Cultural Competency: The Imperatives
(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 the second course in the Cultural Competency Series.
Please read the background lecture, Cultural Competency:
The Building Blocks before you take this
course. If you are taking this course for contact hours, completion
of the Building Blocks course is required.
Imperatives for cultural competency
(Adapted
from The National Center for Cultural Competence, Goode & Doone, 2003)
Course objectives
After completion of the module, the participant will be able to explain
the following imperatives for cultural competency:
1. The changing demographics.
2. The economic imperative.
3. Meeting quality of care standards.
4. It's the law: The legal imperative.
5. Professional and ethical imperatives.
Cultural
Imperatives Exam
Course Evaluation.
________________________________________________________________
Lessons:
I. The Demographic Imperative
II. The Economic Imperative
III. The Regulatory Imperative
IV. The Legal Imperative
V. Professional and Ethical Imperatives
I. The Demographic Imperative
Cultural competence is a critical skill in today’s increasingly diverse
national and local populations.
According to the US Census Bureau estimate in 2003, the nation's
foreign-born population numbered 32.5 million, accounting for
11.5 percent of the total U.S. population.
Among the foreign-born population, 52 percent were born in Latin America,
26 percent in Asia, 14 percent in Europe and the remaining 8 percent in
other regions of the world, such as Africa and Oceania. See chart below.
Health care professionals are going to provide services to a more diverse
population in the future. It is imperative to learn about the beliefs, values,
and practices of these clients as they impact professional nursing care.
Foreign-Born People by Region of Birth: 2002
(in percent)
Source: U.S. Census Bureau, Current Population Survey, March 2002 (http://www.census.gov/Press-Release/www/2003/cb03-42.html)
According to the CDC report in 2003, nearly 1-in-5 people, or 47
million U.S. residents age 5 and older, spoke a language other than English
at home in 2000. That was an increase of 15 million people since 1990.
Among those who spoke a language other than English at home were almost
11 million additional Spanish speakers. According to the report, Spanish
speakers increased from 17.3 million in 1990 to 28.1 million in 2000, a
62
percent rise. Just over half the Spanish speakers reported speaking
English "very well."
The number of people who spoke a non-English language at home at least
doubled in six states between 1990 and 2000, with the largest percentage
increase in Nevada (193 percent). Georgia's residents who spoke a
non-English language at home increased by 164 percent, followed by North
Carolina (151 percent).
After English (215.4 million) and Spanish (28.1 million),
Chinese
(2 million) was the language most commonly spoken at home (CDC 2003).
Of the 20 non-English languages spoken most widely at home, the
largest proportional increase in the 1990s was Russian. Speakers of
this language nearly tripled from the 1990s to 2000 (CDC 2003). The second
largest increase was among French Creole speakers (including Haitian
Creoles), whose numbers more than doubled during this time period.
Culturally competent care is needed to eliminate disparities
in the health status of people of diverse racial, ethnic and cultural backgrounds
(National Center for Cultural Competence
2004; Krieger, N. et. al, 2005). The causes of health disparities
are complex and may be related to social class, language and communication
barriers, rather than ethnicity (http://www.cancer.gov/newscenter/healthdisparities).
According to the CDC, since racial and ethnic minority groups are projected
to make up an increasingly larger proportion of the population in the coming
years, the number of people affected by disparities in health care will
only increase without culturally appropriate, community-driven programs
(CDC 2003).
There are six areas that reflect health disparities according to the Department
of Health and Human Services (HHS):
Health Disparities:
Source: CDC 2005
http://www.cdc.gov/omh/AboutUs/disparities.htm
1. Infant mortality:
African-American, American Indian, and Puerto Rican infants have higher
death rates than white infants. In 2000, the black-to-white ratio in infant
mortality was 2.5 (up from 2.4 in 1998).
2. Cancer screening and management
African-American women are more than twice as likely to die of cervical
cancer than are white women and are more likely to die of breast cancer than
are women of any other racial or ethnic group.
3. Cardovascular disease (CVD)
Heart disease and stroke are the leading causes of death for all racial
and ethnic groups in the United States. In 2000, rates of death from diseases
of the heart were 29 percent higher among African-American adults than among
white adults, and death rates from stroke were 40 percent higher.
4. Diabetes
In 2000, American Indians and Alaska Natives were 2.6 times more likely
to have diagnosed diabetes compared with non-Hispanic Whites, African Americans
were 2.0 times more likely, and Hispanics were 1.9 times more likely.
