Cultural Competency: The Building Blocks
(2 contact hours)
Instructor: Marlene V. Obermeyer, MA, RN
MEMBER: KANCEP
Culture Advantage is approved as a provider of continuing nursing education by the Kansas State Board of Nursing. This course is approved for 2 contact hours applicable for relicensure for RNs, LPNs, and LMHTs.Kansas State Board of Nursing: Provider # LT0243-1250.
This is an introductory course in cultural competency. It is strongly recommended to start with this course before proceeding to the culture-specific courses.
To take the exam, log in at the etraining site after reading the lessons.
Start the course:
Lessons:
I. Cultural Competency: Rationale for cultural competency
II. Cultural Competency: Terminology
III. The CLAS standards.
IV. History of Cultural Competency in Nursing
V. Developing cultural competence: awareness, knowledge and skills.
VI. References (available with registration)
Course Objectives:
After completion of the module, the participant will be able to:
1. Define culture, cultural competence, and linguistic competence in healthcare.
2. Explain at least 4 CLAS standards that affect nursing practice (Standards 1,2,3,4).
3. Discuss the history of cultural competency in nursing.
4. Describe culturally competent attitudes, knowledge and skills.
I. Rationale for cultural competency in healthecare.
The United States population is increasingly more diverse racially and ethnically. In the 1990s, over 26 percent of the US population constituted of linguistic and cultural minority populations. It is predicted that by 2010,the minority populations will constitute over 30 percent of the population and by 2050, almost 50 percent of the total population will be members of ethnic and racial minorities (US Census 2004).
Research has shown that culture shapes a person's attitudes, beliefs, and practices toward health and disease; culture influences the patient-caregiver relationships; and cultural differences contribute to the health disparities in society.
This course introduces the basic concepts of cultural and linguistic competency, the guidelines and mandates for cultural competency in practice, the development of cultural competency in nursing, and basic concepts of culturally competent attitudes, knowledge and skills.
II. Terminology
A. Definition of culture.
In order to understand cultural competency, we must first define what culture is. Culture has many definitions. One of the definitions is that culture is the shared beliefs, values andpractices that are learned and transmitted throughout a society, andinfluence the way that a group of people live and make decisions and interact.
Culture has been described as the learned and shared patterns of information that a group uses to generate meaning among its members. (Diversity.org 2001)
Health care professionals can be said to have a “culture” in the sensethat they have a shared set of beliefs, norms, and values. This is reflectedin the terminology that they use, in emphasis of scientific evidence intheir work, and in their mindset, or way of looking at the world. (SurgeonGeneral, 1999)
B. Definition of cultural competency.
Just as there are different definitions of culture, there are also different ways of defining cultural competency.
One of the generally accepted descriptions of cultural competency is that it is a developmental process that is developed over time in order to increase understanding and knowledge of cultural differences that affect the healthcare experience.
According to some sources, the U.S. healthcare profession has not beenvery well-prepared to provide culturally competent care (Surgeon GeneralReport 2005).
According to Cross (1991), cultural competency is: a set of congruent behaviors, attitudes and policies that enable a system, agency or professionals to work effectively in cross-cultural situations.
Cultural situations are encounters with cultural differences that may or may not includerace and ethnicity. The concept of cultural diversity in healthcareincludes not only race, ethnicity, national origin, age, gender and religion,
but also language, sexual orientation, mental or physical abilities, social class, educational level, and other attributes of society that result in differentperspectives about health and disease.
Biology and culture are equally important in the person’s experience of illness. In addition, society’s economic and political structures play a critical part in the risks of diseases and availability and accessibility of treatments.
Every encounter with a healthcare provider is shaped by the cultural frameworks of both the client and the medical professional. In today’s increasingly diversesociety, cultural competence becomes a critical skill in our personal, professionaland social environment (Joralemon 1999).
C. Linguistic competence means communicating effectively.
Linguistic competence is the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences .(Source: NCCC 2004).
D.The goal of cultural competency is to make healthcare more efficient and more effective.
It is reducing costs of unnecessary tests and procedures, gaining trustand compliance with treatment in order to promote positive outcomes, andrespecting and acknowledging that beliefs, practices, and genetic heritageof clients can affect their treatments and outcomes.
It is not learning everything about all the different cultures that youwill encounter; it is developing the skills and resources to deal with thedifferences. It is not learning all the different languages that clientsspeak, but the knowledge and skills to communicate effectively with and withoutinterpreters.
