Culturally Competent Care
Chia-Ling Mao, Ph.D., RN.
Associate Professor
School of Nursing
San Jose State University
Objectives
• Define ethnocentrism
• Discuss how the cultural background of the
nurse influences the way in which care is
delivered.
• Understand the variety of influences that
culture and ethnicity have on the
interpretations of the concepts of health and
illness.
Culture
• A set of standard for behavior which a group of
people attribute to those around them and which they
used to orient their behavior
• Meanings, values, and behavioral norms that are
learned and transmitted in the dominant society and
within its social groups.
• Culture powerfully influences cognitions, feelings,
and the “self” concept, as well as the diagnostic
process and treatment decision (DSM-IV)
Jewish
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Inter culture difference
– Ashkenazi – from Russian, Eastern Europe
– Sephardic – Spain, Portugal, the Mediterranean area
– Sabra – Born in Israel black Jews from Ethiopia
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value the nuclear family and community
Health seeking beliefs and behaviors are seen as a responsibility to maintain good
health.
Kosher diet – no pork and shellfish; dietary practices
genetic disorders (especially Ashkenazi Jews) – Tay-Sachs disease, Gaucher
Disease and Canavan Disease
Religion
– Torah –Hebrew bible, tree of life,
– Sabbath – no work
– Rabbi -
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The dying person should not be left alone, after the person dies the body should be
wrapped and is put on the floor with the feet facing the door for a short period, a
candle may be placed at the head; no creamation
Vienamese
• Nodding is done out of respect and does not necessarily mean
agreement or understanding. Direct eye contact is viewed as
disrespectful as is a man touching a woman in public or
anyone touching another’s head which is considered sacred
• It is inappropriate for women to discuss childbearing, sex, or
contraception in the presence of men
• Causes of illness is viewed from Yin & yang; supernatural or
spiritual influences, biomedical reasons
• Mental illness is stigmatized – PTSD, depression, anxiety.
• SUNDS sudden unexpected nocturnal death syndrome
Race
• A number of broad division of the human
species, based on a common geographic origin,
certain shared physical characteristics and
distinguished from other by a characteristic
distribution of gene frequencies.
Ethnicity
• Collectively of people within a larger society
defined on the basis of both common origins,
shared symbols and standards for behavior
Population in the U.S.
Year 2000
• Whites – 69.4%
• Black – 12.7%
• Hispanic – 12.6%
• Asian – 3.8%
Year 2050
• Whites – 50%
• Black – 14.6%
• Hispanic – 24.4%
• Asian – 8%
US Census Bureau, 2004
US POPULATION
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1998
WHITE 72%
BLACK 12%
HISPANIC 11%
ASIAN 4%
NATIVE AMERICAN
1%
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PROJECTED 2030
WHITE 60%
BLACK 13%
HISPANIC 19%
ASIAN 7%
NATIVE AMERICAN
1%
Sources: US Census Bureau
Population in San Jose (2000)
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Whites - 47.5%
Hispanic - 30.2%
Asian - 26.9%
Black - 3.5%
U.S. Census Bureau (2006)
Minorities Receive Lower Quality Health
Care Than Whites
• Institute of Medicine, 100 studies reviewed over past
10 yrs.
