cultural competence among cardiovascular healthcare providers with black patients in rock island
TRANSCRIPT
University of IowaIowa Research Online
Theses and Dissertations
Summer 2010
Cultural competence among cardiovascularhealthcare providers with Black patients in RockIsland County, IllinoisAlesia J. Grice-DyerUniversity of Iowa
Copyright 2010 Alesia J Grice-Dyer
This thesis is available at Iowa Research Online: https://ir.uiowa.edu/etd/676
Follow this and additional works at: https://ir.uiowa.edu/etd
Part of the Community Health Commons
Recommended CitationGrice-Dyer, Alesia J.. "Cultural competence among cardiovascular healthcare providers with Black patients in Rock Island County,Illinois." MS (Master of Science) thesis, University of Iowa, 2010.https://doi.org/10.17077/etd.7c9cx31p.
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CULTURAL COMPETENCE AMONG CARDIOVASCULAR HEALTHCARE
PROVIDERS WITH BLACK PATIENTS IN ROCK ISLAND COUNTY, ILLINOIS
by
Alesia J. Grice-Dyer
A thesis submitted in partial fulfillment of the requirements for the Master of
Science degree in Community and Behavioral Health in the Graduate College of
The University of Iowa
July 2010
Thesis Supervisor: Professor Joe Dan Coulter
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Copyright by
ALESIA J. GRICE-DYER
2010
All Rights Reserved
Graduate College The University of Iowa
Iowa City, Iowa
CERTIFICATE OF APPROVAL
_______________________
MASTER'S THESIS
_______________
This is to certify that the Master's thesis of
Alesia J. Grice-Dyer
has been approved by the Examining Committee for the thesis requirement for the Master of Science degree in Community and Behavioral Health at the July 2010 graduation.
Thesis Committee: ___________________________________ Joe Dan Coulter, Thesis Supervisor
___________________________________ Linda Snetselaar
___________________________________ Anne Baber Wallis
___________________________________ Faryle Nothwehr
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To James and Gertrude Grice, Dorothy Grice, and Willie Earl Dyer.
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Birds of a feather flock together, eagles fly alone.
Isaiah 40
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ACKNOWLEDGMENTS
The completion of this thesis would not have been possible without the support
and guidance of God and the Professors in the Department of Community and Behavioral
Health, who consistently challenged me to aim high and reach even higher. My deepest
gratitude to Professors Mary Aquilino and Anne Baber Wallis, who, in spite of myself,
kept me grounded and within normal limits and Professor Linda Snetselaar, who brought
sanity to this process. I want to thank The Nursing Education and Research Department
at Trinity Medical Center, Rock Island Campus and Mary Petersen, who helped and
guided me through the IRB process, they are very gracious. Thank you to The Nursing
Education Department at Genesis Medical Center, Illini Campus, who were very helpful
and gracious. I would also like to thank all of the nurses who participated in the study
and made this thesis possible. A Very Special thanks to Amy Engelmann, who started the
whole ball rolling
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TABLE OF CONTENTS
LIST OF TABLES.............................................................................................................vii
LIST OF FIGURES..........................................................................................................viii
LIST OF ABBREVIATIONS............................................................................................ix
CHAPTER I INTRODUCTION ....................................................................................1 Background .......................................................................................................1 Statement of the problem ..................................................................................4 Research Aim ....................................................................................................6 Organization of the Study .................................................................................7
CHAPTER II REVIEW OF THE LITERATURE .........................................................8
Introduction .......................................................................................................8 Culture and Cultural Competency ....................................................................8 Constructs of Cultural Competency..................................................................9
Cultural Awareness .................................................................................10 Cultural Knowledge .................................................................................11 Cultural Skill ...........................................................................................12 Cultural Encounters .................................................................................12 Cultural Desire .........................................................................................13 Cultural Mistrust ......................................................................................13
Perceptions of Racism and Mistrust in Health Care Model (PRMHC) ........................................................................15 Cardiovascular Disease Prevalence and Health Disparities ...........................16 The Process of Cultural Competence in the Delivery of Health Care Services .......................................................................................19 Health Behavior Theory .................................................................................19
CHAPTER III METHODS ..............................................................................................20
Research Aim .................................................................................................20 Hypothesis ......................................................................................................20 Design .............................................................................................................21 Setting .............................................................................................................22 Subjects ..........................................................................................................22 Data Collection Instruments ...........................................................................22 Methodology ...................................................................................................24
Data Collection .......................................................................................24 Analysis ..........................................................................................................25 Results.............................................................................................................26
Deomgraphis Flysheet .............................................................................26 Questionnaire Results ..............................................................................39
CHAPTER IV CONCLUSION .....................................................................................48 Discussion .......................................................................................................48
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Summary......................................................................................................... 51
Study Limitations............................................................................................ 53
Recommendations........................................................................................... 53
REFERENCES ........................................................................................................... 56
