Because of the nation's increasing diversity, support for cultural competency has come from every direction within and outside of healthcare. Nursing organizations' position papers and policy statements clearly state their commitment to strengthening cultural competency among nurses.1–3 But what exactly is culturally competent care, and how can you use it to lessen healthcare disparities among your patients?
Cultural competency can be defined as having specific cognitive and affective skills that are essential for building culturally relevant relationships between providers and patients.4 Obtaining cultural competency is an ongoing, lifetime process, not an endpoint.5 Becoming culturally competent requires continuous self-evaluation, skill development, and knowledge building about culturally diverse groups.
It's important to understand your motivation, purpose, and goals for becoming culturally competent. Important questions to ask yourself include:
- What does being culturally competent mean to me and the patients I serve?
- Which cultural competency model and/or assessment tool is most useful to me, given my patient population?
- As I gain cultural knowledge and skills, how can I use that knowledge to improve my patients' healthcare outcomes and assist in reducing healthcare disparities for underserved populations?
Accreditation bodies for hospitals, other healthcare facilities, and schools of nursing emphasize the need for practicing nurses and students to develop skills in cultural competency.4,6 Within healthcare, several agencies provide clear guidelines for providing culturally sensitive nursing care to patients.7 For example, the Department of Health and Human Services, Office of Minority Health developed 14 standards for providing Culturally and Linguistically Appropriate Services.8 These guidelines direct nurses and other healthcare providers in their provision of culturally linguistic care.
Healthcare disparities are inequalities in healthcare access, quality, and/or outcomes between groups. In the United States, these inequalities may be due to differences in care-seeking behaviors, cultural beliefs, health practices, linguistic barriers, degree of trust in healthcare providers, geographical access to care, insurance status, or ability to pay.9–11 Factors influencing these disparities include education, housing, nutrition, biological factors, economics, and sociopolitical power.12
For example, children from poor families are over 28% more likely than children from high-income families to experience poor communication with their healthcare providers. Hispanics have a rate of AIDS more than 3.5 times higher than that of non-Hispanic Whites. Black children have the greatest proportion of hospitalizations for asthma. Asian adults are 50% more likely than Whites to lack immunization against pneumonia. Blacks and persons of lower socioeconomic status have higher rates of death from cancer.9
As the largest body of healthcare providers, nurses are at the front lines of confronting these healthcare disparities. Yet some nurses seem unwilling or unable to respond.13,14 Becoming culturally competent and reducing healthcare disparities aren't easy.
Models may muddle
Several models of cultural competency exist.5,15–17 In a model called The Process of Cultural Competence in the Delivery of Healthcare Services, by Campinha-Bacote, nurses are directed to ask themselves questions based on the five constructs—awareness, skill, knowledge, encounters, and desire (ASKED)—to determine their own cultural competency.5 According to this model, nurses need an awareness of their own cultural biases and prejudices, cultural knowledge, and assessment and communication skills. Nurses also need to be motivated to have encounters with culturally diverse groups. In its most recent form, this model suggests that these encounters are the pivotal key constructs in the process of developing cultural competency.5
Another assessment model, The Purnell Model for Cultural Competence, depicts a circle with several rims illustrating a global society, the community, a family, and the person.16 A pie-shaped interior is divided into 12 sections representing 12 cultural domains and their related concepts. Nurses may use these domains as a framework for their cultural assessment of patients.
The Giger and Davidhizar Transcultural Assessment Model identifies six cultural phenomena nurses and other healthcare providers assess in their patients: biological variations, environmental control, time, social organization, space, and communication.17
Spector's Health Traditions Model reflects a continuum of cultural behavior patterns ranging from one that's traditional to patterns that reflect acculturation. Acculturation refers to an individual's efforts to adopt or modify his or her own culture as he or she contacts with and integrates into another culture.18 Staff should select a model that best fits your specific work setting and patient population.
Although many cultural competency models are available, using them can be problematic. Some may provide narrow definitions of culture, with an overemphasis on race and ethnicity. The lack of a universally accepted definition for cultural competency and a lack of evidence to support the use of a particular model are other barriers.4,6,13,14 These problems are distractions that can deter you from envisioning a clear path toward cultural competence.
Discussions about culture in healthcare often focus on race and ethnicity.6,13 Taking this approach excludes other factors (biological, psychological, religious, economical, political) that are all aspects of one's cultural experience. When race and ethnicity are overemphasized in conversations about healthcare disparities, the results can be polarizing because nursing remains a White, female-dominated profession. Also, emphasis on racial difference over other equally important differences sets up an “us versus them” dynamic between nurses that may lead to some minority nurses' disengagement from these initiatives.14
By virtue of their minority status, some nurses of color may believe that they already have diversity experience and that becoming culturally competent refers to nurses in the majority becoming more sensitive to issues impacting minorities. Every nurse, regardless of race or ethnicity, should engage in the ongoing process of developing cultural and linguistic skills when caring for individuals who are culturally different from themselves.
