Culturally Competent Care is Patient Centered Care · Organizational Assessment: Why Culturally Competent Care • Reduces care disparities in the patient population • Increases

Culturally Competent Care

is Patient Centered Care

Larry D. Purnell PhD, RN, FAAN

Larry D. Purnell PhD, RN, FAAN

Professor Emeritus

University of Delaware

Newark, DE

Faculty

Learning Objectives

1. Assess whether or not culturally competent care

is being delivered in your organization

2. Recognize and understand the cultural and

clinical dynamics that impact patient encounters in

your organization

3. Analyze demographic data and propose

standards for delivering culturally competent care to

cancer patients and caregivers in your organization

4. Identify key components of staff education

programs in cultural competence

Introduction

• Cultural competence in health care describes the ability to

provide care to patients with diverse values, beliefs and

behaviors, including tailoring health and nursing care delivery to

meet patients’ social, cultural, and linguistic needs

• Cultural competence training does not guarantee cultural

competence: Only provides the knowledge, skills, and abilities

to become culturally competent.

• Currently no tool that measures staff cultural competence.

Would need to do initial and ongoing observation of caregivers

assessment and find evidence in the medical record.

Purnell (2016)

Organizational Assessment: Why Culturally Competent Care

• Increases trust

• Increases community participation and involvement in

health issues

• Assists patients and families in their care

• Promotes patient and family responsibilities for health

• Improves patient data collection

• Increases preventive care by patients

American Hospital Association

Organizational Assessment: Why Culturally Competent Care

• Reduces care disparities in the patient population

• Increases cost savings from a reduction in medical errors,

number of treatments, and legal costs

• Reduces the number of missed medical visits

• Improves health outcomes, increases respect, and

increases participation from the local community

• Organizations that are culturally competent may have lower

costs and fewer care disparities

American Hospital Association

Organization’s Responsibility

• Mission and philosophy reflects respect and values related

to diversity and inclusivity

• Need a managerial taskforce to oversee diversity and

cultural competence

• Provide staff with adequate resources to deliver culturally

competent care

• Include cultural competence in job descriptions

• Translation should be that of the local TV/radio stations

Lewin Group, 2002


• Signage is in different languages

• Pictures and décor consistent with ethnicity of the client

population

• Toys reflective of ethnicity: Dolls for example

• Organization conducts fairs: distributes literature, and

conducts health screenings

• Partner with hospice and palliative care


• Seeks advice from individuals and groups in the

communities they serve: can help healthcare systems to

develop educational materials, increase patient access to

services, and improve health literacy.

• Board of Trustees should have members who are

representatives of the community.

• Satisfaction surveys in different languages: Back translate

by at least one native speaker of the language.

Cultural and Clinical Dynamics

• Recognize we all possess biases and stereotypes, some of

which we may not be fully aware

• Patient has the right to know their condition and the right

not to know - beneficence is seen differently

• Becoming culturally competent involves developing and

acquiring the skills needed to identify and assist patients

from diverse cultures.

• Starts with critical reflection – cultural self-awareness


• Do staff make derogatory comments, slurs, about certain

ethnicities or vulnerable populations, includes LGBT.

Establish a no tolerance policy.

• Are we open to different approaches to the same problem?

Accepting of complementary and alternative medicine?

• Be aware of and accepting of cultural differences – but not

illegal ones such as female circumcision.

• Power dynamics: power is bestowed upon us by our titles,

white coats, education, etc.


• If we believe in a particular treatment for a patient and the

patient does not agree based on cultural differences,

because of our power we may not respect and work with

that difference

• Sometimes we “work” the patient to fit into what we think is

best for them – especially with allopathic medicine

• The curing versus caring paradigm and the concept of

disease versus illness contribute to the development of

attitudes that influence empathic behavior in clinical

encounters.


• Interpersonal dynamics operate in clinician–patient

encounters,

– to comply with the orders of authority figures

– to uncritically accept authority figures

– may be too polite to disagree and just nod their head which

does not mean “yes” or “no” but “I hear you”

– a nod of the head does not necessarily mean agreement

but that “I hear you.”

Demographic Data and Standards

• Develop a data collection system to monitor demographics

(culture, ethnicity) served by the organization

• Obtain state and local census tract information and include

income and employment

• What are the elementary school enrollments? What are

their ethnicities, languages, and cultural backgrounds?

• The older population: how many long-term care facilities

are in the catchment area

Demographic Data and Standards

• Ethnicity as a variable of cancer and other biological

illnesses – i.e. which groups have increased incidences of

specific cancers: breast, colon, prostate, etc.