APPENDIX A DEMOGRAPHICS SHEET .............................................................. 62
APPENDIX B GENESIS INSTITUTIONAL REVIEW BOARD ........................... 64
APPENDIX C TRINITY INSTITUTIONAL REVIEW BOARD............................. 67
APPENDIX D UNIVERSITY OF IOWA INSTITUTIONAL REVIEW BOARD ... 69
APPENDIX E POSTERS/FLYERS FOR PARTICIPATION .................................... 71
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LIST OF TABLES
Table
2.1 Trinity Demographic Age Range ............................................................... 29
2.2 Scoring Key for Demographics Age Range............................................... 29
2.3 Illini Demographic Age Range................................................................... 31
2.4 Scoring Key for Demographic Age Range................................................. 31
2.5 Illini and Trinity Race/Ethnicity of Nursing Workforce vs.
Race/Ethnicity of Rock Island County Hospital Nurses ............................ 33
2.6 Racial Demographics of Rock Island County Population.......................... 34
2.7 Study Participants’ Job Title/Level of Nursing.......................................... 35
2.8 Study Participants’ Years of Training (Schooling) .................................... 35
2.9 Study Participant’s Years in the Nursing Profession ................................. 36
2.10 Number and Percentage of Black Patients Treated in Rock Island
County ........................................................................................................ 37
2.11 Cultural Competency Scores for Trinity Regional Health System ............ 42
2.12 Cultural Competency Scores for Genesis Medical Center, Illini
Campus ...................................................................................................... 44
2.13 Illini and Trinity Cultural Competency Scores ......................................... 46
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LIST OF FIGURES
Figure
2.1 Trinity Demographic Age Range ............................................................... 30
2.2 Illini Demographic Age Range ................................................................... 32
2.3 Percentage of Black Patents Treated .......................................................... 38
2.4 Cultural Competency Scores for Trinity Regional Health System ............ 43
2.5 Cultural Competency Scores for Genesis Medical Center, Illini Campus . 45
2.6 Illini and Trinity Cultural Competency Scores .......................................... 47
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LIST OF ABBREVIATIONS
1. The Perception of Racism and Mistrust in Health Care Model PRMHC
2. National Association for the Advancement of Colored People NAACP
3. Department of Health and Human Services DHHS
4. The Inventory for Assessing the Process of Cultural
Competence Among Healthcare Professionals-Revised IAPCC-R
5. Institute of Medicine IOM
6. Perceptions of Racism and Mistrust In Health Care Model PRMHC
7. Registered Nurses RNs
8. Licensed Practical Nurses LPNs
9. Nurse Practitioner NPs
10. Bureau of Labor Statistics BLS
11. Nursing Workforce survey NRC
12. Health Resources and Services Administration HRSA
13. National Sample Survey of Registered Nurses NSSRN
14. Center for Disease Control and Prevention CDC
15. Society for Public Health Education SOPHE
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CHAPTER I
INTRODUCTION
This study details a plan of applied research using a cross-sectional survey methodology
to identify the multi-dimensional aspects of cultural competence. Identifying a wider
conceptualization of cultural competence that embraces cultural knowledge, cultural self-
awareness, cultural skills and cultural encounters; the theoretical framework was based on The
Process of Cultural Competence in the Delivery of Healthcare Services Model
Background
1 (Campinha-
Bacote, 1999), Health Behavior Theory, and a mid-range theoretical model entitled Perceptions
of Racism and Mistrust in Health Care2 (Benkert, Peters, Clark, and Keves-Fostor, 2006). These
theories address the lack of cultural competence within the health care profession, resulting in
mistrust and directly influencing the delivery of quality health care to Black3
Recent trends in the nursing population in the United States are encouraging with the
overall representation of non-white nurses increasing from 7% in 1980 to 12.2% in 2004. Yet,
the nursing workforce diversity remains far below minority representation in the general
patients. For
purposes of this research study, the population sampled was nurses who treat Black patients with
cardiovascular conditions.
1 According to Campinha-Bacote (1999), “this model views cultural competence as an ongoing process that
the health care provider (nurse) continuously strives to attain the ability to effectively work within the cultural context of the client and involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.”
2 The Perception of Racism and Mistrust in Health Care Model (PRMHC), according to its authors, hypothesize that perceived racism influences cultural mistrust, which affects trust in providers (Benkert et al., 2006).
3 For purposes of this study, Black was defined as Black, non-Hispanic.
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population, which was nearly 33% in 2004 (Health Resources and Service administration,
(2006).
A study by Betancourt, Green, and Carrillo (2000) found many barriers to the delivery of
culturally competent care, including the lack of a diverse healthcare leadership and workforce, a
deficient system of care designed for diverse patient populations, and reduced cross-cultural
communication between providers and patients. The inability of a provider to understand
socioeconomic or other differences may lead to patient noncompliance, which can affect health
outcomes.
Disparity in health outcomes based on culture has been recognized as a phenomenon in
both access to and quality of health care, but there is not an understanding and agreement
regarding definitions. According to a report by Walker & Avant (2002), antecedents of the
concept of health care disparity are “a positive or negative experience with a health care
establishment or service and a measurement of the quality of health care received or access to
health care services.” Antecedents are events that must be present for the concept to occur
(Walker & Avant, 2005). Antecedents of the concept of health disparity are a positive or
negative state of health or physical, psychological, and socio-cultural well-being, and the
measurement of a health variable that includes incidence, prevalence, mortality, burden of
disease, or other adverse health conditions. A health care disparity may lead to a disparate
treatment of disease (Walker & Avant, 2005).
A study by Spector (2002), using a theory developed by researchers Estes and Zitzow
(1980) describes the impact of cultural competence. Spector (2002) cites Estes and Zitzow‘s
theory to describe “the degree to which one’s lifestyle reflects his or her respective tribal
culture”. “The values indicating heritage consistency exist on a continuum and a person can
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possess value characteristics of both a consistent heritage (traditional) and an inconsistent
heritage (acculturated- modern).” Spector (2002) details the concept of heritage consistency,
which includes a determination of one’s cultural, ethnic, and religious background. The
perception is that the deeper a person identifies with a traditional heritage, the greater the chance
they will follow traditional health and illness beliefs and practices derived from their ethno-
cultural heritage.
The concept of cultural sensitivity, defined by Fonda (2008), is a term that is
interchangeable with cultural competence, dependent upon the researcher conducting the study.
For purposes of this study, cultural competence was used with the understanding that cultural
sensitivity is encompassed within the definition of cultural competence. The use of the term
cultural competence, in this study, includes the broadest audience possible.
The application of the concept of culturally competent care historically has operated
from a predominately White4
4 For purposes of this study, White was defined as White, non-Hispanic.
, dominant culture perspective (Canales and Bowers, 2001).
Studies by Canales and Bowers (2001), Betancourt (2006), Benkert, Peters, Clark, and Keves-
Foster (2006), and Campinha-Bacote (1999) indicate a strong correlation between cultural
competence and cardiovascular health care among Black patients. The link to racial/ethnic
disparities in cardiovascular health is relevant because of the connection between cultural
competence of effective communication, trust, and healthy outcomes (Betancourt, 2006).
