Cultural Competency and Healthcare in Canada

Cultural Competency Health Professionals Canada

This paper discusses cultural competency for health professionals in Canada. Defining cultural competence for healthcare as respectful awareness of cultural differences, the importance of this perspective is discussed. Aspects of cultural competency, ranging from the purview of the healthcare insurance industry, to the perspective of the Canadian Nurses Association, are presented. Also, Rani Srivastava's 'Guide to Clinical Cultural Competence' is used to guide the discussion. Also, articles from scholarly journals are explored for the analysis.

Defining and classifying Cultural Competency

According to the United States National Institutes of Health (NIH, 2015), cultural competency, as applied to healthcare, 'enables providers to deliver services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients'. In another place it is defined as "a set of congruent behaviors, attitudes and policies that come together to enable a system, organization or professionals to work effectively in cross-cultural situations" (Srivastava, 2007). Using a question-and-answer format, with questions such as 'Can cultural competency make a difference?' The NIH guide explains that cultural competency is required for appropriate delivery of health care, and 'cultural competence is also critical for achieving accuracy in medical research' (NIH, 2015). The classic cautionary 'story' told to illustrate the importance of cultural competence concerns use of 'traditional and herbal medications and teas' by patients -- that may directly counteract and/or interfere with physician-prescriptions. The healthcare practitioner needs to be sensitive to, and aware of, cultural differences that might impact the patient's well-being, and be an important part of the patient/patient-family dynamic that must be considered.

Yet another perspective on cultural competence is found in The Healthcare Professionals Guide to Clinical Cultural Competence by Rani Srivastava (2007). This book can be counted among the leading works dealing with development of cultural competence with regards to a healthcare setting. Focusing on healthcare that is client-centered, this book offers an introduction to development of cultural competence. Ms. Srivastava's book begins by defining the concept of 'cultural competence' (vide infra), and from there moves into deeper levels of practical and theoretical aspects of cultural competence. Application of the concepts to clinical setting(s) and to different populations are also illustrated (Srivastava, 2007).

A stylistic comment: the Canadian and British authors in references herein use the word 'competence' where we 'Americans' would say 'competency'. They are used interchangeably throughout this work.

The Growth of Cultural Competency in Canadian Healthcare

Srivastava defines cultural competency as "The application of knowledge, attitudes, and skills that enhance cross-cultural communication and foster meaningful, respectful interactions with others." (Srivastava, 2009, p. 25).Cultural competency is an important strategy for improving quality and eliminating ethnic/racial disparities with regards to healthcare. This concept has increasingly garnered attention. In 2002, interviews were conducted with cultural competence experts from the government, academe, and managed care in Canada and globally, in order to understand their opinions pertaining to the field. Research findings were presented and current cultural competence trends were identified, with focus on healthcare practice, policy and education. The analysis shows that several stakeholders in healthcare are involved in the development of cultural competence initiatives (Betancourt et al., 2005). Still, motivations for making advances in cultural competence, as well as approaches adopted, differ based on goals, mission and spheres of influence.

Cultural competence can be seen as an important emerging strategy for addressing disparities in healthcare amongst stakeholders in academe, managed care, and government. It has caught the attention of policymakers in healthcare, healthcare providers, educators and insurers as a tactic for improving quality and eliminating ethnic/racial healthcare disparities. Cultural competence's goal is creation of a healthcare workforce and system that has the capability to deliver top-quality healthcare to all patients irrespective of culture, ethnicity, race or proficiency of language. Achieving this requires different healthcare sectors, with different approaches, leverage points and motivation to act and make progress in the field (Betancourt et al., 2005).