• Track data from patient satisfaction scores

• Track data from healthcare disparities data: much of it

comes from local hospitals and outpatient clinics as well as

national data from the Centers for Disease Control and

Prevention

https://www.cdc.gov/

Educational Components

• Begins with some definitions: enculturation, ethnocentrism,

acculturation, assimilation, cultural awareness, culture

sensitivity, cultural competence, cultural congruence,

generalization versus stereotype, cultural imperialism,

cultural imposition, cultural relativism, ethnic group, and

subculture.

• Objective culture includes things that people make such

as art, music, and styles of clothing and dress. Subjective

culture is a way of perceiving the social environment that

includes ideas, beliefs, and values, including those related

to health and health care


Levels of subjective culture

A primary level that represents the deepest level in which

rules are known by all, observed by all, implicit, and taken for

granted.

A secondary level, in which only members know the rules of

behavior and can articulate them. The healthcare provider

must make a conscious effort to uncover them.

A tertiary level visible to outsiders: things that can be seen,

worn, or otherwise observed: the objective culture


• Nurses (all healthcare providers) need specific knowledge

about the major groups of culturally diverse individuals,

families, and communities they serve

• Start with individual versus collectivistic cultures as a

framework.


• Provide in-service classes on the basic terminology of

culture and anthropology. Could be as simple as a handout

with definitions and a quiz that could include case studies

and be online

• Institute a Train the Trainer program for staff to bring

cultural related information on a 24 hour basis.

• Develop an internal website where staff can access

culturally general and culturally specific information.

• Attend formal courses and conference concentrating on

culture.

Douglas et al. (2014)


• Use a comprehensive cultural assessment tool that can be

added to as time and circumstances permit.

• Specific content of the groups should include the overview

and heritage of the group, communication practices, family

roles and organization, workforce issues, biocultural

ecology, high-risk health behaviors, nutrition, pregnancy

and the child-bearing family, death rituals, spirituality and

religion, healthcare practices, and healthcare practitioners

Purnell (2013); Purnell (2014)

Variant Characteristics of Culture

• Nationality

• Race

• Color

• Age

• Religious affiliation

• Educational status

• Socioeconomic status

• Occupation

• Language spoken

• Literacy level

• Military experience

• Political beliefs

Purnell (2013); Purnell (2014).

Variant Characteristics of Culture

• Educational status

• Urban versus rural

residence

• Enclave identity

• Marital status

• Parental status

• Sexual orientation

Purnell (2013); Purnell (2014)

• Gender issues

• Physical characteristics

• Immigration status

(sojourner, immigrant,

or undocumented

status)

• Length of time away

from home country


• Provide orientation and annual in-service training in cultural

competence for all levels of staff, including management,

professionals, and auxiliary staff in any department with

patient contact.

• Establish journal clubs to review current literature about the

most common cultural groups served to ensure evidence-

based practice.

• Simulation labs–network with local college/medical center

• Online courses and webinars


• Invite ethnic individuals to workshops

• Include “lunch and learn” where staff addresses

cultural and ethnic issues and practices

• Have diverse staff talk about their culture

• Health screenings at fire stations and local libraries –

combine with book/video sales

Douglas, et al. (2014)

References/Resources – American Hospital Association. Health Research & Educational Trust. (2013). Becoming a culturally

competent health care organization. Available at http://www.hpoe.org/becoming-culturally-

competent

– American Nurses Association. Cultural self-assessment.

http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-

Your-Practice/Diversity-Awareness/Self-Assessment.html

– American Association of Colleges Nursing. Tool kit for cult competent education. Available at

http://www.aacn.nche.edu/education-resources/toolkit.pdf

– Campinha-Bacote. J. (2015). The Process Of Cultural Competence In The Delivery Of Healthcare

Services. Available at http://transculturalcare.net/the-process-of-cultural-competence-in-the-

delivery-of-healthcare-services/ Has tools for measuring cultural competence. However, there is a

charge for each time you administer the tool

– Department Health and Human Services, Office of Minority Health (2001). National Standards for

Culturally and Linguistically Appropriate Services in Health Care. Available at

https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

References/Resources – Douglas, M., Rosenketter, M., Pacquiao, D., Clark Callister, L., Hattar-Pollara, M., Lauderdale, L.

Milsted, J., Nardi, D. & Purnell. L., & Purnell, L. (2014). Guidelines for implementing culturally

competent nursing care. Journal of Transcultural Nursing, 25(2), 109-221.