Betancourt (2006) asserts in his commentary that “poorly handled cross-cultural issues result in
negative clinical consequences.” Another part of the problem is the collective memory among
Blacks about their exploitation by the medical establishment (Gamble, 2002; Erlen, 2003).
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These memories cultivate fears of genocide and create barriers that impede the process of health
promotion within the Black population and other racial/ethnic populations.
Cultural competence plays an important role when addressing racial/ethnic health
disparities. Cultural competence is defined as a set of attitudes, skills, behaviors and policies that
enable health professionals to work effectively in cross-cultural situations, taking into account
the client’s health beliefs, cultural values, disease prevalence, and treatment efficacy (Edwards
and Erwin-Johnson, 2003; Richardson and Jacobs, 2002; Kim-Goodwin, Clark, and Barton,
2001). Without awareness of cultural differences, the Western values of individualism,
autonomy, independence, self-reliance, and self-control may conflict with families of other
cultures that may not have such values (Kim-Godwin, Clarke, and Barton, 2001).
Statement of the Problem
Professional interest in cultural competence among nurses and health care professionals
is predated by a rich and varied history on the subject and many decades of debate regarding the
profession’s response or lack of response to the service needs of diverse clients (Jackson, 2005).
The concept of cultural competence has moved through a progression of ideas and theoretical
constructs favoring cultural pluralism, cultural sensitivity, multiculturalism, and a trans-cultural
orientation to the health care profession (Gould, 1995). The majority of health care providers
perceive themselves as culturally competent, aware and knowledgeable. The lack of cultural
diversity especially in the cardiovascular health care field may influence the delivery of health
care to Black clients as evidenced by the Black population’s perceptions and complaints about
discriminatory treatment from health care providers (Gould, 1995). Cultural health disparities
are represented in the high levels of incidence and prevalence of cardiovascular disease, in
equally high morbidity and mortality rates among Black patients. All health care providers need
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to master culturally competent knowledge, awareness and skills because the pluralistic and
multicultural society is a social reality according to Gould (1995). A pluralistic society is one
where different groups can interact while showing a certain degree of tolerance for one another,
where different cultures can coexist without major conflicts, and where minority cultures are
encouraged to uphold their customs (Kellan, 1915). Cultural pluralism is the dynamic by which
minority groups participate fully in the dominant society and maintain their cultural differences.
Black/African American culture necessitates freedom from total assimilation and retains their
cultural heritage in the face of demands for cultural conformity (Kellan, 1915).
In a report to the National Association for the Advancement of Colored People (NAACP)
(Edwards and Erwin-Johnson, 2003), it was noted that of the 15 leading causes of death, Blacks
have the highest incidence rates in 13 of them. It is known that all persons respond culturally to
sickness and disease, so if a health care provider ignores the cultural influences at work, these
limitations will be barriers to success. In this context, the term institutional racism was defined
as differential access to goods, services and opportunities of society by race. Institutional racism
is normative, sometime legalized, and often manifests as inherited disadvantage. It is a structural
and unmentioned code within the medical institutions, a perpetrator using the guise of customs,
practices, and unwritten laws (Jones, 2002). One consequence of this persistent and continuous
racism, discrimination, and cultural insensitivity is an unequal burden of illness and premature
death experienced by racial and ethnic minorities according to an article by Thomas (2001).
Thomas notes that in a study by Freeman and Payne (2001), there is a subtle form of racial bias
on the part of medical care providers. The level and extent of these problems is unknown, but
are real and potentially harmful, even though predominately unintentional. Medical care
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providers must place a greater emphasis on people’s cultural and behavioral attitudes, beliefs,
lifestyle patterns, diet, and environmental living conditions (Erlen, 2003).
In the findings of the 108th session of Congress (2004), the Senate identified 12 points
that need immediate attention, several of which are blatant and include the following concepts;
(a) as medical science and technology have advanced at a rapid pace, the health care delivery
system has not been able to provide consistent high quality care to all Americans; (b) recent
studies have raised significant questions regarding differences in clinical care provided to racial
and ethnic minorities and other health disparity populations, which are often grouped under the
broad heading of “health disparities”; (c) despite considerable efforts by the Department of
Health and Human Services (DHHS), data collection efforts governing racial, ethnic, and health
disparity populations remain inconsistent and inadequate. These efforts often quantify
disparities, but shed little light in their causes; there is a need to ensure appropriate representation
of racial and ethnic minorities and other health disparities populations in the health care
professions and in the fields of biomedical, clinical, behavioral and health services research.
The specific aim of this study was to examine the level of self-perceived cultural
competence of the health care providers treating Black patients with cardiovascular disease and
the resulting comorbid conditions, assessed by The Inventory for Assessing the Process of
Cultural Competence Among Healthcare Professionals-Revised [(IAPCC-R) Campinha-Bacote,
2002].
Research Aim
All items included Likert scale responses to assess the direction and intensity of
perception and actual concepts of the respondents. This questionnaire incorporated a four-point
scale to eliminate the availability of a middle option of "Neither agree nor disagree"
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Cardiovascular health care providers in Rock Island County perceive themselves as
culturally competent, as evidenced by institutional mission statements, online job descriptions
and program goals. I hypothesized self-reported cultural competence levels, measured by the
IAPCC-R (Campinha-Bacote, 2002), will not be as high as believed by the healthcare
providers.
The study proceeds in three chapters. Chapter Two regards key definitions of cultural
competence and includes a literature review addressing cultural competency, cultural mistrust,
and the effect of cultural mistrust upon disparities in cardiovascular health, methodology,
identification of the study population of health care professionals in Rock Island County, Illinois,
instrumentation, data collection, and data analysis of the survey. Chapter Three provides an
evaluative summary, future directions, and implications of this research.
Organization of the Study
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CHAPTER II
REVIEW OF THE LITERATURE
A review of selected literature provides rationale for the need for cultural competence in
a multicultural society. The first section of this chapter defines cultural competency in
relationship to the health care profession, the context in which contact with Black patients
originates. The definition of cultural mistrust and the impact on disparities in cardiovascular
health concludes the literature review.
Introduction
Culture, according to Carrillo, Green, and Betancourt (1999), is defined as “a shared
system of values, beliefs, and learned pattern of behavior and not simply defined by ethnicity.”
