Cultural Competence:
Cultural Care
Chapter 2
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Chapter 2: Cultural Competence: Cultural Care
Cultural Competency
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Who are you meeting for the first time?
Where does the patient come from?
What is his or her heritage?
What is his or her cultural background:
ethnicity and religion?
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-2
Chapter 2: Cultural Competence: Cultural Care
Cultural Competency (cont.)
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Does the patient understand, speak, and read
English?
What language does her or she understand,
speak, and read?
What is his or her health and illness beliefs
and practices?
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-3
Chapter 2: Cultural Competence: Cultural Care
Objectives
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Demographic profile of United States
National Standards for Culturally and Linguistically
Appropriate Services
Background of Heritage Assessment
Methods for conducting Heritage Assessment
Traditional health and illness beliefs and practices
Steps to cultural competence
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-4
Chapter 2: Cultural Competence: Cultural Care
Health and Illness
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Health:
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Balance of a person is a complex, interrelated
phenomenon:
• Within one’s being: physical, mental, spiritual
• In outside world: natural, communal, metaphysical
Illness:
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Loss of a person’s balance:
• Within one’s being: physical, mental, spiritual
• In outside world: natural, communal, metaphysical
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-5
Chapter 2: Cultural Competence: Cultural Care
Demographic Profile of
United States
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Total population passed 300 million in 2006
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1 out of 3 residents are in a group other than
single-race, non-Hispanic white
Minority, or emerging majority populations total 98
million people
Hispanics: largest and fastest growing group
Blacks: second largest population
Asians, American Indians, Alaska natives, Native
Hawaiians, and other Pacific Islanders make up
the third largest part of the population
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-6
Chapter 2: Cultural Competence: Cultural Care
Demographic Profile of
United States (cont.)
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Emerging majority groups tend to be:
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Younger
Lower median ages
Higher proportions under 18 years old
Dominant, non-Hispanic, single-race, white
population is:
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Older median age
 Smaller proportion under 18 years old
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-7
Chapter 2: Cultural Competence: Cultural Care
Demographic Profile of
United States (cont.)
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One birth every 8 seconds
One death every 13 seconds
One international migrant (net) every 30
seconds
Net gain of one person every 11 seconds
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Slide 2-8
Chapter 2: Cultural Competence: Cultural Care
Immigration
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Categories of Interest to Health Care
Providers
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Legal permanent residents
Naturalized citizens
Undocumented aliens
Refugees, asylees, and parolees
Legal nonimmigrant residents
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Slide 2-9
Chapter 2: Cultural Competence: Cultural Care
Immigration (cont.)
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Many new immigrants have only minimal
understanding of:
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Modern health care delivery system
Modern medical and nursing practices and
interventions
English language
It is imperative that the nurse’s care be
tailored to meet the person’s perceived needs
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-10
Chapter 2: Cultural Competence: Cultural Care
National Standards
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National Standards for Culturally and
Linguistically Appropriate Services
in Health Care
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First and Landmark Standard
• Health care organizations should ensure that patients
receive from all staff members effective, understandable
and respectful care that is provided in a manner
compatible with their cultural health beliefs and practices
and preferred language*
*Source: National Standards for Culturally and Linguistically Appropriate Services in Health Care,
Final Report, March 2001, Washington, DC: Office of Minority Health, DHHS
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-11
Chapter 2: Cultural Competence: Cultural Care
National Standards (cont.)
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Effective care: positive outcomes and
satisfaction for patient
Respectful care: considers values,
preferences, and expressed needs of patient
Cultural and linguistic competence: congruent
behaviors, attitudes, and policies that come
together in a system among professionals
that enables work in cross-cultural situations
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-12
Chapter 2: Cultural Competence: Cultural Care
Linguistic Competence
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Title VI of Civil Rights Act of 1964:
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47 million Americans over 5 years of age
speak a language other than English in their
homes
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Services cannot be denied to people of limited
English proficiency
An increase of 15 million people over 1990 census
Some states require providers to offer
language assistance in health care settings:
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California, Massachusetts, and New York
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-13
Chapter 2: Cultural Competence: Cultural Care
Linguistic Competence (cont.)
