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Journal of Transcultural Nursing
http://tcn.sagepub.com
American Academy of Nursing Expert Panel Report: Developing Cultural Competence to Eliminate
Health Disparities in Ethnic Minorities and Other Vulnerable Populations
Joyce Giger, Ruth E. Davidhizar, Larry Purnell, J. Taylor Harden, Janice Phillips and Ora Strickland
J Transcult Nurs 2007; 18; 95
DOI: 10.1177/1043659606298618
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© 2007 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
American Academy of Nursing Expert Panel
Report: Developing Cultural Competence to
Eliminate Health Disparities in Ethnic Minorities
and Other Vulnerable Populations
JOYCE GIGER, EdD, RN, ARPN, BC, FAAN
University of California, Los Angeles
RUTH E. DAVIDHIZAR, DNS, RN, APRN, BC, FAAN
Bethel College
LARRY PURNELL, PhD, RN, FAAN
University of Delaware
J. TAYLOR HARDEN, PhD, RN, FAAN
National Institute on Aging, National Institutes of Health
JANICE PHILLIPS, PhD, RN, FAAN
University of Chicago Hospitals
ORA STRICKLAND, PhD, RN, FAAN
Emory University
The members of the Expert Panel on Cultural Competence of
the American Academy of Nursing (AAN) envisioned this
article to serve as a catalyst to action by the Academy to
take the lead in ensuring that measurable outcomes be
achieved that reduce or eliminate health disparities commonly found among racial, ethnic, uninsured, underserved,
and underrepresented populations residing throughout the
United States. The purposes of this article are to (a) assess
current issues related to closing the gap in health disparities
and achieving cultural competence, (b) discuss a beginning
plan of action from the Expert Panel on Cultural Competence
for future endeavors and continued work in these areas
beyond the 2002 annual conference on Closing the Gap in
Health Disparities, and (c) provide clearly delineated recommendations to assist the Academy to plan strategies and to
step forward in taking the lead in reshaping health care policies to eliminate health care and health disparities.
Keywords: cultural competence; culture; health disparities; vulnerable populations
Journal of Transcultural Nursing, Vol. 18 No. 2, April 2007 95-102
DOI: 10.1177/1043659606298618
© 2007 Sage Publications
E
stablished in 1973 under the aegis of the American Nurses
Association, the American Academy of Nursing (AAN) has as
its mission service to the public and to the nursing profession
by way of advancing health policy and practice through the
generation, synthesis, and dissemination of nursing knowledge (http://www.aannet.org/about). The AAN, considered the
“think tank of nursing,” was also established in an effort to
anticipate national and international trends in health care, as
well as to address resulting issues of health care knowledge
and policy. When a candidate is invited to fellowship in the
AAN, it is considered to be one of the highest recognitions of
one’s accomplishments within the nursing profession. Such an
invitation also affords an individual an excellent opportunity
to work with other leaders in health care in addressing the
issues of the day. Currently, there are more than 1,500 people
throughout the United States who are fellows of the AAN.
Within its infrastructure, the AAN has a number of standing committees, including the Annual Meeting Planning
Committee, Communications and Publicity Committee, Development Committee, Fellow Selection Committee, Finance
Committee, Media Awards Committee, Nursing Outlook
Editorial Board, Nominating Committee, Commission on
Workforce, and Workforce Commission Committee on the
Preparation of the Nursing Workforce. Likewise, it has a
number of what are termed expert panels. Membership on
95
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JOURNAL OF TRANSCULTURAL NURSING / April 2007
these expert panels is by invitation with the purpose of providing public service in a designated area of expertise such
as cultural competence (http://www.aannet.org/about). It
is under this umbrella that the Expert Panel on Cultural
Competence embarked on synthesizing and writing this article in an effort to provide guidance in this critical area.
