-centered care beyond the classroom and textbook.

Through the lens of the Nursing Theory of Complex Adaptive Systems, we understand nurses as not only caretakers of individuals, but as healthcare participants and influencers at the program, policy, national and international levels. Therefore, DNP students become advanced practice nurses who are prepared to make an intentional, evidence-based impact at all these levels. NTCASs is not just a framework: it is a living and breathing process built on cultural humility and respect.

Whether we are traveling abroad or at home in our own communities, we must practice cultural humility by considering each individual encounter an opportunity to learn, reflect and grow. It is only with this attitude that we can move forward to build knowledge capacity within ourselves and others and optimize the role of the DNP prepared nurse.

References

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About Hannah Scranton

Hannah Scranton is a Doctor of Nursing Practice – Family Nurse Practitioner student at the Johns Hopkins School of Nursing, and a student intern for the Johns Hopkins Center for Global Initiatives. Hannah has a B.A. in Cultural Anthropology from Vassar College (2007), and trained as a birth doula in Peru. Hannah has always been deeply curious about what shapes the human experience at individual and population levels. She currently lives in upstate New York where she works as a Labor and Delivery nurse and Spanish-English medical interpreter. She is honored to be a recipient of a National Health Service Corps scholarship, and is looking forward to transitioning to a Nurse Practitioner role at a Federally Qualified Health Center in her home community in the fall.