Cultural Competence in Nursing: Emerging

Cultural Competence in Nursing: Emerging Standards of Care

The objective of this work is to review emerging standards of care and to examine the issues of culturally competent care as the vehicle through which successful implementation of emerging standards of care will be accomplished. This work will identify the population served and issues relating to population vulnerability as well as identifying the standard used to assess areas of compliance and non-compliance. This work will further identify potential impacts on the delivery of nursing care where standards are being met and where standards are not being met.

The following terms & definitions are necessary for understanding the content and context of this report:

Acculturation: The process of adapting to another culture; to acquire the majority group's culture. (AMSA,

Cultural group: The integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group. (AMSA,

Ethnic: Belonging to a common group; often linked by race, nationality and language with a common cultural heritage and/or derivation. (AMSA,

Minority Group: Globally, non-Caucasians constitute a majority, thus the term is used to refer to a variety of groups who have been disadvantaged in one way or another. (AMSA,

Race: A socially defined population that is derived from distinguishable physical characteristics that are genetically transmitted. (AMSA,

Stereotype: The notion that all people from a given group are the same. (AMSA,

INTRODUCTION

The work of Foley and Wurmser (2004) entitled: "Culture Diversity/a Mobile Workforce Command Creative Leadership, New Partnerships, and Innovative Approaches to Integration states that today's healthcare environment "requires that nursing leaders meet the needs of a growing multicultural workforce and patient population. Cultural factors may be overlooked as healthcare delivery becomes increasingly dominated by technological, economic, and social changes. Through creative leadership, the chief nurse executive (CNE) can encourage staff to pay closer attention to cultural factors that will impact on patient, staff, and hospital outcomes. The CNE can begin by enhancing his/her own multicultural competency, building these competencies in his/her staff, and then empowering staff to respect and accommodate cultural differences." (2004) Additionally stated by Foley and Wurmser is that the nursing gaining an "understanding of transcultural nursing theory can enhance the development and maintenance of a multicultural perspective." (2004)

The American Medical Students Association work entitled: "Cultural competency in Medicine" states that approximately 50 million people in the United States are ethnically diverse." (2008) This is because the United States "attracts two thirds of the world's immigration and 85% of American immigrants come from Central and South America." (American Medical Students Association, 2008) in recent years the health industry has began to "realize the importance of cultural sensitivity." (American Medical Students Association, 2008) the AMSA states that culture is defined as "the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group." (American Medical Students Association, 2008) the AMSA defines 'cultural competency' as "a set of academic and personal skills that allow us to increase our understanding and appreciation of cultural differences between groups." (American Medical Students Association, 2008) Cultural competence involves a developmental process which is stated to be inclusive of six stages "each delineated by an attitude and associated with action or nonaction." (American Medical Students Association, 2008) Culture is stated to be a predominant force in shaping behavior, values and institutions." (American Medical Students Association, 2008) the cultural differences that exist impact the delivery of health care however; culturally competent health care professionals "appreciate family ties and realize that they are defined differently for each culture.

I. UNITED STATES DEPARTMENT of JUSTICE 'EXECUTIVE ORDER' (2000)

August 11, 2000, the United States Department of Justice - Coordination and Review Section of the White House issued an 'Executive Order', specifically Executive Order 13166 Improving Access to Services for Persons with Limited English Proficiency" which in essence states that the funds and services that are government provisioned must be made accessible to individuals who are eligible to receive these funds and services but who are not "proficient in the English language." (United States Department of Justice, 2000) Each agency was required by this Executive Order to "prepare and plan and improve access to their programs and activities by LEP persons." (United States Department of Justice, 2000)

II. GOALS of CULTURALLY COMPETENT CARE

The goals of cultural awareness include the appreciation and acceptance of differences as well as cultural knowledge which involves the deliberate seeking out of "various world views and explanatory models of disease. Required as well is cultural skill which is gained through learning how to "...culturally assess a patient to avoid relying only on written "facts;" explaining an issue from another's perspective; reducing resistance and defensiveness; and acknowledging interactive mistakes that may hinder the desire to communicate." (AMSA, 2009) Also required are cultural encounters which involve "...meeting and working with people of a different culture will help dispel stereotypes and may contradict academic knowledge. Although it is crucial to gather cultural knowledge, it is an equally important, but sometimes neglected, culturally competent skill to be humble enough to let go of the security of stereotypes and remain open to the individuality of each patient." (AMSA, 2008)