The members of the Expert Panel on Cultural Competence
of the AAN envision that this article will serve as a catalyst to
substantive action by the Academy to take the lead in ensuring
that measurable outcomes be achieved that reduce or eliminate health disparities commonly found among racial, ethnic,
uninsured, underserved, and underrepresented populations
residing throughout the United States. According to Giger and
Davidhizar (2002, 2004), demography is destiny, demographic
change is reality, and demographic sensitivity is without
doubt imperative. In 2003, 70.18% of the U.S. population were
White of European descent, 12.30% were African American,
12.52% were Hispanic American, 4.10% were Asian
American, and 0.90% were Native American Indian (U.S.
Census Bureau, 2002a). In 2003, approximately 43 million
people in the United States were uninsured (U.S. Department
of Commerce, 2002). Whereas the number of underserved
and underrepresented is essentially undocumentable, some
clearly demarcated areas exist where the underserved and
underrepresented reside. An example of a demarcated area is
the estimated 27 million people living in federally defined
areas of Appalachia, covering nearly 20 million square miles
across 410 counties in 13 states in the eastern United States
(U.S. Census Bureau, 2002a).
The expert panel readily acknowledges that interventions
in health care alone, especially those focused on cultural
competence, may not necessarily reduce or eliminate health
disparities. Health policies that specifically address outcomes
that will ameliorate health disparities among the ethnic/
racially diverse, the underserved, the underrepresented, and
the uninsured must exist at the national and state levels. Steps
to activate and facilitate change in our society and our health
care system can start with education of nursing leaders and
spotlight social health policies.
We believe that the Academy’s expert panels are an appropriate mechanism to facilitate the contributions of nursing
leaders in the expanding discussion over diversity, health disparities, and the role of cultural competence. The Expert Panel
on Cultural Competence is providing expert opinion on the
issues of diversity, disparity, and the potential application of
cultural competence in enhancing understanding of disadvantaged groups in the United States and in redressing U.S. health
disparities. The purposes of this article are to (a) assess current
issues related to closing the gap in health disparities and achieving cultural competence, (b) discuss a beginning plan of action
from the Expert Panel on Cultural Competence for future
endeavors and continued work in these areas beyond the 2002
annual conference on Closing the Gap in Health Disparities,
and (c) provide clearly delineated recommendations to assist
the Academy to plan strategies and to step forward in taking the
lead in reshaping health care policies to eliminate healthcare
and health disparities evidenced in today’s society.
ADDRESSING A CRITICAL NEED
Diversity: The Changing Face of America
More than 4 million babies are born each year in the
United States and the U.S. population is growing by about 2.5
million people each year. Immigration contributes more than
1 million people to the U.S. population annually. Using the
Census Bureau’s medium projections, the U.S. population
will grow to 394 million by the year 2050. Hispanic/Latinos
now represent the largest ethnic minority groups residing in
the United States. This changing demographic will necessitate a change in the way health care providers address illness
and wellness issues among and across this vulnerable population. The older population represents a cultural entity unto
itself. The older population, those age 65 years or older, has
assumed a larger share of the total national population during
the past century, representing 12% of the population (National
Center for Health Statistics, 2002). In 2000, individuals reaching the age of 65 had an additional life expectancy of about
17.9 years on average, with 19.2 additional years for women
and 16.3 years for men. By 2050, one in five citizens of the
United States is projected to be age 65 or older. These projected shifts in demographics warrant special attention as we
move forward to close the gap in health disparities. Ethnic
minority groups and older adults will continue to profoundly
shape our cultures and health care system.
Ten years ago, the 1991-1992 Expert Panel on Cultural
Competence proposed 10 recommendations. Significant
improvements have been made in this time. However, 10
years later, much work remains for the Academy. Today, as
then, the issue of cultural competence remains one of the significant aspects for addressing health disparities. However,
the conceptualization, implementation, and evaluation of cultural competence remain unclear as evidenced by the lack of
deliberate and sustained action on the recommendations of
the 1992 AAN Expert Panel on Cultural Competence. To
facilitate the adoption of the concept of cultural competence
by our scientific community, we must advance clarity and
understanding of the concept; intersubjectivity is paramount.
Second, we must demonstrate the usefulness of the concept
in affecting health disparities given the changing face of our
nation.