According to Srivastava, cultural competence is guided by "the shared and transmitted knowledge of values, beliefs, norms and life ways of a particular group of people that guides an individual or group in their thinking, decisions, and actions in patterned ways" (as cited in Srivastava, 2007, p. 14). Three practical explanations can be given for the emergence of cultural competence as a significant issue. First, as the United States (U.S.) and other countries globally, becomes more culturally diverse, healthcare practitioners will increasingly come across patients having a wide range of viewpoints with regards to health, normally shaped by their cultural or social backgrounds. For example, patients may explain the symptoms they are experiencing in a very different manner from that explained in medical texts. Their proficiency in English may be limited, and they might have different healthcare-seeking thresholds, or expectations regarding their care. Also, unfamiliar cultural perspectives may influence whether they follow providers' recommendations or not. Second, studies have depicted that communication between provider and patient is associated with patient satisfaction, adherence to medical advice, and effects on health (Betancourt et. al, 2005). Therefore, poorer outcomes in health may ensue when there is no reconciliation of socio-cultural disparities between providers and patients in clinical encounters. These barriers, ultimately, do not only apply to minorities but may only be more obvious in these instances. A landmark report from the Institute of Medicine (IOM) - Crossing the Quality Chasm- emphasizes the significance of cultural competence and patient-centered healthcare in quality improvement and elimination of ethnic/racial differences in healthcare (IOM, 2001).

Current trends in the health care field confirm these perspectives concerning cultural competence. For instance, health insurers like Aetna, Blue Cross and Blue Shield of Florida, and Kaiser Permanente have established cultural competence initiatives. Long-standing endeavors have been made by Kaiser Permanente, ranging from educational articles on cultural competence to complete "Centers of Excellence in Cultural Competence" that target specific population segments (Betancourt et al., 2005). Aetna began collecting data on ethnicity and race from its members, and devised 'culturally competent programs on disease management'. Aetna also mandated training in cultural competence for its in-house medical directors, case managers, and nurses. Florida's Blue Cross & Blue Shield has also taken on cultural competence initiatives, including in-house diversity training, as well as education in cultural competence for healthcare providers (Betancourt et al., 2005).

Furthermore, healthcare purchasing coalitions such as the National Business Group on Health have actively informed their members about ethnic/racial healthcare disparities and cultural competence. Accreditation agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA), have also been looking for opportunities to incorporate measures for tracking cultural competence and disparities (Betancourt et al., 2005). Overall, major developments have taken place in the cultural competence field ranging from healthcare insurers to healthcare purchasers, and including managed care policies. However, strong resistance still exists to investments in the field of cultural competence, because financing entities look for evidence supporting the possibility of costs savings and quality improvement. Organizations that have made investments in the field of cultural competence perceive themselves to be committed to equity, quality, and diversity issues. These organizations accept the possibility of increasing share of market by marketing these efforts.

Effect of Cultural Competency on Health Professionals in Canada

The patient population in Canada is diverse and increasingly so in recent times, requiring the professionals to be more alert to racial equality, cultural ethos and competent to discharge duties sensitively to ethnic concerns. In most of the cases that have been documented under improper treatment, there is little evidence of concerted racial discrimination or bias. The disparities arise out of common professional causes arising out of pressures of time. Such constraints cause an impulsive stereotyped response and lack of concentration causes "application error." Meaning the professionals fail to apply specific epidemiological data to the patient under consideration owing to pressures of multitasking. These are not directed cultural bias, instead a common occurrence in the harried medical profession where the physician or healthcare worker has a lapse of concentration and sensitivity to cultural consideration of the patient. (Geiger, 2001).

Health care quality suffers and disparities arise out of racial diversities. This fact is well documented. The solution to such issues is to improve the cultural competency of professionals and organizations in the field. 'Cultural Competence' is the ability of to discharge duties equitably across cultural Diasporas- interpersonal relations with patients and amongst the workers. Sensitization to cultural attributes and understanding the effect of such influences in interpersonal interaction and finding ways to attend to them is the way forward according to experts and commentators.