• Full report www.nap.edu/books/030908265X/html
• Minorities less likely to receive sophisticated Txs for
AIDS
• More likely to have leg amputations for diabetes
• Poorer relationships with MDs
Institute of Medicine:
• Among 13,000 heart patients for every 100 whites
who had a procedure to clear the heart arteries, only
74 blacks did
• Of 15,578 urban ER patients blacks were 1.5 times
more likely to be denied authorization by managed
care providers
• Differences exist even when insurance, income, age,
and the severity of the disease are the same for both
groups
Health Issues: Cardiovascular
• Cardiovascular- death rate from heart attack
30% higher in African Americans
• Heart attacks declined by 29% in whites vs
21 % for African Americans
• Death rates from stroke were 40% higher in
African American adults
HHS Disparities Initiative, 9/24/2002
Health Issues: Diabetes
• Diabetes is 2 times higher in African
Americans and 1.9 times higher in Hispanics
• Native Americans have 2.6 times the rate of
Diabetes and Pima Natives of Arizona have
the highest known prevalence in the world
National Center for Health Statistics, 2002
Disparities: Syphilis/Hepatitis
• Cases of primary and secondary syphilis in
1999 with 30 times greater rate in African
Americans
• Asian Americans represent 50% of those
infected with Hepatitis B
• Minority teens with higher incidence of
Hepatitis B and C
AAP, Committee on Infectious Disease, 2000
National Center for HIV, STD, and TB Prevention
Disparities : Tuberculosis
• Of all tuberculosis cases reported in 19912001, 80% were in racial and ethnic minorities
• Tuberculosis increased by 51% for Asian
Americans and 30% for Hispanics
• Asian Americans and Pacific Islanders, 4% of
the US population had 22% of the cases
NCHSTP Division of TB Elimination
Immunizations
• 48% African American and 56% Hispanic
receive influenza vaccine compared to 67%
Whites
• 31% of African American and 30% of
Hispanics receive pneumococcal vaccine
compared to 57% Whites
• In 2001 African Americans and Hispanic aged
65 and older were less likely to report having
received vaccination
Morbidity and Mortality Weekly, 2002
Disparities: Mental Health
• Native Americans disproportionate rate of
depression and substance abuse
• Minorities have less access to mental health
services and receive poorer quality services
• Under-represented in mental health research
National Center for Health Statistics, 2002
Other Cultural Domains
• Folk beliefs/religion - can be confused with
“religiosity”
• Stereotyping labels - avoid generalizations
• Ethnopharmacology - genetic influence, effect,
metabolism
• Herbal therapies - interactions with meds
• Folk healers & treatment approaches, e.g.., hysteria,
psychosis
Cultural competence &
impact on clinical outcomes
• Patients fear of being misunderstood or disrespected;
• Providers are not familiar with the prevalence of
conditions among certain minority groups
• Providers may fail to take into account differing
responses to medication
• Providers may lack knowledge about traditional
remedies, leading to harmful drug interactions
• Patients may not adhere to medical advice because they
do not understand or do not trust the provider;
• Providers may order more or fewer diagnostic tests for
patients of different cultural backgrounds
Ethnic Disparities in Health Care
• African American women are more likely than
European American women to die from breast cancer,
despite having a lower incidence of the disease.
• Infant mortality rates are 2.5 times greater for African
Americans and 1.5times greater for Native Americans
than for European Americans.
• Influenza death rates are higher for African Americans
and American Indian/Alaska Natives/Native Alaskans
than they are for European Americans.
• Mortality for colorectal cancer is highest for African
Americans, followed by Native Alaskans, and then
Hawaiians.
Needs for cultural competence
• American nurses experienced a lack of cultural
confidence in caring for culturally diverse
populations - Coffman, Shellman, & Bernal
(2004) and Hagman (2006)
• There were gaps in healthcare providers’
knowledge of other cultures and how to care
for them in culturally sensitive ways - Jones,
Cason, and Bond (2004)
Other evidences
• Negative racial stereotypes - rate black patients as
more likely to abuse drugs and alcohol, less likely
to comply with medical advice, and less likely to
participate in cardiac rehab than white patients Van Ryn and Burke (2000)
• Less Dx test - physicians were less likely to
recommend catheterization procedures for black
female patients than white or black male patients
if they experienced the same kind of symptoms.
Schulman et al. (1999)
Cultural Competence is a Process
• American Nurses Association published its first
guidelines on cultural diversity in nursing curricula in
1986 - understanding the concept of human diversity
including cultural and racial variations
• The Board of Registered Nursing of California (2006)
has required all nursing schools in California to
include cultural diversity and competence into their
curricula
Language barriers and disparity
• Utilization of health care services
– Fewer doctor visit and less preventive services
– More diagnostic test to compensate communication
problems
• Satisfaction
– Less satisfied unless with interpreter
• Adherence
– Miss the appointment or drop out
• Outcomes
• Patient education
Health Disparities
• President Clinton (1998) set the goal – reduce
health disparities by the year 2010.
• Target areas: (NIH, 2003)
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Infant mortality,
Cancer screening and management,
Cardiovascular disease,
Diabetes,
HIV/AIDS,
Immunization
Problems with Health Disparities
- with cultural factors
Flaskerud, J. et al (2002) – a review of 79
articles in the past 5 decades:
– Ignorance of certain groups (indigenous
peoples)
– Inappropriate lump together
• Hispanic members of disparate groups with
their own cultural identity eg., Puerto Ricans,
Mexicans, Cubans, Dominicans
• Asian & Pacific islanders
Impact of Cultural Competency
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More successful patient education
Increases in pt’s health care seeking behavior
More appropriate testing and screening
Fewer diagnostic errors.