E. Some of the benefits of cultural competence in healthcare (MCC 2005):
Improves communication with patients Helps with negotiating differences Promotes disclosure of patient information Makes more effective use of time with patients Promotes patient adherence to treatment Decreases health worker and patient stress Builds trust in a relationship Increases patient and provider satisfaction Meets increasingly stringent government regulations and standards Positively affects clinical outcomes The Office of Minority Health recently released its findings on the business case for culturally appropriate services. The findings point out that implementing the CLAS Standards can have benefits in many different areas such as cost reduction, equity, efficiency, quality and reduction of medical errors. Reguired reading: MAKING THE BUSINESS CASE FOR CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES IN HEALTH CARE: CASE STUDIES FROM THE FIELD (2007) Pages 5 to 7. Some of the case studies include examples of: - Increased market share among limited English proficient patients. Health care organizations implementing CLAS standards have achieved increases in enrollment and patient services among the insured. Cultural competency attracts business.
- Substantial reductions in outsourced language interpretation services and subsequent savings in related costs. Many health care organizations that address the threshold issue of language services have found very efficient ways to make better use of their own bilingual staff or volunteers, thereby reducing substantial costs of outsourcing interpretation services.
- Increased patient and provider satisfaction. A numberof health care organizations indicate that projects designed to implementany of the CLAS Standards have improved patient and provider satisfactionwith the health care process.
- More efficient use of staff time by reducing communication delays between patients and providers. Simply by addressing language issues, providers, provider office staff and patients enjoy reduced delays and a moreefficient health care interaction.
- Cost-savings resulting from shorter hospital stays and more prompt and efficient patient discharges. Efficient and culturally competent solutions to providing discharge instructions and education in a language other than English have resulted in improvements in hospital-wide discharge practices and have yielded significant savings.
III. The CLAS standards
Required Reading: ExecutiveSummary.
Pages 27 to 31.
Alternate site: Final Report on the CLAS standards. PDF file pages 14, 15, 16 and 17. http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf
A. CLAS stands for Culturally and Linguistically Appropriate Services.
The Standards (link).
The CLAS standards were developed and issued by the U.S Department of Health and Human Services’ Office of Minority Health in 2000.
The standards are guidelines for accreditation and credentialing agencies:
- to assess and compare providers who say they provide culturally competent services, and
- to assure quality for diverse populations. (Please refer to CLAS link recommended reading pages 7-12).
The 14 standards are organized by themes:
Standards 1-3: Culturally competent care
Standards 4-7: Linguistic competency
Stamdards 8-14: Organizational supports for cultural competency. (UMCC2005)
B. Standards 1, 2 and 3 (Culturally Competent Care “Guidelines”): Health organizations should: (Source: OMH 2005)
Standard 1: ensure that patients/consumers receive from all staff members effective, understandable, and respectful carethat is provided in a manner compatible with their cultural health beliefs and practices and preferred language;
Standard 2: implement strategies to recruit, retain, and promote at all levels of the organization diverse staff and leadership that are representative of the demographic characteristics of the service area;
Standard 3: ensurethat staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery
Language access service: Title VI of the Civil Rights Act of 1964 mandates linguistic competency.
Standard 4: describes language access, stating that the healthcare organization must offer and provide linguistically appropriate services.
C. Title VI of the 1964 Civil Rights Act states that services provided with funding from the federal government must be delivered without regard to race, color, or national origin.
To comply with Title VI, a program, service or agency must provide "meaningful access" at no cost to the LEP individual. Recipients covered by the Guidance include all public and private entities that receive federal financial assistance.
Examples of such health and social service entities are hospitals, managed care organizations, state and local welfare agencies, physicians, and research programs.
They include providers of services funded through Medicaid, Temporary Assistance for Needy Families (TANF), the State Children's Health Insurance Program (SCHIP),Head Start, and other programs for families and youth.
IV. History of Cultural Competency in nursing.
A. In the 1950s, nurse theorist Madeline Leininger started to develop the concepts of cultural competency in nursing, based on cultural care diversity and universality.
After completing her doctorate degree in anthropology, she establishedthe field of Transcultural Nursing, which is focused on comparative cultural caring, health and nursing phenomena and cultures worldwide (Leininger, 1991).
B. Leininger coined the term Transcultural. Today it is used interchangeably with cross-cultural, intercultural and multicultural or ethnic nursing.She has mentored over 200 transcultural nursing studies and today some of the nurses she has mentored are making advances in the Transcultural nursing field (Boyle, Andrews, & Carr, 2002).
The goal of Transcultural nursing is to develop a scientific and humanistic body of knowledge in order to provide culturally congruent care. Transcultural nursing blends nursing and similarities and differences in human care and caring. Transcultural nursing is not anthropology or medical anthropology.
Although Transcultural nursing studies cultural behavior patterns, thefocus is on the cultural caring phenomena and not with diseases or specificcultural practices (Leininger, 1991).
C. According to Leininger(1991), culture consists of the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guide their thinking, decisions, and actions in patterned ways.