It has also been brought out in scholarly studies that the worst sufferers of discrimination in healthcare services are children. Minority and disadvantaged children carry most of the early childhood experiences into their adulthood and this primary aspect is reflected in their cognitive and educational outcomes as well. In addition to low income group and less privileged population, the same also applies to racial and cultural discrimination, leading to an overall negative in quality of life. (Grant, Parry, & Guerin, 2013)

Here it becomes important to define 'culture', as a proper understanding would lead to a better grasp of the skills, to counter discrimination instantiation in healthcare practices. It follows that lack of consistency of the term 'culture' leads to certain amount of confusion and hence in practices arising out of these attributes. Culture, according to one of the definitions is an integration of various characteristics of an individual or group influenced by language, practices, values, beliefs, rituals and customs and expectations founded on political, social, professional, racial, religious, ethnical and social group. The policy makers need to incorporate this thought into the framework for imbuing cultural competency. The minority groups, including those from different ethnicities and cultural backgrounds, and those with disabilities, same-sex affectations and refugee backgrounds need to be incorporated under the umbrella policy of marginalized and disadvantaged group (Rowan et al., 2013). The marginalized people should be given due care based on their history and background through clearly stated policies and legal sanction as their children are exposed to disturbing conditions (Rowan et al., 2013).

However, it is noted that in a study carried out by Hammerich (2014), there is a general lack to the policy structure and framework for in-the-making healthcare professionals to pursue cultural competency as an independent subject or even as a standalone curriculum. As such, the healthcare professionals are not equipped to treat and deal with ethnically and culturally diverse patient populations. The opinion is that students should be given the opportunity to explore these concerns while in formative years and training. Secondly, the faculty should be trained under continuing education premises to teach and deliver to ethnically diverse population with emphasis on cultural competency (Hammerich, 2014). Indeed, it is the requirement of the emerging population mix that cultural competence and safety be made an integral part of the core skills being taught to students at the institutional level in Canada (Rowan et al., 2013).

There is then, the general lament about lack of adequate funding to attend to these concerns of training in cultural safety and cultural competency. The only bright spot was that targeted attention was given to imbibe cultural ethos about Aboriginals and their linguistic and cultural influences (Rowan et al., 2013). Additionally there is also a dearth of adequate and knowledgeable faculty members and seniors who could guide the students in their pursuit of understanding the complexity arising out of cultural considerations of the marginalized populations or the visible minorities (Rowan et al., 2013).

Towards providing these attributes to healthcare professionals the Office of Minority Health has set up standards for cultural competency and due training schedules have been designed thereto. ACGME (Accreditation Council on Graduate Medical Education) requires the trainee medical professionals to be alert to cultural disparities and practice sensitivity while treating patients under their care during their training period.

In a controlled study carried out in Canada, four mental healthcare professionals were trained in cultural competency. They were rated highly in their values for empathy, professional skills, trustworthiness and equality when presented with cases brought forward from low-income group Afro-Americans. This study lasted for four hours of counseling. In yet another experiment, the professionals were taught Spanish for 20 hours and the patients' opinion was similar following the intervention. In another three-day, state sponsored drive towards improving social equality and cultural competency of the supporting staff in healthcare facilities, the emphasis was on clinical issues, team training, cultural competency and recipient recovery principles. The response of the patients upon this intervention was that the staff was humane and sensitive to their concerns. In all the trials thus conducted it became evident that cultural competence puts the patient at ease and evokes a sense of being well-looked after, though similar positive feedback about clinical outcomes is not documented explicitly. (Beach, et al., 2011).

It has been noted that the quality of healthcare service provided by an organization or a clinic is influenced by the cultural competency professed by interacting team members and professionals within the organization and those of them with the patients. The team members need to be aware of social, cultural, economic and political influence that each team member carries because of his nationality and ethnicity. Due recognition and appreciation of subtle defining characteristics play an important part in providing adequate and safe care, in the similar manner as interaction between the healthcare giver and patient does. The importance of power differential between different categories (for example: physician/nurses; nurses/physiotherapist, physiotherapist/physician) of the services sector should also be given due respect and recognition (Oelke, Thurston, & Arthur, 2013).

That brings into discussion the organizational level at which cultural competency should be introduced. The implementation should be sought at both the organizational (hospital, clinic) as well as the institutional level. As long as the organization is concerned, it should pursue the ethos of cultural tolerance and respect as a matter of corporate policy with such virtues imbued deeply by way of training and other means (seminars and workshops). Such initiatives bode well for a well managed and run organization in the healthcare sector. The virtues that need to be taught at both organizational as well as institutional levels should aim for respect of cultural diversity and practices, due consideration of patient care and other colleagues in the organization through appreciation of individual socio-cultural and political influences.