Every culture has health components of health preservation, prevention, illness, treatment,
coping styles, and beliefs about death and dying (Carrillo, Green, and Betancourt, 1999). Culture
provides the beliefs and values that give individuals a sense of identity, self-worth and
belonging, as well as providing the rules of behavior along with the values, beliefs, and practices
that their cultural group has about health promotion and illness prevention (Cortis, 2003).
Culture is dynamically affected by social transformation, social conflicts, and migration, which,
allowing for intra-and intergenerational chance can change over time (Cortis, 2003).
Culture and Cultural Competency
Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations
and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use
knowledge of the health-related beliefs, attitudes, practices and communication patterns of
clients and their families to improve services, strengthen programs, increase community
participation, and close the gaps in health status among diverse population groups. Department
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of Health and Human Services (n.d.) notes cultural competence also focuses on population-
specific issues including health-related beliefs and cultural values (the socioeconomic
perspective), disease prevalence (the epidemiologic perspective), and treatment efficacy (the
outcome perspective).
According to studies by Campinha-Bacote (Campinha-Bacote, 1995, 1999, 2002), the
definition of cultural competence is “a process, not an endpoint,” in which the health care
provider continuously strives to achieve the ability to work within the cultural context of an
individual family, or community, from a diverse cultural/ethnic background. Cultural
competence require awareness of and sensitivity to how patients experience their uniqueness,
deal with their differences and similarities, and cope with a sociopolitical environment that is
commonly unconcerned with the welfare of its people, however diverse their needs will be.
Although the dialogue of culture isolates people by virtue of race, ethnicity or nationality, in
reality people represent intersections of these various cultural groups (Jackson, 2005).
Cultural competence requires the capacity to recognize the interaction of these multiple
identities at the individual, family, group, neighborhood, and community levels and recognizes
the important cultural issues within these relationships. Cultural competence requires a
heightened consciousness of how clients experience their uniqueness and deal with their
differences and similarities within a larger social context (Jackson, 2005). “Cultural competence
is an important building block of clinical care, an expansion of patient-oriented care, and a skill
set that is basic to professionalism, delivery, and quality of care” (Betancourt, 2006).
In studies by Campinha-Bacote (1995, 1999, 2002), the author defines cultural
competence as “the sum of four collateral constructs; awareness, knowledge, skill, and
Constructs of Cultural Competency
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encounters. Because these constructs are interdependent. the intersection of these constructs
represents the true process of cultural competence” (Campinha-Bacote, 1999).
Cultural Awareness
Cultural awareness requires that health care providers are sensitive to the beliefs, values,
practices, and lifestyles of their client’s culture and ethnicity (Campinha-Bacote, 1995, 1999).
The cultural awareness process involves in-depth examination of an individual’s own prejudices
and biases toward other cultures as well as self-examination of their own cultural background.
Campinha-Bacote (1999) finds that “without being aware of the influence of self values and
beliefs, the risk is that health care providers may impose their own cultural values, beliefs, and
practices. Respect for the client’s culture is directly related to respect for the health care
provider’s own inherent culture in tandem with adapting the inherent perspective and beliefs of
Black patients.
According to Campinha-Bacote (1995, 1999), the four stages of cultural awareness are
identified as; unconscious incompetence, conscious incompetence, conscious competence, and
unconscious competence, which are directly related to an individual’s level of awareness
regarding interactions outside of their personal culture. Unconscious incompetence is when the
health care provider is unaware that cultural differences exist because a client may look and
behave much like the health care provider, which is an erroneous assumption based on the
concept of intra-ethnic variation. The health care provider is unaware of the biological
variations, diseases and health conditions, and variations of drug metabolism of Black or
ethnically diverse populations. Conscious incompetence is being aware that cultural differences
exist or as Campinha-Bacote (1995, 1999) describes as, health care providers who possess the
“know that” knowledge but not the “know how” knowledge, to effectively communicate with
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clients from different cultural backgrounds. Health care providers at this stage know that culture
plays an important role in treating a diverse patient population, but do not know how to
effectively use this knowledge. Conscious competence is the conscious act of learning about the
client’s culture and providing culturally relevant interventions. Often health care providers at
this stage are overly conscious about being politically correct, which can interfere with effective
communication with the client. The unconscious competence health care provider will
automatically provide culturally congruent care to the diverse client population and interacts
naturally with patients from diverse cultures.
Health care providers, in the process of awareness, move along a continuum (Campinha-
Bacote, 1995) beginning at avoidance and progress to protection, in which the health care
provider feels that cultural differences threaten their own self-identity and minimize cultural
differences while emphasizing the unifying aspects of humanity. Health care providers that
reach the other end of the continuum reflect a perspective that adapts, accepts, and integrates
cultural differences into practice.
Cultural Knowledge
Campinha-Bacote (1995, 1999) defines cultural knowledge as “the process of seeking
and obtaining a sound educational foundation concerning the various world views of different
cultures.” Obtaining the knowledge base involves a focus on the integration of three specific
issues; health related beliefs and cultural values, disease incidence and prevalence, and treatment
efficacy (Campinha-Bacote, 1995, 1999). Cultural knowledge about the client’s health related
beliefs and values involves understanding their worldview, which will explain how the client
interprets illness and how this knowledge guides their thinking, doing and being (Campinha-
Bacote, 1995, 1999). Cultural knowledge about disease incidence and prevalence among
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minority populations is varied. It is essential that the knowledge base includes accurate
epidemiological data to guide decisions about treatment, health education, and prevention
programs to positively impact health outcomes. Treatment efficacy involves knowledge about
variation in the biological process, hereditary, endemic and topographic diseases, home
environment, and psychological affect that can affect healthy outcomes (Campinha-Bacote,
1995). Specific knowledge on therapeutic barriers formed by specific biological variations
present among different ethnic groups, identified as bio-cultural ecology, an area of biological
variations, disease and health conditions, and variation in drug metabolism also known as ethnic
pharmacology (Campinha-Bacote,1999) is a relatively new area of research.