Both race and ethnicity are inextricably linked to socioeconomic status. Studies show that health is largely influenced by socioeconomic factors.12,18 For example, in the United States in 2010, over 27% of Blacks and 26% of Hispanics were poor compared with 12% of Asians and nearly 10% of non-Hispanic Whites.19 Of those who were uninsured, Hispanics represented 14% of the population but over 30% of the uninsured. Many of the uninsured are Hispanic noncitizens.20
Make sure you understand the role that factors such as poverty, homelessness, unemployment, immigration status, and lack of social support play in determining access and quality of healthcare for your patients, irrespective of race and ethnicity. Avoid stereotyping, which can distract from the most important aspects of care—developing a rapport and getting to know and understand the patients you serve.6 Although cultural competency models are important, they can't substitute for good interpersonal and patient-centered communication that lets you establish a trusting relationship with your patients.21,22
Taking it all in
You can gain helpful information by performing a cultural assessment and using a broad definition of culture that reflects the differences in healthcare besides race and ethnicity. These definitions include age, gender, disability, sexual orientation, immigration status, employment status, socioeconomic status, culture, and religion.
To avoid stereotyping, keep in mind that individuals within a particular group can vary in many respects. For example, among older adults, certain characteristics may be typical but some older adults may demonstrate attributes that differ from the group.14 Many believe that all older people resist the use of modern technology; however, many people who are elderly enjoy using smartphones, tablets, electronic readers, and other devices. These intracultural differences are important to consider; having group knowledge never justifies predicting behaviors of any individual members. As part of a cultural assessment, determine the specific values, beliefs, attitudes, and health needs of each patient. See Performing a cultural assessment for an example using the Giger and Davidhizar Transcultural Assessment Model.
In the United States, the healthcare system is a cultural entity with its own norms and values. Yet nurses may overlook a facility's institutional culture when they consider the impact culture has on patients' healthcare access and outcomes.6 Both organizational and hospital unit culture play a role in determining the quality of care a patient receives. For example, language barriers may be a major issue in a healthcare facility where the medical and nursing staff is homogeneous, reflecting a predominately White, middle-class workforce but the hospital serves a largely Hispanic community. This situation requires the hospital to offer staff development in Spanish for healthcare personnel, as well as provide medically trained interpreters and medical literature and documents in the patients' language.
Staff should weigh all of these aspects of culture when caring for your patients. Cultural differences may exist between the patient and the nurse, the nurse and other nurses or healthcare providers, and the patient and the healthcare institution.6 When you can determine what interpersonal or institutional barriers exist within a particular institution, clinic, or community setting, you're better able to assist your patients in overcoming them to achieve better healthcare outcomes. For example, in the author's experience, one urban hospital recognized a problem faced by patients who were poor having difficulty traveling a distance from their homes to make their clinic visits. A program was established to assist indigent patients with transportation to and from visits. This effort by the hospital addressed a major healthcare disparity, that of access to medical care for patients who are poor.
Goals of cultural competency
How do you know whether you're providing culturally competent care? Some believe that they've reached the goal of cultural competency as they gain new knowledge or skills, or have encounters with culturally diverse groups. But achieving the goal of becoming culturally competent should always be linked to patient-care outcomes.
To provide care that's culturally specific, emphasize nurse-patient communication, patient education, and patient satisfaction. After each encounter, staff should assess the effectiveness of their communication with the patient by asking:
- Did the patient demonstrate an understanding of what I was trying to convey or teach?
- Was the patient satisfied with the care he or she received?
- What can I do to improve the quality of care I deliver to members of this group?
Patient-care outcomes can be measured and documented as evidence of your effectiveness as a culturally competent caregiver. Gaining cultural competence, or achieving some level of it, can also be a means to the larger goal of reducing healthcare disparities.
Evidence shows that having cultural competency skills promotes better nurse-patient communication.4 New cultural partnerships that emerge between patients and nurses enhance patients' and caregivers' understanding of the patients' disease process and treatment needs. When nurses collaborate with patients about the kind of care they desire, patients are more likely to adhere to treatment protocols.
As the largest group of healthcare providers, nurses in all areas and levels of nursing have a significant role to play in performing cultural assessments and delivering culturally and linguistically appropriate care. Nurse educators have an obligation to prepare new nurses in developing culturally competent skills that address the healthcare disparities that exist.
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2. National League for Nursing. Patient Protection and Affordable Care Act & Healthcare and Educational Reconciliation Act. http://www.nln.org/governmentaffairs/pdf/nln_analysis_final_hcr_bills.pdf
3. U.S. Department of Health and Human Services. Transforming the face of health professions through cultural and linguistic competence education: the role of HRSA Centers of Excellence. http://www.hrsa.gov/culturalcompetence/cultcompedu.pdf
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19. U.S. Bureau of the Census. Income, poverty, and health insurance coverage in the United States. http://www.census.gov/prod/2011pubs/p60–239.pdf
20. U.S. Department of Health and Human Services. Overview of the uninsured in the United States: a summary of the 2011 current population survey. http://aspe.hhs.gov/health/reports/2011/CPSHealthIns2011/ib.pdf
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