In the healthcare system, though due consideration is being given to the improvement of cultural competency of physicians, doctors, nurses and physiotherapist who are involved in the clinical services and processes, little attention has been given to others, like receptionists, managers and administrators in the organization. There is growing evidence to show that the overall cultural competency of an organization feeds on each of its member leading to an improvement in its quality of healthcare service and more satisfied patients (Oelke et al., 2013).

Effect of Cultural Competency on Patients in Canada

In recent times, especially in the last decade, there is an increasing awareness and cognizance about patient centeredness and cultural competence. These two are independent qualities in healthcare domain. They attend to different aspects of patient well-being. Patient Centeredness is about customer service- involving qualified, highest standard of measurable service benchmarks and highly individualized attention leading to better interpersonal relationship while in treatment. The overall effect of patient centeredness is to provide quality service to all patients. Cultural competency goes a step further and takes into account the race and ethnicity of the patient to provide better service with emphasis on equity in addition to quality. Cultural competency aims to remove the disparities based on patients' color, ethnicity or socio-economic status. There are obvious differences in the approaches and aims of the two attributes in healthcare, however, there are again, many common ways in which these principles are practiced or put into operation (Saha, Beach, & Cooper, 2010).

According to a Commonwealth Fund survey, 1995, 21% of the minorities face language problems in Canada. Such barriers are tantamount to satisfaction, utilization, and adherence issues. The solution obviously is to have a language interpreter intervention. Disparities arising out of limited proficiency in English (LEP) have negative outcomes of reduced visits of the physician and lack of preventive services even after taking into account factors like economic conditions, regular source of care, health insurance, and literacy. The survey indicated that patients having lower English proficiency show lesser satisfaction values compared to those with better language acumen within the same ethnicity. (Brach & Fraserirector, 2000).

Patients who speak same language that the physician does are more likely to follow the appointments and receipt of deliverance regimen than the ones who find it difficult to understand the caregiver. One survey found that in most cases language barriers have a negative outcome on adherence rates, too. However, in another survey language difficulties did not lead to dropout from appointment or adherence on the part of the patient conclusively. Since the literature show opposite outcomes when the same factors are studied for outcomes, a clear picture relating language barrier with adherence cannot be inferred. (Brach & Fraserirector, 2000).

The importance of cultural competency is accentuated when it is realized that the visible minority ( visible minority is defined as those apart from aboriginals and are non-Caucasian; the visible minority belong to no-European countries like the Filipino, Latin American, South Asian, Chinese, Arabs, Southeast Asian, Japanese and the Koreans) population is increasing the rate of over 27%. Compared to the overall growth of about 65 total population growth this is a much larger growth causing cultural competency in healthcare profession to be of vital importance given the importance Canada as a nation gives to healthcare for all its citizens equitably. The language barrier presented by the non-English speaking population influx is also a cause of concern in the medical and healthcare domain (Grant et al., 2013).

However, there are studies that clearly show that there is a lack of 'quality of communication' and rapport between the physician and the patient and that leads to misunderstood diagnoses and medication regime to be followed when the patient speaks a language different than that of the physician (Erzinger 1991; Shapiro and Saltzer 1981). The negative outcome on healthcare may be attributed to both cultural as well as linguistic problems. This inference is drawn from a study where positive outcomes were noticed when the patient and the physician, both belonged to the same ethnicity (and hence spoke the same tongue). The healthcare professionals coming from minority are less likely to show ethnic and racial discrimination -- a reason why many Canadian organizations in the healthcare industry employ them. Racial and ethnic discrimination, as an established factor in healthcare causing biased services has not been proven conclusively. There is although, a certain degree of ambivalence about it (Brach & Fraserirector, 2000).