Cultural Skill
Cultural skill is defined as the ability to collect relevant and accurate cultural data of the
client’s health history and chief complaint combined with a culturally based physical assessment.
This process involves learning how to conduct a culturally based physical assessment
(Campinha-Bacote, 1995, 1999). Cultural assessment is a systematic appraisal to determine a
client’s values, beliefs, and practices to determine the needs and interventions that are applicable
to the client. In a culturally based physical assessment, the acquired cultural knowledge of
physical, biological, and physiological variations are used to perform a physical evaluation.
Cultural Encounters
Cultural encounters, according to Campinha-Bacote (1995, 1999), are defined as “a
process that encourages the health care provider to directly engage in cross-cultural interactions
with clients from culturally diverse backgrounds.” “Direct interaction will refine or modify
existing beliefs of the health care provider about a cultural group and prevent stereotyping.” Due
to intra-ethnic variation, an encounter with just three or four members of a specific cultural or
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ethnic group may not represent the expressly defined beliefs, values, or practices of that
particular group and will not make the health care provider an expert of the cultural group.
Campinha-Bacote (1995) states that “health care providers must be cognizant that sometimes
good intentions and usual (self) nonverbal communication styles can be interpreted as offensive
and insulting to a specific cultural group.”
Cultural Desire
Cultural desire as an operational fifth construct is the motivation of health care providers
to engage in the process of becoming culturally aware, culturally knowledgeable, culturally
skilled, and proficient with cultural encounters (Campinha-Bacote, 1999, 2002). Health care
providers must possess a genuine desire to work with a culturally diverse population that is
reflected by their words and actions congruent with their true inner feelings. Genuine caring is
an inherent quality of health care providers and is keenly perceived by Black patients, which will
influence all interactions involving the health care process.
Cultural Mistrust
There is a general sense of mistrust by Blacks of White institutions and health care
providers because of their unfamiliarity with the minority culture and insensitivity to nonwhite
cultures that creates barriers to the delivery of quality health care. Cultural mistrust is defined as
a tendency to distrust Whites based upon a history of direct or vicarious exposure to racism and
discrimination. In response to discriminatory treatment, Blacks have developed a mistrust of
many structural aspects of society. In the United States, White individuals who have historically
mistreated Blacks, dominate all of the structural or institutional systems. Healthcare has a legacy
of poor treatment and abuse of Blacks (Benkert, 2006). Few studies have focused on the
perception of differential treatment due to race when receiving health care services held by
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Blacks or other ethnic minority groups (Hobson, 2001). Individuals reported a perceived
negative attitude as one of the main expressions of race based treatment in a health care setting
(Hobson, 2001). According to Hobson (2001), the perceived negative attitudes exhibited by
health care providers were uncaring or rude, not hostile. Several individuals used the term
“belittle” to describe their experiences. Individuals reported that the manner and actions of some
health care personnel made them feel less than significant compared to other patients due to their
race. Benkert (2006) points out that no study using cultural mistrust as a distinct psychological
aspect of health care delivery could be found, so it is plausible to expect that high levels of
mistrust would affect the level of adherence with prevention interventions, medical plans of care
and treatment, and any follow-up recommendations.
In a report released by the Institute of Medicine (IOM, 2002) titled “Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care,” the panel of experts concluded that
the health provider’s prejudice and the resulting patient mistrust are a fundamental cause of
racially and culturally based disparities in healthcare. According to the Institute of Medicine
(IOM, 2002), “It is reasonable to speculate, however, that if patients convey mistrust, refuse
treatment, or comply poorly with treatment, providers may become less engaged in the treatment
process, and patients are less likely to be provided with more vigorous treatments and services.
However, these kinds of reactions from minority patients may be understandable as a response to
negative racial experiences in other contexts, or to real or perceived mistreatment by providers.
Survey research, for example, indicates that minority patients perceive higher levels of racial
discrimination in healthcare than non-minorities. Patients’ and providers’ behavior and attitudes
may therefore influence each other reciprocally, but reflect the attitudes, expectations, and
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perceptions that each has developed in a context where race and ethnicity are often more salient
than these participants are even aware of.”
Three mechanisms might be operative in healthcare disparities from the provider’s side of
the exchange: bias (or prejudice) against minorities, greater clinical uncertainty when interacting
with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or
health of minorities. Patients might also react to providers’ behavior associated with these
practices in a way that also contributes to disparities (IOM, 2002). Measuring cultural mistrust
when minorities are in the health care setting is a necessary first step to determining the role of
cultural mistrust in minorities’ health-seeking behaviors (Mosley, 2007).
Perceptions of Racism and Mistrust
Benkert, Peters, Clark, and Keves-Fostor, 2006] hypothesize that trust is crucial to the
patient/provider relationship to reduce health disparities (Benkert, Peters, and Clark et. al, 2006).
Black patients experience racism in their interactions with health care providers and the health
care system (Benkert et. al, 2006), which has been supported by past studies citing health care
providers and health care systems whose behavior has been untrustworthy. This has resulted in
an overwhelming sense and perception by Black patients that health professionals will overlook
important health concerns based on racial bias and lack of cultural knowledge (Benkert et. al,
2006). This results in a trust dilemma perpetuating barriers to delivery of quality health care.
According to Benkert et al. (2006), the PRMHC model hypothesizes that: 1) perceived racism
would have a positive and direct effect on cultural mistrust; 2) cultural mistrust would have a
negative and direct effect on trust in the health provider; 3) trust in the health provider would
In Health Care Model [(PRMHC)
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have a positive and direct effect on patient satisfaction, and 4) that cultural mistrust or trust
would mediate the influence of racism on satisfaction.
Disparities in survival rates among the minority population in the United States have
been widely documented with respect to heart disease, cerebrovascular disease, malignant
neoplasms, diabetes mellitus, and other chronic conditions. For example, in the United States,
Blacks have a higher incidence of stroke, more severe strokes, and higher stroke mortality
according to a study by Gillum (1998). This ethnic disparity has been attributed to a higher
prevalence or severity of stroke risk factors in Blacks, biological differences between Blacks and
Whites, and a lower socioeconomic status in Blacks as compared to Whites (Gillum, 1998).