Health Disparities
A modern, yet familiar, adage is that when America
catches a cold, minority and other vulnerable groups get
pneumonia. The adage addresses the disparate burden of illness for ethnic minorities, the underserved, and other vulnerable populations in the United States and, in particular,
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Giger et al. / DEVELOPING CULTURAL COMPETENCE
groups such as African Americans and other marginalized
groups, who suffer higher rates of morbidity and mortality
from just about every major cause of death, including cardiovascular disease, cancer, diabetes, and HIV/AIDS (Perez,
2002).
If, in our diverse nation, nurses and other health care
providers act in culturally and socially competent ways, then
health disparities and perceptions of health disparities may
be altered, and the mandate to reduce and ultimately eliminate disparities may be realized sooner. Disparities in health
between majority and ethnically and racially diverse and
underserved and other vulnerable populations continue to be
well documented. Attention to this disparity was perhaps first
best articulated in 1985 in the landmark document Report of
the Secretary’s Task Force on Black and Minority Health
(U.S. Department of Health and Human Services, 1985). As
highlighted in this document, racial and ethnic minority populations suffered disproportionably from heart disease,
stroke, cirrhosis, diabetes, infant mortality, unintentional
injuries, and homicide. Despite numerous federal, state, and
local initiatives implemented to address these and other disparities in health, racial and ethnic minority populations
remain disproportionately affected by a number of illnesses
and injuries. In some cases and circumstances, disparities are
increasing.
Early research in health disparities perpetuated, to some
degree, racial categories as capturing biological homogeneity and racial differences as being genetically determined
(American Association of Physical Anthropology, 1996;
National Institute on Aging, 2000; Williams, 2002). Many
scientific groups (National Institute on Aging, 2000) are
emphatic in rejecting any notion of race and ethnicity as
defining distinct biological human subgroups. Nonetheless,
other scientific and cultural experts recognize that particular
genotypes and phenotypes give credence to scientific
acceptable definitions for race (Giger & Davidhizar, 2002,
2004; Lewis, 1997).
Health disparities are also defined as differences in the
incidence, prevalence, mortality, and burden of diseases and
other adverse health conditions that exist among specific population groups in the United States. U.S. disparity population
groups are African Americans, Asians, Hispanics, American
Indians, Native Alaskans, Pacific Islanders, the underserved,
and other vulnerable rural and urban-dwelling Americans
(National Institutes of Health [NIH], 2000; Williams, 2002).
It is important to remember that terms such as African American
are census terms and may not be considered appropriately
descriptive of many Blacks in America who hail from areas
throughout the world and have maintained their unique cultural heritage and, in some cases, specific genotypes to the
geographical location (i.e., Haiti, Jamaica, Uganda, etc.).
Health disparities are defined as diseases, disorders, and
conditions that disproportionately afflict individuals who are
members of racial, ethnic minority, underserved, and other
97
vulnerable groups (National Center on Minority Health and
Health Disparities, 2002). There may be a causal relationship between health status and the quality of the care rendered because inequalities in health care result in health and
health care disparities.
Healthcare Disparities
The Institute of Medicine (Smedley, Stith, & Nelson,
2003) defines ethnic/racial disparities in health care “as racial
and ethnic differences in the quality of health care that are not
due to access-related factors or clinical needs, preferences and
appropriateness of intervention” (p. 3). Nonetheless, it is
essential to remember that health disparities also affect those
of lower socioeconomic status (SES), the underserved, and
other vulnerable populations.
Where ethnic/racial minorities are concerned, the Institute
of Medicine committee’s recommendations focusing on
(a) increasing the number of racial and ethnic minority health
care providers, (b) devoting more resources to enforcing civil
rights violations, (c) promoting equity and consistency in
health care, (d) using community health care workers to help
clients navigate the health care system, (e) enhancing the
communication between patient and provider, and (f) structuring payment systems to ensure adequate services for racial
and ethnic populations and educating both professionals and
consumers are certainly commendable. The committee also
emphasized the need for comprehensive and multilevel
strategies to eliminate disparities in health.
