culturally competent care is patient centered care · organizational assessment: why culturally...
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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
Organization’s Responsibility
• 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
Organization’s Responsibility
• 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
Cultural and Clinical Dynamics
• 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.
Cultural and Clinical Dynamics
• 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.
Cultural and Clinical Dynamics
• 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
Educational Components
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
Educational Components
• 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.
Educational Components
• 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)
Educational Components
• 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
Educational Components
• 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
Educational Components
• 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.
Individualistic Cultural Attributes
– 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
Individualistic Cultural Attributes
– 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.
Individualistic Cultural Attributes
– 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.
Individualistic Cultural Attributes
– 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.
Individualistic Cultural Attributes
– 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.
Collectivistic Cultural Attributes
– 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.
Collectivistic Cultural Attributes
– 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.
Collectivistic Cultural Attributes
– 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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