– End of Life Nursing Education Consortium. American Association of Colleges of Nursing. (2017).

Available at http://www.aacn.nche.edu/elnec

– Jeffreys, M. (2012). Self-Efficacy tools. Available at

http://www.mariannejeffreys.com/culturalcompetence/questionnaire.php

– Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational

Cultural Competence Assessment Profile (2002). Lewin Group, Inc. Available at

https://www.hrsa.gov/CulturalCompetence/healthdlvr.pdf

– Lewin Group. (2002). file:///D:/TX_Oncology/lewen%20group.pdfIndicators of Cultural Competence

in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile.

Available at

References/Resources – Nursing Scope and Standards of Practice. (2016). American Nurses Association. Standard 8:

Culturally Congruent Care.

– Oncology Nursing Society Multicultural Outcomes: Guidelines for Cultural Competence (2000).

Oncology Nursing Press, Inc.

– Organizational Cultural Competence Assessment Profile. (2001). U.S. Bureau of the Census.

Available at https://www.census.gov/

– Purnell, L. (2013). Transcultural health care: A culturally competent approach (4 ed.). Philadelphia:

F. A. Davis. For more information go to http://www.fadavis.com/searchresults?product=Purnell This

site has basic Power Point Lectures, quizzes for students and faculty and additional resources

References/Resources – National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and

Health Care: A Condensed Blueprint for Advancing and Sustaining CLAS Policy and Practice.

(2014). New Jersey Department of Available at

http://www.state.nj.us/health/ommh/documents/clas_standards.pdf

– Purnell, L. (2014). Guide to culturally competent health care. Philadelphia: F.A. Davis Co. Being

revised with Purnell & Fenkl sometime in late 2017?. For more information go to

http://www.fadavis.com/searchresults?product=Purnell

– Purnell, L. (2016). Invited scholarly inquiry article: Are we really measuring cultural competence?

Nursing Science Quarterly, 29(2), 124-127.

– Think Cultural Health.org. Available at http://www.ctmhp.org/wp-content/uploads/2011/07/Jacobs-

TCH-Suite-Clearinghouse.pdf This site has continuing education modules for physicians, nurse

practitioners, registered nurses, and social workers.

– Transcultural Nursing Society: Theories and Models. (2013). Available at www.tcns.org This site has

over 100 Power Point Slides for all the major nurse cultural theories and models .

Individualistic Cultural Attributes

– Term used to describe a moral, political, or social outlook

that stresses human independence and the importance of

individual self-reliance, and freedom.

– All cultures and individuals fall on a continuum of 1 to 10.

– Frequently context dependent.

– Do not confuse individualism with individuality

– The individual is the most important element in society.

Some languages do not have a word for “individual” as

someone who stands alone.


– Has a controversial relationship with egotism – selfishness.

– Should be able to choose your own lifestyle, occupation,

partner, etc.

– Stresses doing your own work and taking care of yourself.

– Individualistic cultures: Scandinavian countries, European

American, German, and Appalachian

– The USA was built on “rugged individualism”. Individualism

tolerates individuality more than collectivism


– Low-context, explicit communication is valued over implicit

communication.

– Communication is clearly stated or further explanation is

expected. Communication is direct, linear, and precise

– Although interrupting someone who is talking is considered

rude, it is common practice and forgiven.

– Sharing personal feelings is encouraged, even for sensitive

issues because the stigma does not necessarily extend to

the family.


– Direct explicit communication is expected with illnesses so

plans for the future can be made.

– If a question is asked that can be answered with “yes” or

“no”, the expectation is to tell the truth.

– Minimal touching unless very close family and friends and

is reinforced by sexual harassment policies. One is

expected to ask permission before touching another

person.


– Conversants are expected to maintain eye contact

regardless of class or social standing: lack of eye contact is

usually interpreted as not listening, not caring, or not telling

the truth

– Unless close family and friends, conversants stand 18 to 24

inches (45-60 cm) apart

– Punctuality is valued in both business and social settings

– Futuristic temporality dominates; want to know the possible

ramifications of an illness in the future.


– Value on informality; commonly using first names in most

situations.

– High value is placed on egalitarian spousal relationships

with shared responsibilities and decision making.

– Ask the patient directly who has decision making authority if

not cognitively impaired.

– Primary source of strength may not be family or religion but

work and even material possessions.

Collectivistic Cultural Attributes

– Moral, political, or social outlook that stresses human

interdependence.

– Important to be part of a collective.

– Individual is defined in terms of a reference group – family,

church, work, school, or some other group.