Williams (1999) noted that race and SES combine in complex ways to affect health, with SES accounting substantially,
but not totally, for racial disparities in health. Racism, individual and institutional discrimination, stigma of inferiority,
residence in poor neighborhoods, racial bias in health care,
and the stress of experiencing racism and bias are integral
contributors to health disparities.
Recent studies have revealed that even when ethnic
minorities gain access to the health care system, the care
received differs from what non-Hispanic Whites receive. The
studies have examined access issues (Waidmann & Rajan,
2000) and treatments in several areas including cardiology
and cardiac care, kidney transplantation, general internal medicine, and obstetrics (American Medical Association Council
on Ethical and Judicial Affairs, 1999; Hargraves, Stoddard, &
Trude, 2001; Mayberry, Mili, & Ofili, 2000). It is interesting
that although it has been previously noted that SES plays a
major contributory factor in unequal treatment, in particular
where ethnic minorities are concerned, Braithwaite and
Taylor (2001) assert that even if income levels are standardized and if impediments concerning access to care are eliminated, disparities in health outcomes still exist.
If health disparities are to be eliminated, then a broadbased, multilevel, and multidisciplinary process to reduce and
ultimately eliminate them is necessary. Wang, Remington,
and Kindig (1999) asked the profound question, “How fast
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JOURNAL OF TRANSCULTURAL NURSING / April 2007
can the racial gap in life expectancy between Whites and
Blacks be eliminated?” These investigators answered that if
Blacks could experience substantial improvements in life
expectancy via improvements in cancer, heart disease, homicide, and HIV mortality, then the gap in life expectancy, about
6.9 years (71.0 vs. 76.9 years) in 2002, could be eliminated in
about 40 years. They further highlighted major cause-specific
contributions to the racial gap in health and did not consider
nonmedical determinants of health such as access, utilization
of services, environment, positive health behaviors, or cultural
competence.
Research is crucial to success in reducing and ultimately
eliminating health disparities. However, history reveals that
the typical and usual research participant is a White male.
History, education, culture, language, income and wealth,
geography, racial identity, prejudice, paternalism, and other
social deterrents are implicated in the underrepresentation of
women and ethnic minorities in clinical research (Giuliano et
al., 2000; Underwood, 2000). The director of NIH in consultation with the director of the Office of Research on Women’s
Health and the director of the National Center on Minority
Health and Health Disparities continues ardent support of
Public Law 103-43 (1993), ensuring outreach programs for
the recruitment and retention of women and members of
minority groups as subjects in clinical research. Inclusion of
women and minorities in clinical research remains an explicit
criterion considered in the review of applications for funding
from the NIH (Harden & McFarland, 2000). It should also be
noted that including diverse groups in research samples is not
enough, but research must be conducted with culturally
appropriate interventions related to specific groups.
Research on the topics of diversity, disparities, and cultural
competence coupled with representative samples and minority/ethnic investigators are required pieces of the immense
puzzle and challenge of reducing and eliminating U.S. minority health disparities.
The expert panel supports the following explanatory statements in developing and advancing knowledge in this area:
• Disparities occur in the context of broader history and contemporary social and economic inequality.
• Contributing factors are multilevel and can include health
care systems as a whole, health care providers, patients, and
health care plan managers.
• Bias, stereotyping, prejudice, and clinical uncertainty on the
part of the health care provider may contribute to disparities
in health (Nelson, 2002; Smedley et al., 2003).
CULTURALLY COMPETENT
HEALTH CARE
Purnell and Palunka (2003) note that the term cultural
competence refers to the act whereby a health care professional develops an awareness of one’s existence, sensations,
thoughts, and environment without letting these factors have
an undue influence on those for whom care is provided.
Furthermore, Purnell and Palunka conclude that cultural
competence is the adaptation of care in a manner that is congruent with the client’s culture. According to Giger and
Davidhizar (2002, 2004), cultural competence is a dynamic,
fluid, continuous process whereby an individual, system, or
health care agency finds meaningful and useful care-delivery strategies based on knowledge of the cultural heritage,
attitudes, and behaviors of those to whom they deliver care.