According to the American Stroke/Heart Association (2004), compared with Whites, Blacks
develop high blood pressure earlier in life and their blood pressure is much higher when
diagnosed. As a result, Blacks have a 1.3 times greater rate of nonfatal stroke, a 1.8 times
greater rate of fatal stroke, a 1.5 times greater rate of heart disease death, and a 4.2 times greater
rate of end-stage kidney disease as reported by the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure, Seventh Report (2003).
Cardiovascular Disease Prevalence and Health Disparities
The term “health disparities”, is defined by National Institutes of Health Working Group
on Health Disparities (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005) as “differences in the
incidence, prevalence, mortality, and burden of diseases and other adverse health conditions.”
These disparities have been documented in the United States throughout most of the past two
centuries as outlined in separate studies by various researchers. A health disparity should be
viewed as a chain of events signified by a difference in environment, access to utilization of and
quality of care, health status, or a particular health outcome that deserves scrutiny (Baquet,
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2002). This inequality is strongly depicted in the area of minority health with the health care
status of Blacks as a function of their marginal position to the United States health care system
and a direct result of multiple factors that include the social determinants of lower levels of
education, overall lower socioeconomic status, inadequate and unsafe housing, and housing in
close proximity to environmental hazards (Betancourt, 2006). The Institute of Medicine Panel
(IOM, Betancourt, 2006) found in a 2002 study focused on health care for Black patients by
providers that health disparities that are not a direct result of social determinants and are valid
due to persistent racial and ethnic discrimination in many sectors of American life. The IOM
(Betancourt, 2006) reports find that many sources within the health care system, health care
providers, and patients themselves contribute to health disparities. Health care providers within
the system can be biased, stereotypical, prejudiced and clinically uncertain, while patients are
likely to refuse treatment due to these beliefs. The Healthy People 2010 Report (US Department
of Health and Human Services, 2000) found that Blacks along with other minority populations
would be observant of the socioeconomic effects increasing health disparities to a greater degree
than the dominant White population. This report also indicates that the differences in survival
and health between Blacks and Whites are not exclusively explained by poverty, but by unique
experiences and cultural orientations of a diverse population. An IOM study committee
(Betancourt, 2006) reviewed well over 100 studies that assessed the quality of healthcare for
various racial and ethnic minority groups, while holding constant variations in insurance status,
patient income, and other access-related factors. Many of these studies also controlled for other
potential confounding factors, such as racial differences in the severity or stage of disease
progression, the presence of co-morbid illnesses, where care is received (e.g., public or private
hospitals and health systems) and other patient demographic variables, such as age and gender.
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Some studies that employed more rigorous research designs followed patients prospectively,
using clinical data abstracted from patients’ charts, rather than administrative data used for
insurance claims. The study committee was struck by the consistency of research findings: even
among the better-controlled studies, the vast majority indicated that minorities are less likely
than whites to receive needed services, including clinically necessary procedures. These
disparities exist in a number of disease areas, including cancer, cardiovascular disease,
HIV/AIDS, diabetes, and mental illness, and are found across a range of procedures, including
routine treatments for common health problems.
The use of the term “health disparities” is the United States has the tendency not to
distinguish between the differences in health outcomes that are unavoidable, potentially available
and acceptable, and potentially avoidable unfair and inequitable (Carter-Pokras & Baquet, 2002).
In a study by Bolton, Giger, and Georges (2003), racial and ethnic disparities in health care are
“consistent and persistent regardless of the nature of the illness or the type of health care
received.”
There are three broad domains that help to clarify and promote understanding of the
origins and persistence of racial and ethnic health disparities (Ibrahim, Thomas, and Fine, 2003).
The first domain involves patient-level variables such as biology, individual disease status, and
psychosocial characteristics of cultural or individual preferences. The second domain entails the
characteristics and practices of health care professionals that include racism, stereotyping, racial
discrimination, and cultural or professional incompetence. The third domain involves the system
of health care delivery, the racial and ethnic diversity of the workforce, proximity of health care
facilities to communities in greatest need, accessibility of medical care regardless of income.
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The Process of Cultural Competence
This model developed by Campinha-Bacote in 1998 defines the process of a health care
provider’s self-awareness of becoming culturally competent as opposed to being culturally
incompetent. This model views the interdependent constructs of cultural knowledge, skills,
awareness, encounters, and desire as a process of becoming culturally competent. Health care
providers can enter this process at any construct, but all five constructs must be experienced or
addressed in order to improve a balance. Campinha-Bacote (1998) notes in her study that the
intersection of these constructs reflect the true process of cultural competence.
In the Delivery of Healthcare Services Model
The Health Belief Model (Rosenstock, 1974) is a useful tool to help predict health related
behaviors based on the attitudes and beliefs of individuals, understanding that the individual will
take a health related action to avoid a negative health condition, believes that the
recommendations of a health professional will be effective to avoid the negative health
condition, and that the person can perform the recommended action. Out of the six concepts;
perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to
action, and self-efficacy; perceived barriers are the greatest challenge facing minority
populations in the delivery of quality health care.
Health Behavior Theory
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CHAPTER III
METHODS
The purpose of this study was to examine the level of self-reported cultural competence
of the health care providers treating Black patients with cardiovascular disease and the resulting
comorbid conditions, based on The Inventory for Assessing the Process of Cultural Competence
Among Healthcare Professionals-Revised (IAPCC-R , Campinha-Bacote, 2002). Permission to
use the survey for the study was obtained from the author, Dr. Josepha Campinha-Bacote.
Research Aim
The two medical center sites where the research study was conducted emphasize a high
level of cultural competence. According to Genesis Medical Center’s online job description, the
job details its purpose as: “Provides and directs safe, effective, and culturally-competent patient
care for all age groups requiring stabilization, and/or resuscitation. Key accountabilities include
assessment, diagnosis, outcomes identification, planning, implementation, and evaluation of care
using critical thinking and evidenced-based practice; triaging and prioritizing care needs; crisis
intervention for unique patient populations (e.g., sexual assault survivors); and emergency
operations preparedness; adherence to the Professional Practice Standards as defined by ANA;
and active participation in quality monitoring and performance improvement activities”(Genesis
Medical Center, 2010).