Avoidance of drug complications
Greater adherence to medical advice
Expanded choices and access to high-quality
clinicians.
Negotiation Process
• Listen: to the client’s perspective
• Teach: from your knowledge in language appropriate
for client & family
• Compare: similarities & differences, disagree but do
not devalue client’s view
• Compromise:
– if client treatment not harmful, promote
– If harmful, explain harm and suggest alternatives
Ethnopharmacology
Ethnopharmacology
• Assumptions
– Ethnic culture affects beliefs about health, illness,
medications, interactions with healthcare
providers, & comply with prescribed medications
as well as response physiologically to medications.
Ethnicity affects drug responses
• Genetic and/or cultural factors make influence
on
– Drug’s absorption, metabolism, distribution, and
excretion
– Drugs’ mechanism of action & effects at the target
site
– Patient adherence & education
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Beliefs about health, illness,
medications
• White
• Intolerance to pain
• High expectation to be
cured or well managed
through technology,
powerful drugs
• Management of
microbes > bolster
resistance to them
• Asians
• Drug’s safety profile >
its effectiveness
• Use lower doses and
fewer reported side
effects
• Quick remove of S/S
does not equal to a
permanent cure
Interaction with healthcare providers
• Language barrier
– Nonverbal communication
• Trusting relationships
– Attire, attitude
• Family involvement
– Decision maker
Adherence with prescribed medications
• Beliefs on the medication
– Discontinue the med when symptoms ease
– Thwart the acceptance of drugs with a
delayed onset of action
– Stop taking the med if the diseases is not
common in their original country
Culture preferences, rituals, or fears
• Ways of taking the med. ie. Oral, injection,
• Rituals ie. Fasting
• Concerns about addictive effects
Physiologic response to medications
• Genetic polymorphisms
• 3-5% of whites compare to 15-20% of Asians
are poor metabolizers of drugs affected by
mephenytoin polymorphism ie. Diazepam,
imipromine
• Asians and Eskimos need lower doses of
anxiolytics than white
Physiologic response to medications
(II)
• Jewish & Clozapine – risk for agranulocytosis.
20% as compared with the non-Jewish
population of 1%.
• Asians, Indians, and Pakistanis require lower
doses of lithium and antipsychotic drugs.
• Asians showed more EPS given same dose of
Haldol.
Ethnicity and antihypertensive
drugs
• Captopril found less effective in blacks than in
whites
• Losartan is less effective in lowering BP in
blacks.
• Thiazide diuretics is more effective in blacks.
Nursing implications
• Be knowledgeable about drugs’ varied
responses in patients from different ethnic
groups.
• Careful monitoring
• “No two people are alike”
Ethical dilemmas
Basic Theories
• Utilitarianism – goal-based
the greatest happiness for the greatest number
• Deontology – duty based, love-based
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Autonomy – human right; self-determination
Beneficence – do good
Justice - fairness
Non-maleficence – do no harm
Veracity – telling the truth
Fidelity - keeping promise
Comparison of 2 major theories
Utilitarian
Deontology
• Consequences
• Action & motives
• Who is the majority
• Value
• What is happiness
• knowledge
Ethical theory & scientific theory
• Justify human action
• Explain phenomenon
• Acceptance of theory
• True or false
• Action
• Predict, control
Roles of the nurse
• Nurse’s fundamental responsibility- value,
concern, goals
• Ethics of caring – empathy, nurturing,
commitment, being an advocate
• Participation of the family in decision making
– social assessment
Ethical Issues in Nursing
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Quantity vs. quality of life
Pro-choice vs. pro-life
Freedom vs. control
Truth-telling vs. deception
Distribution of limited resources
Empirical knowledge vs. personal belief
Methods of moral reasoning
• Deductive – code, creed, …
– Inflexibility, value conflict, no motivation
• Inductive – custom, cases, …
– Static & preventing progressive social change
• Intuition – combination of subjective,
objective, & relativistic aspect
• Dialectical – philosophical aspect, art…
Cultural competence training
• Health care institutions
– Interdisciplinary programs
• Nursing service
– Orientation – demographic data of the pop, ethical-legal
consequences, appropriate resources
– In-service –
– Interdisciplinary team
• Nursing education
– Undergraduate level – core course
– Graduate level – specialty areas
Factors to consider
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Time – past vs. present, interpretation
Circumstances – setting, knowledge
Religion – beliefs, creation vs. revolution
Science – hard data vs. philosophy
Technology – change of nature
Leininger’s
Transcultural Care Theory –
Sunrise Enabler
• Developed in the mid-1950s and early 1960s.