Cultural competence is more than an understanding of race
and ethnicity. LaVeist (1994) posits that race actually represents two underlying heterogeneous factors: social factors and
individual-level behaviors that can be linked to cultural
norms. Although they are linked, one can distinguish between
ethnicity and culture. Ethnicity typically is defined as groups
whose members internalize and share a heritage of ancestry,
language, and customs to include social characteristics, cultural symbols, and behavior patterns not shared by outsiders.
According to Campinha-Bacote (2002), the process of
cultural competence in the delivery of health care services
requires that “healthcare providers see themselves as becoming culturally competent” rather than behaving as if cultural
competence is a trait characteristic. Cultural competence
is an iterative process of continuously striving to achieve
knowledge, skills, and abilities to effectively work within the
cultural context of the client, consumer, or colleague.
Giger and Davidhizar (2002, 2004) are ardent in describing cultural competence as a higher level of knowledge and
understanding gained from conceptual and theoretical perspectives encompassing skills, attitudes, and personal beliefs.
Culturally competent health care refers to care designed to
meet the needs of marginalized groups, individuals, and communities of people who have some distinct characteristics that
differentiate them from the mainstream (Hall, Stevens, &
Meleis, 1994). The first imperative of cultural competence is
to be competent in one’s own cultural heritage. After personal
understanding comes respect and appreciation for the values
and behaviors of others. Knowledge of cultural differences is
essential if sensitivity and competence are to occur. Only
when self-awareness combines with insight about others then
true sensitivity can be demonstrated by individuals, health
care systems, and communities.
In December 2000, the U.S. Department of Health and
Human Services Office of Minority Health released national
standards for culturally and linguistically appropriate services (CLAS) in health care. This seminal document includes
14 standards addressing three main components for enhancing culturally competent health care through organizations
and individuals: culturally competent care, language access
services, and support from organizations for cultural competence. Standards 3 and 10 raise significant issues and concerns.
Standard 3 admonishes health care organizations to ensure
that staff at all levels of the organization and across all disciplines receive ongoing education and training in culturally
and linguistically appropriate service delivery. Although the
obvious intent of the standard is lauded, the process for
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Giger et al. / DEVELOPING CULTURAL COMPETENCE
implementation requires further thought, development, guidance, and resources.
As noted by Brach and Fraser (2000), substantial research
evidence exists to suggest that cultural competence is achievable; however, health systems have little evidence about
which techniques are effective and efficacious and less
evidence on when and how to implement them properly.
Standard 10 suggests that health care organizations collect
information on the patient’s race, ethnicity, and spoken and
written languages. This information is to be made part of the
health record and management information system. In this
example, the intent is given low applause by some research
groups such as the American Association of Physical
Anthropology (1996) as the U.S. Department of Health and
Human Services standard appears to ignore the scientific data
that there is no biological basis for race and that there are no
significant biological differences that affect health. The intent
for the inclusion of race is not obvious. Nonetheless, it is
essential to remember that because of specific genotypes and
phenotypes evidenced by some Blacks residing in the United
States, many researchers (Giger, Strickland, Weaver, Acton, &
Taylor, 2005) continue to argue that racial differences are of
significant import to understanding health disparities as they
presently exist in this country. Furthermore, race has social
implications and can limit or increase opportunities. Thus,
recording ethnicity as self-described by the patient or consumer may not be sufficient as originally determined by the
Office of Minority Health (2001). Nonetheless, the CLAS
standards are available online at http://www.omhrc.gov/CLAS.
Examining the Links Between Cultural
Competency and Health Disparities
At a national conference supported by the NIH, National
Center for Minority Health and Health Disparities (Kritek et
al., 2002), cultural competence was repeatedly recommended
as an educational tool to redress issues of health disparity; the
conference generated 598 recommendations. Approximately
one out of every four recommendations suggested education
as the principal mechanism to reduce and ultimately eliminate
health disparities. The theme of education for leaders and
consumers has also emerged from recent research analyses.