Hypothesis
Trinity Regional Health System5
5 Formerly known as Trinity Medical Center, Rock Island Campus.
Department of Nursing’s philosophy of nursing
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practice (2010) emphasize in its mission statement: “We uphold the sanctity of life and recognize
the multi-dimensional aspects of our roles, where the whole person is respected and honored.
Cultural, spiritual, psychosocial, physical, environmental and emotional aspects are considered in
delivering holistic care. We respect the patient’s right to an individualized plan of care that
reflects evidence-based thinking and mutual decision-making. Recognition of diversity and
beneficence in practice supports the individuality of care, demonstrating a personal difference to
those we serve. Trinity College of Nursing and Health Sciences provide a quality higher learning
environment preparing competent practitioners for healthcare professions. Continuous quality
improvement guides the educational process as students prepare to deliver culturally congruent
healthcare, perform as responsible citizens within the global community and seek avenues for
lifelong learning” (Trinity Regional Health System, 2010). Within Trinity Regional Health
System is the Trinity College of Nursing and Health Sciences, an educational and employee
resource base, has as part of its program goals of culture care values: ability to preserve/maintain
cultural identities; ability to accommodate/negotiate diverse life ways; “Ability to re-
pattern/restructure health-care delivery methods; and ability to apply ethical and legal principles
to health care” (Trinity Regional Health System, 2010).
Cardiovascular health care providers in Rock Island County perceive themselves as
culturally competent as evidenced by direct quotes from online job descriptions, institutional
mission statements and programs goals. I hypothesized that the self-reported cultural
competence levels based on the IAPCC-R (Campinha-Bacote, 2002) may not be as high as
believed at the institutional level of each facility.
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This was a cross-sectional, survey-based study to examine the scope of cultural
competence of nurses and health care professionals. Their level of cultural competence directly
influences the delivery of health care to the Black population because of cultural mistrust and
perceived racism during patient to provider interactions. This was an exploratory study using an
integrated quantitative research and evaluation method to determine the scope of self-reported
cultural competence of cardiovascular nurses and health care providers.
Design
This study focused on health care professionals in two locations. The first group of
nurses consisted of cardiovascular health care professionals who work at Genesis Medical Center
Illini Campus, located at 801 Illini Drive, Silvis, Illinois. The second group of nurses consisted
of cardiovascular health care professionals at Trinity Regional Health System West Campus,
Rock Island, Illinois.
Setting
The participants at both locations were all licensed nurses of three levels, Nurse
Practitioners, Registered Nurses (Diploma and Graduate), and Licensed Practical Nurse.
Subjects
The Inventory to Assess the Process of Cultural Competence among Healthcare
Professionals-Revised, [(IAPCC-R), (Campinha-Bacote, 2002), ] was designed to
measure cultural competence among health care professionals based on The Process of Cultural
Competence in Healthcare Services Model measuring the constructs of cultural awareness,
knowledge, skill, and encounters. The IAPCC-R is a pencil/paper self-assessment tool that
measures the level of cultural competence in healthcare delivery. It consists of 25 items that
Data Collection Instruments
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measure the five cultural constructs of desire, awareness, knowledge, skill and encounters. Five
items address each construct. The IAPCC-R uses a 4-point Likert scale reflecting the response
categories of strongly agree, agree, disagree, strongly disagree; very aware, aware, somewhat
aware, not aware; very knowledgeable, knowledgeable, somewhat knowledgeable, not
knowledgeable; very comfortable, comfortable, somewhat comfortable, not comfortable; and
very involved, involved, somewhat involved, not involved. Completion time is approximately
10 -15 minutes.
This questionnaire is designed to measure the level of cultural competence among health
care professionals and specifically intended for health care clinicians (Campinha-Bacote, 2002).
Their level of cultural competence directly influences the delivery of cardiovascular health care
to the Black population because of cultural mistrust and perceived racism during patient to
provider interactions. This was an exploratory study using integrated quantitative research and
evaluation methods to determine the scope of self-reported cultural competence of nurses and
health care professionals.
Cronbach’s alpha a statistic used as a measure of the internal consistency reliability of a
psychometric instrument, of the IAPCC-R was established at .81 (Campinha-Bacote, 2002).
Internal validity and consistency of the IAPCC-R was confirmed using Guttman Split-half6
6 Split-Half Reliability, An alternative way of computing the reliability of a sum scale is to divide it in some random manner into two halves. If the sum scale is perfectly reliable, we would expect that the two halves are perfectly correlated (i.e., r = 1.0). Less than perfect reliability will lead to less than perfect correlations. We can estimate the reliability of the sum scale via the Spearman-Brown split half coefficient or the Guttman split-half: rsb In this formula, rsb is the split-half reliability coefficient, and rxy represents the correlation between the two halves of the scale = 2rxy /(1+rxy).
(.76) and Spearman-Brown (.76), (Mabunda, and White, 2006). Content validity was established
that the items on the IAPCC-R clearly reflect the review of the literature of cultural competence
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in healthcare delivery that identifies awareness/attitudes, skill and knowledge as domains of
cultural competence (Kattner, M. 2006). Face validity was established by reviews of national
experts in the field of transcultural healthcare (Campinha-Bacote, 2002). A demographic flysheet
was attached to the questionnaire to establish demographics of the participants (Appendix A).
Data Collection
Methodology
Telephone contact was initiated by the researcher7
The Nurse Managers of each location distributed informational flyers of my research
study to their respective cardiovascular health care providers/nurses located in the cardiovascular
units and the emergency room departments. Posters/Flyers were placed in the common areas
(bathrooms and break rooms), and near time clocks announcing the details of the research study
(Appendix E). The nurses were not chosen, but up to the first 50 nurses at each location
who volunteered to complete the questionnaire at their leisure were included. I distributed the
to the Nursing Research Coordinators
at Trinity Regional Health System, Rock Island Campus, IL and Genesis Medical Center, Illini
Campus, Silvis, IL, to explain the study, to obtain initial verbal consent for nursing staff
participation, and to identify the contact person for each location. Meetings were arranged with
the Nursing Research Coordinator and their respective department members to detail the study,
research aim, hypothesis, and survey questionnaire. Permission to conduct the research was
obtained from Genesis Institutional Review Board (Appendix B), Trinity Institutional Review
Board (Appendix C), and the University of Iowa Institutional Review Board (Appendix D) after
submitting a research proposal and meetings at each location with administrative members of the
nursing department.