• To discover the meanings and ways to give
care to people who have different values and
lifeways.
• To guide nurses to provide nursing care that
fits with those that are being cared for.
• Not only focuses on nurse-client interaction
but also includes care for families, groups,
communities, cultures and institutions.
Application of Theory
• Care always occurs in a cultural context
• Culture is viewed as framework people use to
solve human problems
• Culture is “the lifeways of an individual or a
group with reference to values, beliefs, norms,
patterns, and practices” (Leininger, 1997, p.
38)
Working with Interpreters
• Qualifications
– Bilingual, bicultural, understands English medical
vocabulary
– Comfort in the medical setting, understands significance of
the health problem
– Preserves confidentiality
• Multiple Roles:
– Translator of Language
– Culture Broker
– Patient Advocate: Convey expectations, concerns
Translation factors
• Language: how are new words created?
– Navajo: Penicillin = “the strong white medicine shot you
get for a cold”
• Minimize jargon, e.g., “machine to look at your
heart” instead of “EKG”
• Nonverbal communication = 60% of all
communication
• Nodding may indicate politeness, not comprehension
• Bilingual interviewing takes at least twice as long as
monolingual interviews!
Caretakers’ Responsibilities in
Using Translator
• Learn and use a few phrases of greeting and
introduction in the patient’s native language.
This conveys respect and demonstrates your
willingness to learn about their culture.
• Tell the patient that the interpreter will
translate everything that is said, so they must
stop after every few sentences.
Caretakers’ Responsibilities (II)
• When speaking or listening, watch the patient, not the
interpreter. Add your gestures, etc. while the interpreter is
translating your message.
• Reinforce verbal interaction with visual aids and materials
written in the client’s language.
• Repeat important information more than once.
• Always give the reason or purpose for a treatment or
prescription.
• Make sure the patient understands by having them explain it
themselves.
• Ask the interpreter to repeat exactly what was said.
• Personal information may be closely guarded and difficult to
obtain.
• Patient often request or bring a specific interpreter to the
clinic.
Caretakers’ Responsibilities
• In some cultures it may not be appropriate to suggest
making a will for dying patients or patients with
terminal illnesses; this is the cultural equivalent of
wishing death on a patient.
• Avoid saying “you must... Instead teach patients their
options and let them decide, e.g., “some people in this
situation would...”
Cultural Diversity and Health Care
It is because we are different that each
of us is special.
HEALTHY PEOPLE 2010
• Plan to eliminate disparities in health care
provision and in health outcomes by 2010
• Addresses highly preventable conditions
• Requires participation by health care providers
to be successful
• Includes issues of cultural and linguistic
competence in access to care
Cultural Competency
• Defined as a set of congruent practice skills,
behaviors, attitudes and policies that come
together in a system, agency or among
providers and professionals that enables that
system, agency, or professionals to work
effectively in cross-cultural situations.
Cross TL, Bazron BJ, et al. Towards a Culturally Competent System of Care. CASSP Technical Assistance Center,
Georgetown University Child Development Center, March 1989
Title VI-Civil Rights Act
• “No person in the United States shall, on the
ground of race, color, or national origin, be
excluded from participation in, be denied the
benefits of, or be subjected to discrimination
under any program or activity receiving
Federal financial assistance.”
CULTURAL COMPETENCE
• Culturally appropriate, community-driven programs
are critical
• Promote cultural awareness
• Encourage cultural competence inclusion in medical
school and health careers curriculum
• Advocate for the needs of the patients by providing
translators, culturally competent information and
instructions in simple language
Impact of Cultural Competency
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More successful patient education
Increases in pt’s health care seeking behavior
More appropriate testing and screening
Fewer diagnostic errors.
Avoidance of drug complications
Greater adherence to medical advice
Expanded choices and access to high-quality
clinicians.