Recommendations of the Expert Panel
on Cultural Competence
The Academy, through its expert panels, should host a
national consensus conference on cultural competence to
fully elaborate the theoretical construct and its role in redressing health disparities. (Comprehensive recommendations
are summarized in Table 1.)
Education. Eliminating health disparities requires the
development of knowledge, skills, basic competencies, and
abilities among health care professionals. This must begin in
99
TABLE 1
Comprehensive Recommendations of Expert
Panel on Cultural Competence of the American
Academy of Nursing (AAN)
1 The AAN, through its publications, mission statements, and yearly
conferences, must make an explicit commitment to quality, culturally
competent care that is equitable and accessible by targeting four
groups: (a) health care consumers, (b) health care providers, (c) health
care systems, and (d) communities.
2 The AAN will collaborate with other organizations and communities
in developing guidelines.
3 The AAN shall develop mechanisms to synthesize existing theoretical
and research knowledge concerning nursing care of ethnic/minorities
and other vulnerable populations.
4 The AAN, through its expert panels and commissions, must create an
interdisciplinary knowledge base that reflects health care practices
within various cultural groups, along with human communication
strategies that transcend interdisciplinary boundaries to provide a
foundation for education, research, and action.
5 The AAN, through its expert panels and commissions, must identify,
describe, and examine methods, theories, and frameworks appropriate
for utilization in the development of knowledge related to health care
of minority, stigmatized, and vulnerable populations.
6 The AAN shall seek resources to develop and sponsor studies to
describe and identify principles used by organization magnets that (a)
provide an environment that enhances knowledge development related
to cross-cultural, ethnic minority/stigmatized populations, and (b)
attract and retain minority and other vulnerable students, faculty, and
clinicians.
7 The AAN, through its various structures, must identify health care
system delivery models that are the most effective in the delivery of
culturally competent care to vulnerable populations and develop
mechanisms to promote the necessary changes in the U.S. health care
delivery system toward the identified models.
8 The AAN must collaborate with other organizations in establishing
ways to teach and guide faculty and nursing students to provide culturally competent nursing care practices to clients in diverse clinical
settings in local, regional, national, and international settings.
9 The AAN must collaborate with racial/ethnic nursing organizations to
develop models of recruitment, education, and retention of nurses
from racial/ethnic minority groups.
10 The AAN will collaborate with other organizations in promoting the
development of a document to support the regulation of content
reflecting diversity in nursing curricula. In addressing regulations,
specific attention needs to be given to the NCLEX examinations, continuing education, and undergraduate curricula.
11 The AAN must take the lead in promulgating support of research
funding for investigation with emphasis on interventions aimed at
eliminating health disparities in culturally and racially diverse groups
and other vulnerable populations in an effort to improve health outcomes. The AAN must take a more proactive stance to encourage policy makers to create policies that address the elimination of health
disparities and ultimately improve health outcomes.
12 The AAN must encourage funding agencies’ requests to solicit proposals focusing on culturally competent interventions designed to
eliminate health disparities.
educational settings and through careful integration of content to develop sensitivity and competence in health care
professional curricula.
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JOURNAL OF TRANSCULTURAL NURSING / April 2007
Practice. All practice settings must be culturally sensitive
and all institutions must assure that culturally competent care
is rendered to those entrusted to their care in all current and
potentially active health care delivery settings. Health care
organizations must provide a supportive climate for culturally competent care. Care must also include an appreciation
for complementary alternative therapies.
Research. Research is crucial to success in reducing and
ultimately eliminating health disparities. Research on diversity, disparities, and cultural competence is needed. Inclusion
of women and ethnic minorities in clinical research is essential to eliminate bias. Use of representative samples is required.
Designated funding is needed to achieve these goals.
Policy. The Academy must take a proactive lead in proposing policies that can focus funds and care in areas that
will change health outcomes to eliminate health disparities.
Education of policy makers is essential.