The patients of Mi'kmaq hospital in Canada opined about differences in cultural ethos by referring to "our ways, their ways" (Baker & Daigle, 2000). Whitty-Rogers (2006) is conducting further research with the women caregivers in the hospital that will clarify the position and real concern. One possible point of conflict may be the large number of visitors to the hospital and the staff may find it difficult to allow the one from the family to visitation right. The hospital fared better with respect to satisfaction levels when they paid personalized attention and due respect to female patients and also allowed large number family members for visits. The equity to race and ethnicity like Aboriginals also helped improve the satisfaction among the patients (Birch, Ruttan, Muth, & Baydala, 2009). Indeed, as observed by The Indigenous Physicians Association of Canada and the Royal College of Physicians and Surgeons of Canada (2009), the in-training physicians and nurses along with other healthcare professionals should be taught to be alert to concerns of the Aboriginal traditions, culture and practices in order to derive safe and successful outcomes that would lead to better satisfaction values (Oelke et al., 2013).

Structure of HealthCare in Canada and Cultural Competency

Since Canada has a much-diversified population, with multitude of ethnicities and cultures cohabiting, the healthcare personnel have to realize the importance of cultural effects on the outcomes health services. The nurses are the amongst the most important cog in the healthcare services and they need to be aware of the customs and beliefs as the accent is on holistic, patient-centered and family centered care. Culture has a large influence on the individual in the way services are expected and given by patients and healthcare professionals correspondingly. The ideal situation would be one where healthcare practice gives more importance to and is influenced by the cultural ethos and linguistic abilities of the patient and his ethnicity. In practice, however, is observed that the reverse is usually dominant, notes Kleinman (1980). Ramsden (20022) also notes that the patient and supporting members' language and ethnicity are important criterion that affects the quality of healthcare services. In Canada, in most of the cases an interaction between the patient and the healthcare giver is bicultural. It ensues that the dominant culture in such interactions is that of the service provider rather than that of the recipient (in this case the patient). The physicians may come from a dominant culture or, alternatively from a less privileged one. Hence, equity and unbiased service requires that caregivers give due attention to sociopolitical and historical issues (Oelke et al., 2013). It is here that most care and sensitivity is required on the part of the nurses. Such an understanding is crucial if the right values and services are to be delivered to the patient for safe and meaningful outcomes to accrue. Canadian society is already a mixture of different ethnicities and cultures. The continued immigration rate will further change the ratio of different ethnicities, making cultural sensitivity an important issue in the health care industry where the national emphasis is on quality and satisfaction (Srivastava, n.d.).

The Canadian healthcare system is based in white, Eurocentric ethos. The main approach in healing is biomedical, which is also the conventional treatment practice in North America, amongst the many other philosophical and scientific treatment methods. The other accepted and prevalent methods of treatment include treatment methods practiced by and rooted in ethnicities like Homoeopathy, Chinese traditional medicine, Ayurvedic (Hindu, or Indian traditional medicine) and the Aboriginal medicine. All practices are different and as such the physician cannot be expected to have thorough knowledge about each therapy or practice. However, it is expected and desirable that the healthcare professional is abreast of the basics of various practices (Srivastava, 2007b). Patients are known to use multiple treatments simultaneously and the physician has to be aware (at least superficially) of the possible effects each such therapy might have as conventional medicine, herbal and folk medicines need to blend together for better outcomes. The nurses might have a defining role in providing additional support for complementary, supplementary or alternative care practice and medicine (CNO, 2009b). The general practice in healthcare in Canada is team work based and the roles and limitations of each member of the team are well demarcated. In different ethnicities or countries (where the patients might belong to), there is often, a single lead caregiver, the physician, and others are supposed to be in supportive, assisting roles (mainly regarded as helpers) (Srivastava, Srivastava, & Srivastava, 2012). Nurses may be viewed as handmaidens of physicians or social workers as merely representatives of the Government with limited authorities in such cases. Such differences in perception lead to an unviable position for the patient as he might not feel inclined to divulge important information with other team members of the healthcare facility. This could result in untoward situations for the patient himself (Srivastava, n.d.).