Transcultural Nursing- Leininger, 1997
• Definition- A formal area of study and practice
focused on comparative holistic culture care,
health and illness patters of people with
respect to differences and similarities in their
cultural values, beliefs, and lifeways with the
goal to provide culturally congruent,
competent and compassionate care
Cultural needs
• Equal access to treatment and care
• Respect for cultural beliefs and practices
• Leininger, (1995) & Narayanasamy, (2003)
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Religious beliefs, taboos, customs
Dietary, personal care needs, daily routines
Dying needs
Communication needs
Cultural safety needs,
Cultural needs (Cont’d)
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Pain
Health practice
Time orientation
Space
Family
Equal access to treatment and care
• Ethnicity
– racial discrimination,
– racial harassment and
– oppression
• Secondary problems
– stress
– psychological trauma
Communication needs
• Barrier
– Impede early detection
– delay prompt treatment and care
• Forms
– Language
– Non-verbal communication
• Translation services
– Interpreters
– Family interpreters
• Health condition – acute illness & crisis
Cultural safety needs
• Engage clients as partners
• Respect & rapport -> self-esteem
• Cultural negotiation & culture compromise
Transcultural Care Practice
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Initiative
Enthusiasm
Commitment of individuals and groups
Strategic planning
Organization & coordination of services
Funding
Education
Recruitment & research
Giger-Davidhizar (2004) Assessment Model
Culturally
Unique
Individual
Communication
Space
Biological
Variations
Environmental
Controls
Social
Organization
Time
Transcultural Nursing : Assessment & Intervention. Mosby
ACCESS Model – Narayanasamy, 2002
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Assessment
Communication
Culture negotiation and compromise
Establishing respect and rapport
Sensitivity
Safety
Campinha-Bacote’s
Cultural Competence Model
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Cultural awareness
Cultural skill
Cultural knowledge
Cultural encounters
Cultural desire
Campinha-Bacote, J.
(2003)
Cultural awareness
• Becoming appreciative, and sensitive to the
values, beliefs, lifeways, practices, and
problem solving strategies of clients'
culture.
• Exam personal prejudices and bias, one's
own cultural background
Cultural knowledge
• seeking and obtaining a sound educational
foundation concerning the various world
views of different cultures.
• obtaining knowledge regarding specific
physical, biological, and physiological
variations among ethnic groups
Cultural skill
• ability to collect relevant cultural data
regarding the client's health histories and
presenting problems as well as accurately
performing a culturally specific physical
assessment.
Cultural Encounter
• Engaging directly in cross-cultural
interactions with clients from culturally
diverse backgrounds.
• Being aware of the intra-ethnic variation,
which refers to the fact that there is more
variation within a cultural group than across
cultural groups
Cultural desire
• the motivation of health care providers to
"want to" engage in the process of cultural
competence
Purnell’s Model
• Macro level – global society, community,
family, individual, health
• Cultural domains – overview, communication, family
roles, workforce issues, bioculturl ecology, high-risk
behaviors, nutrition, pregnancy & childbearing practices, death
rituals, spirituality, health care practice/practitioners
• Cultural consciousness
• Unknown phenomenon
Purnell’s Model for Cultural Competence
Culturally Competent Organization
• US Census Bureau, 2000 – total population = 281,421,906
– Latio 35.5 million = 12.1%
– African American = 12.9%
– Asians
= 4.2% (60% is foreign born)
– Multiracial
= 2.4%
• Ethnic minorities accounts for one fourth of the nation’s
population
• In 2020, it will be near to 40%
• 10% of RNs in the US are from racial/ethnic
minority background (2000)*
Organizational Diversity Competence Model
(Frusti, Niesen, Campion, 2003)
Drivers
measurements
Commitment
Culture
Linkages
Ethic Conflicts
• Genetic counseling
• Family and community involvement in patient
care
• Religious ritual ie Sabbath, fasting
• Delay in help seeking
Negotiation Process
• Listen: to the client’s perspective
• Teach: from your knowledge in language appropriate
for client & family
• Compare: similarities & differences, disagree but do
not devalue client’s view
• Compromise:
– if client treatment not harmful, promote
– If harmful, explain harm and suggest alternatives
Conclusion
• Culture is learned & exists in a constant state of
change
• Nursing is not “culturally free” but rather is
“culturally determined” – avoid ethnocentric
• Much diversity within a cultural group as across
cultural groups.
• Culturally competence is a dynamic, fluid, continuous
process.
• Goal: discover culturally relevant facts about the
client to provide culturally appropriate and competent
care
Globalization :
Q: How to define globalization?
A: Princes Diana’s death
Q: How come?
A: An English princess with an Egyptian boyfriend crashes in a French tunnel, in a German car
with a Dutch engine, driven by a Belgian who was
pissed on Scottish whiskey, followed closely by an
Italian paparazzi, on Japanese motorcycles, treated
by an American doctor, using Brazilian medicines.
And this is sent to you by a Israeli, using Bill Gates’
Technology which he stole from the Taiwanese.