Advocacy. Health care professionals and the Academy
must promote efforts that advocate for diverse groups and
vulnerable populations who cannot advocate for themselves.
Advocacy is the responsibility of every health care professional and must be championed by powerful groups like the
Academy to ensure that change can occur.
SUMMARY
The Expert Panel on Cultural Competence of the AAN has
developed a position paper to serve as a catalyst for substantive action to promote outcomes that reduce or eliminate health
disparities commonly found among racial, ethnic, uninsured,
underserved, and underrepresented populations residing
throughout the United States. The expert panel has provided
recommendations for AAN in the areas of education, practice,
research, policy, and advocacy as well as a specific list of 12
recommendations. However, an understanding of these recommendations should not be limited to the Academy but can serve
as a guide for all professionals who seek to address the problem of health disparities in the United States (see Appendix).
APPENDIX
Understanding Cultural Language to Enhance
Cultural Competence
The Expert Panel on Cultural Competence offers the following as
a glossary and consensus standard for definitions.
Culture: A learned, patterned behavioral response acquired over
time that includes explicit and implicit beliefs, attitudes, values,
customs, norms, taboos, arts, habits, and life ways accepted by a
community of individuals. Culture is primarily learned and transmitted within the family and other social organizations, is shared
by the majority of the group, includes an individualized worldview,
guides decision making, and facilitates self-worth and self-esteem.
Primary Characteristics of Culture: Primary characteristics of
culture determine the degree to which a person adheres to the dominant beliefs and practices of his or her dominant culture and includes
nationality, race, color, gender, age, and religious affiliation. Primary
characteristics are attributes that one cannot easily change.
Secondary Characteristics of Culture: Secondary characteristics of
culture determine the degree to which a person adheres to the dominant beliefs and practices of his or her dominant culture and include
education; occupation; socioeconomic status; political beliefs; military experience; rural versus urban status; marital status; parental status; gender issues; sexual orientation; physical characteristics; length
of time away from the country of origin; and reason for migration
such as undocumented, immigrant, or sojourner. Secondary characteristics are attributes that one can more readily change.
Cultural Diversity: Refers to diversity in race, color, ethnicity,
national origin, religion, age, gender, sexual orientation, ability/disability, social and economic status or class, education, occupation,
religious orientation, marital and parental status, and other related
attributes of groups of people in society.
Cultural Sensitivity: Cultural sensitivity is experienced when neutral language, both verbal and nonverbal, is used in a way that
reflects sensitivity and appreciation for the diversity of another.
Cultural sensitivity is conveyed when words, phrases, categorizations, and so on are intentionally avoided, especially when referring
to any individual who may be interpreted as impolite or offensive.
Cultural Awareness: Cultural awareness is being knowledgeable
about one’s own thoughts, feelings, and sensations and having an
appreciation of the diversity of others in terms of the objective
(material) culture such as the arts, clothing, foods, and other external signs of diversity.
Cultural Competence: Cultural competence is having the knowledge, understanding, and skills about a diverse cultural group that
allows the health care provider to provide acceptable cultural care.
Competence is an ongoing process that involves accepting and
respecting differences and not letting one’s personal beliefs have
an undue influence on those whose worldview is different from
one’s own. Cultural competence includes having general cultural
as well as cultural-specific information so the health care provider
knows what questions to ask.
Cultural Relativism: The belief that behaviors and practices of
people should be judged only in the context of their cultural system. Proponents argue that issues such as abortion, euthanasia,
female circumcision, and physical punishment in childrearing
should be accepted as cultural values without judgment from the
outside world. Opponents argue that cultural relativisms may
undermine condemnation of human rights violations and that
family violence cannot be justified or excused on a cultural basis.
Cultural Imposition: Intrusively applies the majority cultural
view to individuals and families. Prescribing a special diet without
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Giger et al. / DEVELOPING CULTURAL COMPETENCE
regard to the client’s culture and limiting visitors to immediate
family borders on cultural imposition. In this context, health care
providers must be careful in expressing their cultural values too
strongly until cultural issues are more fully understood.