5. HIV Infection/AIDS
Although African Americans and Hispanics represented only 26 percent of
the U.S. population in 2001, they accounted for 66 percent of adult AIDS cases
and 82 percent of pediatric AIDS cases reported in the first half of that
year.
6. Immunizations
In 2001, Hispanics and African Americans aged 65 and older were less likely
than Non-Hispanic whites to report having received influenza and pneumococcal
vaccines.
Causes of health disparities:
(Source: CDC: Eliminate Disparities
in Cardiovascular Disease (CVD) http://www.cdc.gov/omh/AMH/factsheets/cardio.htm)
It is recognized that these disparities occur for a variety of reasons,
including unequal access to health care, discriminations, and language and
cultural barriers.
For example, studies of specific U.S. population groups show an inverse
relationship between socioeconomic status (SES) and CVD (i.e., higher
CVD rates
with lower SES).
Links between lower SES and heart disease:
1) Patients from lower SES strata have less favorable patterns of established
major
lifestyle and biomedical risk factors (smoking, adverse diet, sedentary
lifestyle, high serum cholesterol, high blood pressure, obesity, diabetes)
compared with patients from
higher-SES strata.
2) Patients from lower SES have less favorable patterns of psychosocial
factors (hostility, depression, low social support, social isolation, racism,
job instability-
insecurity-strain- powerlessness, unemployment) compared with patients
from higher-SES strata.
Mental Health Disparities:
Another related goal is to eliminate disparities in the mental health status
of diverse racial, ethnic and cultural groups.
The mental health status of the diverse population is affected
and complicated by social, economic, political, behavioral and biological
factors (CDC 2005). Mental illness must
be understood within the social and cultural context in order to provide
quality care to the diverse populations.
Because of disparities in mental health services, a disproportionate number
of minorities with mental illnesses do not fully benefit from, or contribute
to, the opportunities and prosperity of our society. This preventable disability
from mental illness exacts a high societal toll and affects all Americans
(Surgeon General’s Report 2005).[1]
According to the Surgeon General’s Report (2005), most
minority groups are less likely than whites to use services, and they receive
poorer quality mental health care, although they have similar rates of mental
disorders.
Combined lower utilization, poorer quality care and overrepresentation among
the country’s vulnerable and high need groups such as the homeless and
incarcerated persons, these subpopulations have higher rates of mental
disorders than other groups in the community.
The major barriers include the cost of mental health care, social
stigma of mental illness, and the fragmentation of services. In addition,
health workers lack of awareness of cultural issues, bias, or inability
to speak the client’s language, and the client’s fear and mistrust of health
care authority affect the access, utilization, and outcome of services (CDC
2005).
“The ability for consumers and providers to communicate with one another
is essential for all aspects of health care, yet it carries special significance
in the area of mental health because mental disorders affect thoughts, moods,
and the highest integrative aspects of behavior. The diagnosis and treatment
of mental disorders greatly depend on verbal communication and trust between
patient and clinician" (CDC 2005). Therefore, communication and language
barriers need to be addressed in the care of diverse populations.
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[1] http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-3.html
II. The economic imperative:
According to a study led by Betancourt (2005),
cultural competence initiatives can help control healthcare costs by making
the healthcare system more efficient and effective. In addition, managed
care experts and academic experts all agree that cultural competence is driven
by both quality and business imperatives.
For example, Aetna, a leader in healthcare management plans, is developing
culturally competent disease management programs as a way to control costs
and reduce healthcare disparities.
American Journal of Managed Care (2004): "Acknowledging the unique healthcare
conditions of low-income racial and ethnic minority populations and by recruiting
and hiring primary care providers who have a commitment to treat underserved
populations, costs are reduced and patients are more satisfied with the
quality of care."
There are multiple reasons for plans to undertake improvements in cultural
and linguistic competence (Agency for Healthcare Research and Quality (2003)):
- To improve services, care, and health outcomes for current
members (improved understanding leads to better adherence and satisfaction).
- To increase market penetration by appealing to potential
culturally and linguistically diverse members.
- To enhance the cost-effectiveness of service provision.
- To reduce potential liability from medical errors and
Title VI (Civil Rights Act) violations.
One financial incentive for cultural competence could be to secure more
private business by improving the organization's performance on quality measures
of interest to private purchasers (AHRQ 2002).
Another financial incentive for healthcare organizations is reimbursement
from Medicare and Medicaid. Medicare, Medicaid, and other public purchasers
are placing increased emphasis on cultural competence and quality (AHRQ
2002).
