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Special Feature

Culturally Competent Care

Using the ESFT Model in Nursing

Beard, Kenya V. EdD, GNP-BC, NP-C, ACNP-BC, CNE; Gwanmesia, Eunice MSN, MSHCA, RN; Miranda-Diaz, Gina DNP, MS, MPH, RN

Author Information
AJN, American Journal of Nursing: June 2015 - Volume 115 - Issue 6 - p 58-62
doi: 10.1097/01.NAJ.0000466326.99804.c4
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Despite efforts to improve the health of all people, disparities in health care continue to be widespread in the United States. The Centers for Medicare and Medicaid Services defines the term health care disparities as differences between two or more groups in regard to access to care, care coverage, and quality of care; the term health disparities refers to differences between groups in terms of indicators such as health status and disease prevalence. According to the 2011 National Healthcare Disparities Report from the Agency for Healthcare Research and Quality (AHRQ), two major, overarching factors contributing to health care disparities are differences in access to and quality of care.1 Both factors are closely linked to an individual's socioeconomic status and race. However, even after differences in income and in access to health care and health insurance are controlled for, racial and ethnic minorities still experience a lower quality of health care services.2

The U.S. Department of Health and Human Services (HHS) Healthy People 2020 agenda includes achieving health equity and eliminating health care disparities as one of its four central goals. The initiative's Web site ( defines health equity as “the attainment of the highest level of health for all people” and adds that, to achieve health equity, societal efforts to explore ways to eliminate health care disparities are needed. The 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities also emphasizes the need to step up efforts to resolve health disparities.3

There has been a growing understanding that efforts to eliminate health and health care disparities must take into consideration social determinants of health, which include factors such as where an individual was born and where she or he currently works and lives. The HHS action plan emphasizes as well the importance of taking into account additional influences on health, such as literacy and access to culturally sensitive health care providers.

The purpose of this article is to strengthen nurses’ awareness of how they can reduce health care disparities through effective communication and culturally competent care. The ESFT model, which was developed by Betancourt and colleagues in 1999 and widely used since,4 is presented as a tool to facilitate culturally responsive care and enhance cross-cultural communication between the nurse and the patient. Using the ESFT model in nursing could strengthen nurse–patient communication and lead to reduced health care disparities.


Gaining access to health care has not always been easy for people who are poor or who come from ethnically and racially diverse groups (blacks, Asians, American Indians, Alaska Natives, and Hispanics/Latinos). Racial and ethnic minorities typically experience more barriers to care than whites, and individuals who are poor tend to have worse access to care than those with high incomes.1

Although minorities and people who are economically disadvantaged are more likely to encounter barriers to access, removing access-related variables does not always result in health care equity. This has been partly attributed to the suboptimal quality of health care that some groups receive. The AHRQ 2013 National Healthcare Disparities Report reviewed various quality measures. Here are some of its conclusions5:

  • Blacks and Hispanics received worse care than whites for about 40% of quality measures.
  • American Indians and Alaska Natives received worse care than whites for about one-third of quality measures.
  • Poor people received worse care than high-income people for about 60% of quality measures.

The report noted as well that the quality of care an individual receives is influenced by place of residence, language spoken, and the ability of local organizations to support culturally competent services. In addition, the report reinforced the point that patient–provider communication contributes to health care disparities.


Cultural competence has been described as an integral element in a strategy focused on improving health care quality and eliminating racial and ethnic disparities.6-8 The Office of Minority Health, a division of HHS, lists 15 standards for culturally and linguistically appropriate services (CLAS) in health and health care to improve quality and promote health equity.9 The CLAS standards provide a framework to guide health care providers in delivering care in a way that respects the values and cultural health beliefs of individuals. For example, standard number four emphasizes that providers across disciplines and at every level of an organization should be educated on culturally responsive practices. (The full list of CLAS standards can be found on the Office of Minority Health Web site:

With the increase in globalization as well as in ethnically and racially diverse populations in the United States, there is a greater need for nurses to be culturally competent and to communicate effectively with diverse populations. However, cultural competence is sometimes misunderstood by nurses, and incongruities in perspectives, beliefs, and practices may preclude effective communication. A small qualitative study by Reeves and Fogg found that half of a group of recent nursing graduates did not feel that they were adequately prepared to provide culturally competent care and were unsure about how to best provide care to patients with diverse backgrounds.10