The nurse and the client engage in decisions to: maintain or preserve,accommodate or negotiate, or repattern or restructure the client’s behaviorin congruence with his/her values, beliefs and lifeways.
Transcultural nursing theory recognizes that clients and caregivers arecultural beings and bring their own beliefs, values and lifeways to the culturalencounter, within the context of the healthcare setting.
D. The interrelationship of the three cultures, the nurse, the patient, and the setting, is complex and requires cultural sensitivity, research-based knowledge of cultural differences, and interpersonal skills in order to prevent inappropriate and unethical cultural imposition.
E. Personal experience asan ethnic minority does not confer expertise in practicing Transcultural nursing if not accompanied with a background in theory and research-based cultural knowledge.
V. Developing cultural competence: awareness, knowledge and skills.
Culturally competent attitudes, knowledge and skills are the affective,cognitive, and behavioral domains that influence the nurse’s caregiving practices. The Campinha-Bacote Model views cultural competence as a journey, with the following dimensions (ASKED):
1. A is for AWARENESS: Awareness of the impact of cultural differences on patient’s health and illness necessitates self-assessment and self-knowledge one’s own values, beliefs and practices. Caregivers need to examine their biases and preconceptions and how they potentially impact the care and treatment of clients.
Promoting mutual respect, awareness of the varying degrees of acculturation, a client-centered perspective, acceptance that beliefs may influence a patient’s response to health, illness, disease and death. (From the Seven Domains of Cultural Competence.)
2. S is for SKILLS:Culturally competent skills include the ability to conduct cultural assessmentof individual clients, groups, families, communities and institutions aswell as culturally-based physical assessment.
The nurse needs to be knowledgeable in biological variations (Mongolianspot in infants), genetic traits and disorders, such as Tay Sachs diseaseand Sickle Cell Anemia, risk factors for particular diseases and injuries(for example occupational hazards), health conditions, and variations indrug metabolism among different ethnic and cultural groups.
Culturally competent behaviors and skills include development of new behavior patterns based on cultural knowledge. For example, it includes the ability to send and receive verbal and nonverbal messages accurately and appropriately. It also requires adaptation of the environment, processes service delivery to meet the needs of diverse clients (for example, keeping longer office hoursto accommodate working women).
Providing alternatives to written communication; accomodating the physical environment to the client's needs; culturally appropriate materials, resources, and interior design; literacy sensitive magazines, brochures, audio and visual materials.
(From the Seven Domains), )
3. K is for KNOWLEDGE: The professional needs to base his/her practice on theory and research-based knowledgeof cultural differences in beliefs, traditions and other cultural dimensionssuch as communication patterns, space and time variations.
The professional healthcare provider needs to possess specific knowledge about the particular group with which he or she is working, their history and experiences (for example, political refugee or high-tech immigrant worker), lifestyle and values, (for example, New Age belief in alternative healthcare practices or expectations of high-tech care), and how these factors potentially impact the healthcare experience.
Population-based clinical practice; culturally skilled clinicians avoidmisapplication of scientific knowledge; avoiding stereotyping while appreciatingthe importance of culture; knowing one's own worldviews; learning about thechanges in demographics; understanding sociopolitical infuences; practicingintervention skills and strategies.
(From the Seven Domains)
4. E is for ENCOUNTERS: The process where the healthcare professional engages in face-to-face encounters with diverse clients in order to gain first-hand knowledge and experience, and to modify preconceptions about cultural groups. Learning about cultural differences is not a substitute for personal knowledge from experience.
Continuous, active involvement of community leaders and members; written policies and procedures and mission statements reflect engagement in the community;multicultural and multilingual staff reflecting the community.
(From the Seven Domains)
5. D is for DESIRE:According to Campinha-Bacote, "Cultural desire is the motivation of the healthcare professional to “want to” engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful and seeking cultural encounters; not the “have to.” "
The professional engages in life-learning not only for professional, but also for continued personal development.
Conclusion:
Developing cultural competence requires the integration of cultural awareness, knowledge and skills in the practice of professional nursing. Culturally competentcare requires the ability and the capacity to provide respectful and effectivepatient care.
CONGRATULATIONS! You are now ready for the exam!
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Culture Advantage is approved as a provider of continuing nursing education by the Kansas State Board of Nursing. This course is approved for 2 contact hours applicable forrelicensure for RNs, LPNs, and LMHTs.
Kansas State Board of Nursing: Provider # LT0243-1250.
FAQs.
Course requirements:
- Complete the lessons and the required readings.You should spend approximately the same number of minutes as the contact hours provided for the course.
- Provide a valid name, state of licensure and license number.
- Pass the exam. The required passing grade is 70% on the exam.
- Complete the course evaluation.
- Print, sign and date your certificate.
- Completion of the course indicates agreement to the course requirements.
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