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People with limited ability to speak, read,
write, and understand English encounter
countless barriers that limit access to critical
public health, hospital, and other medical and
social services to which they are legally
entitled
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-14
Chapter 2: Cultural Competence: Cultural Care
Cultural Competence
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Culturally sensitive:
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Possessing basic knowledge of and constructive
attitudes toward diverse cultural populations
Culturally appropriate:
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Applying underlying background knowledge
necessary to provide the best possible health care
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-15
Chapter 2: Cultural Competence: Cultural Care
Cultural Competence (cont.)
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Culturally competent:
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Understanding and attending to total context of
patient’s situation including:
• Immigration status
• Stress factors
• Social factors
• Cultural similarities and differences
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-16
Chapter 2: Cultural Competence: Cultural Care
Heritage
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Culture
Ethnicity
Religion and Spirituality
Socialization
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Acculturation
Assimilation
Biculturalism
Time Orientation
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-17
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Heritage consistency:
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Degree to which a person’s lifestyle reflects his or
her traditional heritage
Heritage consistency continuum:
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Traditional: living within norms of traditional culture
Modern: acculturated to norms of dominant
society
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-18
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Culture:
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Thoughts, communications, actions, beliefs,
values, and institutions of racial, ethnic, religious,
or social groups
 Characteristics of culture
• Learned
• Shared
• Adapted
• Dynamic
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-19
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Ethnicity
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Describes a group united by:
• Common geographic origin
• Migratory status
• Religion
• Race
• Language
• Shared values, traditions, or symbols
• Food preferences
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-20
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Religion:
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Belief in divine or superhuman power, or powers
to be obeyed and worshipped as creator/ruler of
universe
 System of beliefs, practices, and ethical values
 Shared experience of spirituality
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-21
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Socialization
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Process of being raised within a culture and
acquiring characteristics of that group
Related terms:
• Acculturation: process of adapting to and acquiring
another culture
• Assimilation: process of developing a new cultural
identity and becoming like members of dominant culture
• Biculturalism: dual pattern of identification and often of
divided loyalty
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-22
Chapter 2: Cultural Competence: Cultural Care
Heritage (cont.)
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Time Orientation
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Focus on past
• Traditions and ancestors play important role in person’s
life
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Focus on present
• Little attention paid to past or future; concerned with now,
and future perceived as vague or unpredictable
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Focus on future
• Progress and change highly valued; person may express
discontent with both past and present
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-23
Chapter 2: Cultural Competence: Cultural Care
Heritage Assessment
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Indicators of heritage consistency
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Childhood occurred in country of origin or
immigrant neighborhood of like ethnic group
 Extended family support of traditional activities
 Frequent visits to old country or old neighborhood
 Family home within ethnic community to which
they belong
 Participation in ethnic cultural events
 Raised in extended family setting
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-24
Chapter 2: Cultural Competence: Cultural Care
Heritage Assessment (cont.)
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Indicators of heritage consistency (cont.)
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Regular contact with extended family
Name not anglicized
Educated in parochial school
Social activities primarily with members of ethnic
community
Knowledge of language and culture of origin
Expresses pride in heritage
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Slide 2-25
Chapter 2: Cultural Competence: Cultural Care
Health-Related Beliefs
and Practices
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Health-Related Behaviors Affected by
Religion
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Meditating
Exercising/physical fitness
Sleep habits
Vaccinations
Willingness to undergo physical examination
Pilgrimage
Truthfulness about how patient feels
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Slide 2-26
Chapter 2: Cultural Competence: Cultural Care
Health-Related Beliefs
and Practices (cont.)
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Health-Related Behaviors Affected by
Religion (cont.)
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Maintenance of family viability
Hoping for recovery
Coping with stress
Genetic screening and counseling
Living with a disability
Caring for children
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Slide 2-27
Chapter 2: Cultural Competence: Cultural Care
Health-Related Beliefs
and Practices (cont.)