Another business imperative is the potential market share in the diverse
population.
Providers recognize the growing diverse population as a source of market
share in the future. Recruitment and retention of a diverse staff is a priority
in order to try to mirror the diversity of the population served. The ethnic
population represents an untapped market for future services, such as in
the marketing of health services and cost-effective health care delivery
(Federal Reserve, 2001).
III. Compliance with accreditation and quality standards
Organizations and programs have multiple responsibilities to comply with
Federal, state and local regulations for the delivery of quality health
services.
The Civil Rights Act of 1964 Title VI mandate that “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” (Department
of Justice, 2000).
The Age Discrimination Act of 1975 is a national law that prohibits
discrimination on the basis of age in programs or activities receiving Federal
financial assistance. The law mandates age-appropriate services regardless
of age (Office of Civil Rights, 2001).
The Health Care Fairness Act of 1999 was passed as PL 106-525 to establish
a Center at the National Institutes of Health for addressing continuing
disparities in the burden of illness and death experienced by diverse racial,
ethnic and cultural groups Department of Health and Human Services (2000).
The Maternal and Child Health Bureau, through its program efforts related
to state accountability and Healthy People Year 2000/2010 Objectives
includes an emphasis on cultural competency as an integral component of
health service delivery.
The National Health Promotion and Disease Prevention Objectives emphasize
cultural competence as an integral component of the delivery of health and
nutrition services.
State and Federal agencies increasingly rely on private accreditation entities
to set standards and monitor compliance with these standards.
(Major source: National Center for Cultural Competence 2004)
The Joint Commission on the Accreditation of Healthcare Organizations
(2005), which accredits hospitals and other health care institutions, the
Liaison Committee on Medical Education (2005), the accrediting organization
for medical education, and the National Committee for Quality Assurance,
which accredits managed care organizations and behavioral health managed
care organizations, support standards that require cultural and linguistic
competence in health care.
IV. The legal imperative:
(Source: Office of Minority
Health 2003)
IT’s THE LAW!
As mentioned, Title VI of the Civil Rights Act
of 1964 not only ensures quality of care, it also mandates linguistic
competency. Title VI prohibits discrimination under any program or activity
receiving Federal financial assistance, which includes receiving Medicare
or Medicaid funding.
Title VI is the basis for legal obligations to provide language access accommodations
for persons who are limited in English language proficiency when they access
health care.
Executive Order 13166 clarifies the mandate for Federal agencies
to develop and implement a system to provide non-discriminatory services to
LEP patients.
The Hill Burton Hospital Survey and Construction Act of 1964 requires
providers to serve all patients living in the service areas without discrimination.
The Disadvantaged Minority Health Improvement Act of 1990 requires
all federally-funded community health centers to provide primary health
services in the language of the intended recipient.
The Emergency Medical Treatment and Active Labor Act, also known
as the Patient Anti-dumping Act, requires hospitals that participate in the
Medicare program that have emergency departments to treat all patients (including
women in labor) in an emergency without regard to their ability to pay.
Hospitals that fail to provide language assistance to persons of limited-English
proficiency are potentially liable to Federal authorities for civil penalties.
The liability of cultural ignorance could lead to injury and potential
life-threatening situations. For example, issues of informed consent may
be raised because of poor communication or language difficulties.
Research has shown that ineffective communication between physicians and
patients, not poor treatment or negligence puts most physicians at risk
of malpractice lawsuits (Leibman 2005, Physicians Insurance Exchange 1995).
Cultural and language barriers can create potential life and health threatening
situations that breach professional, ethical and legal standards.
Clients have rights to health care access, to language translation and
interpretation services, to non-discriminatory marketing and delivery of
services. Inability to speak the language and miscommunications can result
in lack of informed consent and disregard for religious, spiritual and cultural
beliefs (Randall, 2005).
V. The professional imperative:
Patient diversity
The American Nurses Association (ANA) maintains that knowledge of
cultural diversity is vital to professional nursing practice (American Nurses
Association, 2005). The ANA position statement includes recognition that
health beliefs and values are culture-bound and that both clients and care-givers
bring their cultural heritage to bear in the health care interaction.
The American Association of Colleges of Nursing recognizes the connection
between a culturally diverse workforce and the ability to provide quality
patient care (American Association of Colleges of
Nursing, 2003; Murphy, N. et al 2005).