– Collectivism stifles individuality and diversity = common

social identity.

– Most collectivist cultures are high-context.


– Do not reveal sensitive issues that may cause a stigma to

the family or others unless agreed upon by the patient.

– Direct communication and discussing palliative care may

mean giving up hope: approach these issues subtly.

– Many have difficulty with saying “no” because it is seen as

disrespectful: Do not ask questions that have a “yes” or “no”

answer.


– Touching is common among same sex friends and new

acquaintances but a high degree of modesty necessitates

explaining the necessity of touching: ask permission before

doing so.

– Time is more relaxed; punctuality is valued only in business

and situation where it is essential such as in making

transportation connections.

– Most value formality: always greet the patient and family

members formally until told to do otherwise.


– In most traditional cultures, but not all, men have decision-

making authority. May be reluctant to appoint a family

member for decision making for fear of isolating other

family members and increase family conflict.

– Gender roles are less fluid; expectations upon immigration

may cause significant family discord.

Cultural Imposition

– Cultural Imposition: Intrusively applies the majority cultural view to

individuals and families.

– Prescribing a special diet without regard to the client’s culture and

limiting visitors to immediate family borders on cultural imposition.

– In this context, healthcare providers must be careful in expressing

their cultural values too strongly until cultural issues are more fully

understood.

– The practice of extending policies and procedures of one

organization (usually the dominant one) to disenfranchised and

minority groups.

Cultural Imposition

– Proponents appeal to universal human rights, values, and

standards.

– Opponents posit that universal standards are a disguise for

the dominant culture to destroy or eradicate traditional

cultures through worldwide public policy.

Cultural Imperialism

– Cultural imperialism is the practice of extending the policies

and practices of one group (usually the dominant one) to

disenfranchised and minority groups.

– Proponents appeal to universal human rights values and

standards.

– Opponents posit that universal standards are a disguise for

the dominant culture to destroy or eradicate traditional

cultures through worldwide public policy.

Cultural Relativism

– The belief that behaviors and practices of people should

only be judged in the context of their cultural system.

– Proponents argue that issues such as abortion, euthanasia,

female circumcision, and physical punishment in

childrearing should be accepted as cultural values without

judgment from the outside world.

– Opponents argue that cultural relativism may undermine

condemnation of human rights violations and that family

violence cannot be excused on any level.

Stereotype versus Generalization

– Stereotype: A simplified and standardized conception,

opinion, or belief about a person or group.

– A healthcare provider who fails to recognize individuality

within a group is jumping to conclusions about the

individual or family.

– Generalization: Begins with assumptions about the

individual or family within an ethnocultural group but leads

to further information seeking about the individual or family.

– Uses aggregate data: a research principle.

Some Basic Definitions

– Acculturation: Gradually adopting and incorporating the

characteristics of the prevailing culture.

– Assimilation: Modification of the culture of a group or

individual as a result of contact with another individual or

group.

– Enculturation: Enculturation is a natural conscious and

unconscious conditioning process of learning accepted

cultural norms, values, and roles in society and achieving

competence in one’s culture through socialization.

Some Basic Definitions

– Cultural awareness has to do with an appreciation of the

external signs of diversity, such as the arts, music, dress,

foods, and physical characteristics.

– Cultural sensitivity has to do with personal attitudes and

not saying things that might be offensive to someone from a

cultural or ethnic background different from the healthcare

provider’s own.

– Cultural competence in health care is having the

knowledge, abilities, and skills to become culturally

competent.

Ethnocentrism

Ethnocentrism—the universal tendency of human beings to

think that their ways of thinking, acting, and believing are the

only right, proper, and natural ways (which most people

practice to some degree)—can be a major barrier to providing

culturally competent care. Ethnocentrism perpetuates an

attitude in which beliefs that differ greatly from one’s own are

strange, bizarre, or unenlightened and, therefore, wrong.

Subculture

Subculture: a group of people with a culture that

differentiates them from the larger culture of which they are a

part. Subcultures may be distinct or hidden (e.g., gay, lesbian,

bisexual, and transgendered populations; bikers; Alcoholics

Anonymous, etc.). A subculture can include members from the

European American, Thai, Chinese, Hispanic, and other

cultures.

– Counterculture: characterized by a systematic opposition to

the dominant culture (examples are goths, punks, and

stoners; although popular lay literature might call these

groups cultures instead of subcultures). A counterculture

would include cults.

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Culturally Competent Care is Patient Centered Care · Organizational Assessment: Why Culturally Competent Care • Reduces care disparities in the patient population • Increases