Cultural Imperialism: The practice of extending policies and practices of one organization (usually the dominant one) to disenfranchised and minority groups. Proponents appeal to universal human
rights values and standards. Opponents posit that universal standards are a disguise for the dominant culture to destroy or eradicate
traditional cultures through worldwide public policy.
Health Disparity: Health disparity is defined as differences in the
incidence, prevalence, mortality, and burden of diseases and other
adverse health conditions that exist among specific population groups
in the United States.
Health Care Disparity: A health care disparity exists when persons
of different races, ethnic groups, and cultures do not receive equal
health care, and illness occurs disproportionately from one group to
the other.
Race: Race is a viable term that relates to biology but has sociological implications. Members of a particular race share distinguishing
physical features such as skin color, bone structure, or blood group.
Race is a social construct, which limits or increases opportunities
depending on the setting.
Racism: Racism refers to feelings of prejudice against persons of
another race or group of people. Racist practices lead to interpersonal tension, isolation, discrimination, and covert anger.
Stereotype: Stereotype includes having a simplified and standardized conception, image, opinion, or belief about a person or group.
A health care provider who fails to recognize individuality within a
group is jumping to conclusions and therefore stereotyping.
Generalization: Generalizations begin with assumptions about the
individual or family within an ethnocultural group but lead to further information seeking about the individual or family.
Ethnocentrism: Ethnocentrism is a universal tendency to believe that
one’s own worldview is superior to another’s. It is often experienced
in the health care arena, in particular when the health care provider’s
own culture or ethnic group is considered superior to another.
Ethnic Group: An ethnic group is a group of people whose members
have different experiences and backgrounds from the dominant culture
by status, background, residence, religion, education, or other factors
that functionally unify the group and act collectively on each other.
Stigma: A characteristic or trait that causes a stain or reproach on
a group’s or individual’s reputation or being.
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Joyce Giger, EdD, RN, APRN, BC, FAAN, is Professor and Lulu
Wolff Hassenplug endowed Chair at the UCLA School of Nursing.
She is the co-author of the Giger & Davidhizar Transcultural
Assessment Model, a model that provides strategic guidelines for
assessing health disparities and providing guidelines to eliminate
these health disparities based on development of cultural competence. Dr. Giger’s area of research is genetic and other CHD indicators in pre-menopausal African American women.
Ruth E. Davidhizar, DNS, RN, APRN, BC, FAAN, is Professor
and Dean of Nursing at the School of Nursing, Bethel College,
Mishawaka, Indiana. She received her DNS in Nursing Research
from Indiana University in Indianapolis. Her major interest and
research area is cultural competency and health disparities.
Larry Purnell, PhD, RN, FAAN, is a professor in the School of
Nursing at the University of Delaware. He is the co-editor with
Betty Paulanka of Guide to culturally competent healthcare and
transcultural health care: A culturally competent approach; and
co-editor with J. Black-Lattanzi & L. Purnell of Developing cultural competence in physical therapy practice.
J. Taylor Harden, PhD, RN, FAAN, is Assistant to the Director
for Special Populations at the National Institute on Aging, National
Institutes of Health. She received her PhD from the University of
Texas at Austin. Her major research interest is in aging with specialization in minority and women’s health, and health disparities
among older adults.
Janice Phillips, PhD, RN, FAAN, is a nurse researcher at the
University of Chicago Hospitals, where she is responsible for facilitating and supporting clinical nursing research. Her research
focuses on health disparities and breast cancer and African
American women. She is currently working on her second edited
book “Advancing Oncology Nursing Science.” Dr Phillips holds a
PhD In Nursing Science from the University of Illinois in Chicago.
Ora Strickland, PhD, RN, FAAN, is a professor in the
Department of Family and Community Nursing at the Nell
Hodgson Woodruff School of Nursing at Emory University. She
received her PhD in Child Development and Family Relations at
the University of North Carolina at Greensboro. Her interests
include measurement, research design, women's health, and
vulnerable populations.
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