The American Association of Critical Care and the American Holistic Nurses
Association (2004) and other professional organizations endorse the
need for culturally competent practice as integral to providing holistic
care (Covington, L. (2001) Honor Society of Nursing,
2005).
Cultural competency is recognized as a standard for quality and ethical
care by the Canadian Nurses Association (CAN) (2004). CNA’s Code
of Ethics for Registered Nurses provides clear guidance about how nurses
carry out professional responsibilities with respect to culture.
“CNA believes that to provide the best possible patient outcomes, nurses
must provide culturally competent care.
CNA believes the responsibility of supporting culturally competent care
is shared between individuals, professional associations, regulatory bodies,
health services delivery and accreditation organizations, educational institutions
and governments.” CAN 2004.
According to the CNA, the individual nurse is responsible for acquiring,
maintaining, and continually enhancing cultural competencies in patient
care. The nurse is responsible for incorporating culture into all phases
of the nursing process and in all domains of nursing practice.
In Canada, culture is considered to be one of the 12 key determinants of
health. According to the CAN, understanding and providing culturally competent
care will make a difference to the health outcomes of many cultural groups
including Canada’s aboriginal population (CAN 2004).
Aboriginals, primarily North American Indian, Métis and Inuit, comprise
4.4 per cent of the population in Canada and have higher rates of infant mortality,
chronic disease and suicide than other Canadians (CAN 2004).
In Australia, cultural and linguistically appropriate standards
are being developed to address the needs and health care disparities of
diverse populations.
Acording to the latest study funded by the Australian Department of Services:
“The primary goal of culturally safe and culturally competent care is to
ensure the provision of safe and quality care to people from diverse racial,
ethno-cultural and language backgrounds and to eliminate the disparities
in health and health care..."(Johnston, J., Kanitsaki,
O. (2005). Cultural Safety and Cultural Competence in Health Care and Nursing:
An Australian Study. Page 10.)
Workforce diversity
Clients and caregivers are cultural beings who bring their
own beliefs, values and lifeways to the encounter (Leininger 1991). The
interrelationship of the three cultures: the nurse, the patient, and the
organizational setting, is complex and requires cultural sensitivity, research-based
knowledge of cultural differences, and interpersonal skills.
Cultural value differences between staff and patients, between staff and
other team members, and between staff and organizational policies impact
the efficiency and effectiveness of health care organizations.
The Department of Health and Human Services Culturally and Linguistically
Appropriate Services (CLAS) standards recommend the recruitment, retention
and promotion of a diverse staff and leadership at all levels of the organization
(CLAS standard # 2).
With an expected nurse shortage of 800,000 and physicians shortage of 200,000
by 2020, U.S. hospitals are increasingly looking abroad to resolve staffing
needs. Currently 22 percent of physicians and 12 percent of nurses in the
United States are foreign born. (AcademyHealth.org 2005).
Cultural differences between health care professionals and
patients, and between healthcare workers themselves within the organization,
can cause potential conflict in the workplace and can create barriers in
providing quality care. Ongoing education and training in cultural competency
is imperative to ensure effective and consistent care of all clients.
“Health care organizations should ensure that staff at all levels and
across all disciplines receive ongoing education and training in culturally
and linguistically appropriate service delivery” (CLAS
standard #3). (Source: DHHS 2000.)
VI. The Ethical Imperative
The enjoyment of health is the realization of every person’s fundamental
human rights (Randall 1999, 2005; United Nations Department
of Public Information, 2005; Global Lawyers and Physicians, 2005).
Ethics is viewed as a systematic way of examining the
moral life to discern right and wrong; it also requires a decision or action
based on moral reasoning. Ethical conflicts occur when a person, group or
society is uncertain about what to do when faced with competing moral choices.(1)
The International Council of Nurses Code of Ethics for Nurses (2005)
states:(2)
“Inherent in nursing is respect for human rights, including cultural rights,
the right to life and choice, to dignity and to be treated with respect.
Nursing care is respectful of and unrestricted by considerations of age,
colour, creed, culture, disability or illness, gender, sexual orientation,
nationality, politics, race or social status.”
According to the American Nurses Association, health care ethics is
concerned with the rights, responsibilities, and obligations of health care
professionals, institutions of care, and clients. Upon entering the profession
of nursing, nurses accept the responsibilities and trust that have accrued
to nursing over the years and also the obligation to adhere to the professions's
code for ethics.
The Code for Nurses, published by the American Nurses Association, is the
standard by which ethical conduct is guided and evaluated by the profession.