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Differing views of epilepsy:
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Uganda: contagious, untreatable
Greece: source of family shame
Mexican-American community: evidence of
physical imbalance
Hutterites: evidence of having endured trial by
God
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Slide 2-28
Chapter 2: Cultural Competence: Cultural Care
Developmental Care
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Culture affects choices parents make for
children regarding:
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Presumed cause of illness
First treatment tried
Acceptability of treatments offered by clinicians
For older patients, culture is likely to
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Define their family responsibilities
 Affect their view and knowledge of health care
systems used by dominant culture
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Slide 2-29
Chapter 2: Cultural Competence: Cultural Care
Traditional Causes of Illness
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Biomedical
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Assumes cause and effect
Views the body as a machine
Life can be divided into parts
Endorses germ theory
Naturalistic
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Forces of nature must be kept in balance
 Embraces idea of opposing categories or forces
• Yin and yang, hot and cold
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Slide 2-30
Chapter 2: Cultural Competence: Cultural Care
Traditional Causes
of Illness (cont.)
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Magicoreligious
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Supernatural powers predominate in area of
health and illness
• Examples include voodoo, witchcraft, and faith healing
Healing and culture
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In addition to seeking help from health care
providers, patients may also seek help from folk or
religious healers
Hispanics or American Indians may believe that
cure is incomplete unless healing of body, mind,
and spirit are all carried out
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Slide 2-31
Chapter 2: Cultural Competence: Cultural Care
Traditional Causes
of Illness (cont.)
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Folk Healers
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Hispanic: curandero, espiritualista, yerbo, or
sabedor
 Black: hougan, spiritualist, old lady
 American Indian: shaman, medicine woman,
medicine man
 Asian: herbalists, acupuncturists, bone setters
 Amish: braucher
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Slide 2-32
Chapter 2: Cultural Competence: Cultural Care
Transcultural Expressions of
Illness
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Transcultural expression of pain
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Expectations, manifestations, and management of
pain are all embedded in a cultural context
Pain has been found to be a highly personal
experience, depending on cultural learning, the
meaning of the situation, and other factors unique
to the person
Silent suffering has been identified as the most
valued response to pain by health care
professionals
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-33
Chapter 2: Cultural Competence: Cultural Care
Transcultural Expressions of
Illness (cont.)
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Culture-bound syndromes
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Condition that is culturally defined
• Some have no equivalent in a biomedical, scientific
perspective
• Anorexia nervosa and bulimia are examples of cultural
aspects of illness in dominant cultural population in North
America
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-34
Chapter 2: Cultural Competence: Cultural Care
Transcultural Expressions of
Illness (cont.)
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Culture and treatment
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First effort at treatment is often self-care
 Home treatment attractive for accessibility,
particularly for people from rural or sparsely
populated areas
 Home treatment may mobilize person’s social
support network and provide a caring environment
in which to convalesce
 Alternative or complementary interventions are
gaining recognition from health care professionals
in health care system
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 2-35
Chapter 2: Cultural Competence: Cultural Care
Transcultural Expressions of
Illness (cont.)
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Culture and disease prevalence
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Disparity continues in deaths and illnesses
experienced by racial and ethnic populations
• Diseases are not distributed equally among all segments
of population
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Abnormal biocultural variations may be genetic or
acquired
• Information about disease prevalence for racial and
ethnic groups provides focus for assessment regarding
increased probability that particular conditions may occur
• Nurses must be certain that they have gathered data
needed to support or refute suspicions
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Slide 2-36
Chapter 2: Cultural Competence: Cultural Care
Steps to Cultural Competence
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Understand one’s own heritage-based
values, beliefs, attitudes, and practices
Identify meaning of “health” to patient
Understand how health care system works
Acquire knowledge about social backgrounds
of patients
Become familiar with languages, interpretive
services, and community resources available
to nurses and patients
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Slide 2-37
Chapter 2: Cultural Competence: Cultural Care
Cultural Care Nursing
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Cultural care nursing is goal to strive for
It is a long trajectory
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Slide 2-38
Chapter 2: Cultural Competence: Cultural Care
RESPECT
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Realize you must know heritage of yourself and
patient
Examine patient within cultural context
Select simple questions and speak slowly
Pace questioning throughout exam
Encourage patient to discuss meaning of health
and illness with you
Check patient’s understanding and acceptance of
recommendations
Touch patient within boundaries of his or her
heritage
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Slide 2-39