What is cultural competence? Cultural competence has been defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.”11 In nursing, several theories and models have been used to explain cultural competence and facilitate its delivery. Madeleine Leininger defined culture as the “learned, shared, and transmitted knowledge of values, beliefs, norms, and lifeways of a particular group.”12 She added that values and beliefs are passed on from generation to generation and influence thinking and decision making.13

Leininger's theory reminds health care professionals to recognize individual and group differences and similarities and to individualize care based on the different cultural needs of the patients. Her theory also provides a framework for decision making regarding patient care. This conceptual framework is illustrated in her Sunrise model, which specifies areas such as religion, cultural values, and politics that need to be taken into account when providing culturally competent care.14

The theory of Josepha Campinha-Bacote, who followed Leininger, states that cultural competence depends on seeking out and experiencing many cultural encounters.15 She adds that cultural competence is an ongoing process in which health care providers should continuously strive to achieve the ability to work with a diverse population of individuals or families, or within a diverse community.16

Nurses should be aware that a person's cultural beliefs and social determinants influence how that person communicates and understands information once she or he is a patient. Effective health care considers and adapts to the perspectives and circumstances of culturally diverse populations. But such an approach is not consistently demonstrated in practice settings, and assumptions made about patients can lead to poor outcomes. For example, because it is customary for a nurse to review discharge medications with a patient prior to discharge, and patients are typically asked to sign a form confirming that they understand the purpose of their medications and their questions have been answered, nurses may assume that patients have a home to go to and a caregiver who can and will get the prescription filled, and that they will take the medications as prescribed. These assumptions, if not validated, could contribute to disparities and jeopardize outcomes.

Ensuring that patients can obtain and safely administer their medications is a nursing priority. However, it's equally important to understand how patients’ cultural beliefs and socioeconomic circumstances influence their health practices and affect how they prioritize their needs. Nurses who are aware of and ready to discuss their patient's beliefs, values, and practical circumstances are better positioned to provide culturally responsive care and improve communication.


Promoting effective patient–provider communication is a national priority.1 Tools that help nurses consider linguistic barriers and communicate more effectively in cross-cultural encounters are needed. Different communication models have been put forward to help strengthen cultural competence and improve the way that health professionals communicate with diverse patients. For example, the ESFT model, developed by Betancourt and colleagues, is a cross-cultural communication tool that helps to identify barriers to compliance and strengthen patient–provider communication.4


The ESFT model uses the ESFT mnemonic (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, Therapeutic contracting) to engage patients in culturally responsive conversations and uncover potential threats to treatment adherence (see The ESFT Model). Health care providers have used this model to improve health care outcomes and address health disparities. Betancourt and colleagues have argued that the ESFT model helps clinicians identify barriers to adherence in patients and recognize culturally appropriate strategies that could help improve outcomes.17 Several organizations have recommended using the ESFT model, including the California Endowment, the Health Resources and Services Administration, and the Association of American Medical Colleges. HHS has included the ESFT model in its tool kit to help improve communication during cross-cultural patient encounters and recommends the use of this model on its Web site. Because the ESFT model, originally intended for physicians, has not been widely studied, nurses may want to consider pilot projects to test the effectiveness of this tool for strengthening the delivery of culturally competent care and enhancing cross-cultural communication. In this way, nurses can create a body of evidence that supports its use. The following are the elements of the ESFT model.

Explanatory model of health and illness. Often, when nurses educate patients on diseases, the primary goal is to teach them how to manage their disease. Communication is often unidirectional; therefore, it's often less patient centered. According to Betancourt and colleagues, patients should be given an opportunity to explain and conceptualize their disease.4 The explanatory element of the ESFT model can help in achieving this goal. For example, nurses can ask patients who have diabetes what they call the problem, what they think contributed to its development, and what type of treatment they believe will help them manage their illness. These questions help nurses recognize what their disease means to patients, and they let the patients know that their beliefs are valued and respected.