“Ethnocentric approaches to nursing practice are ineffective in meeting
health and nursing needs of diverse cultural groups of clients. Knowledge
about cultures and their impact on interactions with health care is essential
for nurses, whether they are practicing in a clinical setting, education,
research or administration…” (3)
The nursing profession should be guided by the following principles (ANA
Code for Nurses):
1. Human beings deserve respect as ends in themselves, and therefore,
deserve nursing services that are equitable in terms of accessibility, availability,
affordability and quality;
2. Justice requires that the differences among persons and groups are
to be valued. When those differences contribute to the unequal distribution
of the quality of nursing and health care, then remedial actions are obligated
(Philosophical, 1981).
3. The principle of justice applies to nurses as providers as well as to
nurses as recipients of care. ANA is committed to addressing the need for
racial and ethnic diversity among nurses. Such diversity is a critical element
in providing fair and equitable care.
4. Because nursing care is an essential but sometimes limited commodity,
allocation of care is a pressing issue that cannot be effectively addressed
when specific individuals are excluded or when the burdens of limited access
are borne by particular groups.
Madeleine Leininger, nurse theorist, asserts that it
is a human right for every patient to have his or her cultural beliefs,
values, and practices respected and incorporated in patient care The nurse,
as patient advocate, must “protect clients of diverse cultures from negligent,
offensive, harmful, unethical, non-therapeutic or inappropriate care practices”
(Leininger, 2005).
Cultures have similarities and differences in their values
and beliefs that guide their decision-making or moral reasoning. For example,
the cultural values in the United States are based on the values of individualism
and self-sufficiency (Hofstede 2001).
Most non-Western cultural values are based on collectivism, or the good
of the family, group or community, instead of individual rights. In these
cultures, decisions are made by the group/family as a collective, and not
by the affected individual alone.
Ethical conflicts can occur when the healthcare system
imposes the prevailing mores of the culture in ways that violate the client
and family's rights to their cultural values and beliefs.
Communication is very important in the understanding
of differences between cultural values. "Lack of communication is more likely
to occur when nurses care for international and culturally diverse persons.
The resultant misunderstandings can lead to lack of respect for persons
whose cultural values are different from one’s own and to potential and
real harm to those persons, whether culturally, psychologically, physically,
or spiritually." (4)
Here are some recommendations to reduce misunderstandings and help
resolve some potential ethical conflicts between clients and care-providers
(Ludwick and Silva, 2000)(http://www.nursingworld.org/ojin/ethicol/ethics_4.htm
(4):
1. The first step is recognizing and being aware of your own cultural
values and biases. This is a major step to decreasing ethnocentrism
and cultural imposition.
2. Recognize that there are differences in values and beliefs not only
among different cultures but also within cultures.
3. View values and beliefs from different cultures within historical, health
care, cultural, spiritual, and religious contexts.
4. Take the opportunity to learn as much as you can about the language,
customs, beliefs and values of cultural groups, especially those which you
have the most contact.
5. Understand the nonverbal communications of your own and various cultures
such as personal space preferences, body language, and style of hair and
clothing, etc.
6. Be aware of biocultural differences manifested in the physical exam,
in types of illness, in response to drugs, and in health care practices.
Culturally competent care is the integration of knowledge, attitudes, and
skills that respect basic human rights in the care of individuals, families,
and communities.
Evidence-based findings point to the importance of the health care provider's cultural and linguistic competence in providing quality health care services. Cultural competence can improve the safety and quality of services provided to a culturally diverse population regardless of their race or ethnicity. Nurses and other health care professionals are ethically and professionally bound to evidence-based culturally competent practice.
_ _ _ _ _ _
REFERENCES
(1) Ludwick, R. & Silva, M. (2000). NURSING AROUND THE WORLD: Cultural
Values and Ethical Conflicts. Nursing World Online. Accessed: March 3, 20006.
http://www.nursingworld.org/ojin/ethicol/ethics_4.htm
(2)International Council of Nurses (2005). The ICN Code of Ethics for Nurses.
Accessed: March 3, 2006. http://www.icn.ch/icncode.pdf Geneva, 2005)
(3) ANA Nursing World (2006). Ethics and Human Rights. Effective Date:
September 5, 1991. Accesssed:
March 3, 2006. http://www.nursingworld.org/readroom/position/ethics/etethr.htm
(4) Ludwich and Silva (2000).
REFERENCES
for the Cultural Competency Series.
____________________________________________________________
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Faculty and other accreditation:
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.
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