Areas of dissonance are stated to include the following areas: (1) historical distrust; (2) interpretations of disabilities; (3) concepts of family structure; (4) communication styles and views of professional roles; (5) incompatibility of explanatory models; (6) disease without illness; (7) Misunderstandings of terminology, language or body language. (AMSA, 2008)

Guidelines for practicing in a culturally competent manner include the use of an interpreter and stated is that unless one is "thoroughly effective and fluent in the target language" an interpreter should always be used" and as well one of the same sex as the client is desirable. Use of family members as interpreters is not optimal. It is of great assistance for the healthcare professional to "learn basic words and sentences in the target language; to emphasize by repetition and speak slowly, not loudly; to be patient; address the patient direct; provide instructions in LIST format and have patients repeat as understood; uses short questions and comments; use language the interpreter can easily handle avoiding abstractions, idiomatic expressions, similes and metaphors; and to plan what to say ahead of time. (AMSA, 2008)

The cultural assessment of the patient should assess: (1) the level of ethnic identity; (2) use of informal network and supportive institutions in the ethnic/cultural community values orientation; (3) language and communication process; (4) migration experience; (5) self-concept and self-esteem; (6) influence of religion/spirituality on the belief systems and behavior patterns; (7) views about the role that ethnicity plays; (8) educational level and employment experiences; (9) habits, customs, beliefs; (10) importance and impact associated with physical characteristics; (11) cultural health beliefs and practices; and (12) socioeconomic status. (AMSA, 2008)

The American College of Physicians work entitled: "Racial and Ethnic Disparities in Health Care" published in the Annals of Internal Medicine (2008) states that disparities are clearly present in the health care of racial and ethnic minorities. It is related by the American College of Physicians that cultural competence "techniques use the interpreter sciences, racially or linguistically concordant clinicians and staff, culturally competent education and training and culturally competent health education. These techniques change provider and patient behavior by improving communication, increasing trust, improving racial or ethnically specific knowledge of epidemiology and treatment efficacy, and expanding understanding of patients' cultural behaviors and environment." (AMSA, 2008)

Three health care delivery issues noted by the American College of Physicians are those as follows: (1) Health care organizations should reach out to surrounding community members and involve community representatives in planning and quality improvement initiatives; (2) managed care organizations and other large providers need to take effective steps in reducing disparities in health care; and (3) quality improvement projects should incorporate race or ethnicity and primary language measures. (AMSA, 2008)

The work of Like (nd) entitled: "Cultural Competency Training: Best and Promising Practices" states that "within-group diversity is often greater than between group diversity" and because of this there is "no cookbook approach to treating patients." (Like, nd) it is also necessary to 'avoid stereotyping and overgeneralization." (Like, nd) Stated as well is that "An assets and strengths-based perspective is important to maintain." (Like, nd) Finally, it is stated that it is critical to understand that every encounter is one of a cross-cultural nature. (Like, nd)

The work entitled: "A Manager's Guide to Cultural Competence Education for Health Care Professionals" states that "cultural and linguistic competence is a set of congruent behaviors, knowledge, attitudes and policies that come together in a system, organization or among professionals that enables effective work in cross-cultural situations." (nd) Stated as the goal of cultural competence training for health care professionals is the "mastery of specific knowledge and skills that increase their ability to provide care to diverse populations." (a Manager's Guide to Cultural Competence Education for Health Care Professionals, nd) it is additionally stated that cultural competence "should never stop - it should be an on-going, life-long education." (a Manager's Guide to Cultural Competence Education for Health Care Professionals, nd) Cultural competence is a development process as no individual "becomes culturally competent overnight or with one or two hours of training." (a Manager's Guide to Cultural Competence Education for Health Care Professionals, nd) Cultural competence training is stated to involve "attitude changes and the examining of personal biases and stereotypes as an initial step to acquiring the skills and competencies necessary for quality cross-cultural care." (a Manager's Guide to Cultural Competence Education for Health Care Professionals, nd)

The Kaiser Family Foundation (2003) states in the work entitled: "Compendium of Cultural Competence Initiatives in Health Care" that cultural competency faces challenges which include: (1) the lack of agreement on the terms, definitions and core approaches; (2) limited research on impact and effectiveness; (3) a misperception that the activities are focused exclusively on people of color, rather than also on diverse population groups that, for example, arise from religious affiliation, class, or sexual orientation; and (4) absence of a financing funding source considered sufficient to implement new initiatives. (United States Department of Justice, 2000)