Social and environmental factors. Nurses should consider how social and environmental factors influence treatment adherence, while keeping in mind that cultural beliefs regarding medications can also affect drug adherence. An environmental issue might arise because not all patients have access to a pharmacy or can afford a prescribed medication. Asking a patient how she or he plans to obtain a medication is therefore crucial. An example of a cultural factor is when some individuals put off taking a medication until they receive approval from someone whose opinion they value. Nurses should seek to understand how patients view taking prescription drugs and who helps them in the decision-making process.

Fears and concerns should also be discussed during nurse–patient encounters. For example, medications often have adverse effects. Besides the typical medication-related nausea, some medications can lead to hair loss or changes in libido. Adverse effects that are acceptable to one person can be quite disturbing to another, who might decide not to take the medication as a result. Since not all patients will readily discuss their concerns about medications, nurses should be prepared to engage them in a conversation that addresses this issue.

Patients can also be fearful of getting too much or too little medication and might not take the medication as prescribed. In addition, fears may stem from statements in advertisements or television commercials about the increased risk of cancer or death associated with some medications. Discussing patients’ associated fears may help avert treatment nonadherence. Once any barriers to adherence are identified, they should be communicated to the prescriber.

Therapeutic contracting is the element of the ESFT model that nurses are probably most familiar with. The ethical principle of patient autonomy is emphasized in nursing school, and nurses are expected to ensure that patients are prepared to make informed decisions. During the decision-making process, patients should be allowed to use their values to guide their decision making. When discharging a patient, nurses should discuss how the patient plans to manage her or his condition. According to the American Association of Colleges of Nursing, nurses should respect patients’ preferences, values, and needs and allow them to act as full partners in coordinating their care.18 Engaging patients in a therapeutic contract helps fulfill an essential component of patient-centered care.


Access to care and quality of care are two overarching contributors to health care disparities. But even when access-related factors are removed, health care disparities continue for some racial and ethnic groups. Some groups do not experience the same gains as other groups from advances in health care knowledge and delivery. While health care disparities have multiple causes, poor provider–patient communication and inconsistency in providing culturally competent care are among the most important ongoing challenges.

While cultural competence can be viewed as a mechanism for addressing health disparities, nurses should be aware that it's a process rather than a static state that one achieves. Nurses should seek opportunities to strengthen their level of cultural competence and implement evidence-based strategies that help promote an equitable delivery of care and assuage health care disparities.

Care that is culturally responsive will continue to help nurses improve patient outcomes. The Office of Minority Health has emphasized that providing culturally competent care allows for a sense of trust between patients and health care providers, encouraging patients to discuss their values and beliefs as well as their concerns. In addition, patients who receive culturally competent care are more likely to feel accepted and empowered and to adhere to their treatment regimen.

A culturally competent health professional recognizes that every patient is unique and deserves to be treated with respect. With every encounter, nurses should

  • consider the patient's values, beliefs, preferences, and needs.
  • cultivate awareness of their own personal biases.
  • include patients in the planning of their care.

To these ends, it is vital that nurses adopt easy-to-use, evidence-based models that will enable them to communicate with patients more effectively and remind them to consider patients’ values and beliefs. Using the ESFT model during cross-cultural encounters can provide a valuable framework for responding in a culturally responsive manner.

While the ESFT model is not a panacea for health care disparities and may not totally eliminate gaps in the quality of care experienced by some disadvantaged health care consumers, it is a tool that can help strengthen communication between the nurse and the patient and lead to better health outcomes. Nurses should consider adopting the ESFT model and studying its effects on patient outcomes and health care disparities.


1. Agency for Healthcare Research and Quality. 2011 National healthcare disparities report. Rockville, MD; 2012 Mar. AHRQ Publication No. 12-0006.
2. Smedley BD, et al., eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
3. U.S. Department of Health and Human Services. HHS action plan to reduce racial and ethnic health disparities: a nation free of disparities in health and health care. Washington, DC; 2011 Apr.
4. Betancourt JR, et al. Hypertension in multicultural and minority populations: linking communication to compliance Curr Hypertens Rep. 1999;1(6):482–8
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cross-cultural communication; cultural competence; ESFT model; health care disparities; health disparities; medication adherence

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