7. The researcher is identified as Alesia Grice-Dyer
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questionnaires and demographic flysheet at both locations. To ensure complete anonymity, each
participant deposited the completed responses in a sealed box. The returned questionnaires were
reviewed to count for missing or suspicious data. Completed questionnaire and demographic
data of less than 50% would have been deleted from statistical analysis and retained for record
keeping. Completed demographic data of more than 50% were included; the missing data were
incorporated using the mean answers of the completed questionnaires. Data considered
suspicious, for example, all of the answers on a questionnaire are either yes or no, or the answers
displayed an obvious pattern, were subject to rejection, but none of the questionnaires met this
criteria.
The total number of participating nurses were ninety-two (n = 92). At the Trinity
Regional Health System, forty-five nurses (n = 45) participated. Of the 45 participating nurses,
38 nurses returned the questionnaire with the demographics flysheet; seven did not return the
demographic flysheet. Missing demographic data was not included in the analysis. At Genesis
Medical Center, Illini Campus, forty-seven (n = 47) nurses participated. The data from the
completed questionnaires were reviewed and entered into Websurveyor, a data entry program
provided by the University of Iowa, then exported into an Excel file for analysis. Each
questionnaire was scored according to the scoring key . Possible scores range from
25 -100 and indicate whether a healthcare professional is operating at a level of cultural
proficiency, cultural competence, cultural awareness or cultural incompetence. Higher scores
depict a higher level of cultural competence (Campinha-Bacote, 2002).
The analysis of the IAPCC-R© questionnaire began with descriptive statistics, particularly
measures of central tendency and frequency. Likert responses were summed and scored
Analysis
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according to the IAPCC-R scoring key Attitude was measured, where answers are
given on a scale ranging from complete agreement on one side to complete disagreement on the
other side, with no opinion in the middle. Responses to a single Likert item are normally treated
as ordinal data, because, especially when using only four levels, there is no assumption that
respondents perceive the difference between adjacent levels as equidistant. When treated as
ordinal data, Likert responses can be analyzed using non-parametric tests, such as the Wilcoxon
signed-rank test. Likert scale data can, in principle, be used as a basis for obtaining interval level
estimates by applying the polytomous Rasch model, which permits testing of the hypothesis that
the statements reflect increasing levels of an attitude or traits, as intended (Answers.com, 2009).
This analysis will use a level of significance α = .05.
Results
Demographic Flysheet
Each medical center was analyzed individually. Seven questions were included in the
demographic flysheet (Appendix A). Trinity Regional Health System had 45 nursing
participants (n = 45), with 38 (n = 38) returning the demographic flysheet with the questionnaire.
Genesis Medical Center, Illini Campus had 47 nursing participants (n = 47) and all participants
returned the demographics flysheet with the IAPCC-R questionnaire. This demographic
flysheet was used as a proxy to describe characteristics of my sample population.
The demographics reflected the composition of the sample nursing
participants/workforce in Rock Island County, Illinois. The majority of respondents’ age range
was 46 – 65, indicating the population of nurses treating Black cardiovascular patients in Rock
Island County is aging along with the patients The 2007 Illinois Nursing
Workforce Survey (National Research Corporation [NRC], 2007) finds the most common age
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category for their research participants was between 46 and 65 years of age, which represented
the most common category for LPNs (53.5%), RNs (57.6%), and NPs (73.0%). The second most
common age range was 36 to 45 years of age who participated in the 2007 Illinois Nursing
Workforce survey (NRC, 2007). The least common age range for all three nursing categories was
18 to 25 years of age, which accounted for, 3.0% of LPNs, 3.0% of RNs, and less than 1.0% of
NPs (NRC, 2007). The percentages for the age range of over 65 were 5.3% of LPNs, and
15.5% of RNs. There were no reported NPs over the age of 65.
Ninety-four percent (n = 80) of the respondents were White, which is indicative of
the disparity in the racial composition of health care workforce in Rock Island County, Illinois
(Tables 2.4 and 2.5). Moreover, a culturally diverse nursing population in both locations did not
treat any patients in Rock Island County. This is a permutation of the health disparities and
cultural competence facing an underserved and under-represented patient population. Compared
to Rock Island County population statistics provided by the U. S. Census Bureau (2008), the
sampled nursing workforce is not reflective of the area’s racial and cultural diversity.
Registered Nurses (RNs) were the largest healthcare occupation in 2003, with 2.4 million
jobs, with women comprising 92.1 percent of RNs nationally in 2003. According to the Bureau
of Labor Statistics (BLS), in 2003 nationally, 81.9 percent of RN's were white, 9.9 percent were
black, 7.0 percent were Asian, and 3.9 percent were Hispanic. Compared with total employment
figures in 2003, blacks and Hispanics were underrepresented as registered nurses. Hispanics
represented 12.6 percent of total employment, while blacks represented 10.7 percent. The 2007
Nursing Workforce survey (NRC, 2007) reports that in Rock Island County, the prevailing age
range for all nursing participants was 46 to 55 years, 29.4% for LPNs, 31,6% for RNs, and
50.0% for NPs. The second most common age range was 36 to 45 years for all levels of nursing.
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The percentage years as a licensed nursing professional are similar for participants of
Rock Island County as compared to the state of Illinois statistics. Statewide, the percentage of
LPNs who had more than 20 years of practice been 40.9%, RNs had 62.7% longevity, and of
NPs, 83.1% had more than 20 years of practice (Tables 2.7, 2.8).
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Table 2.1. Trinity Demographic Age. Frequency
N Percent Cumulative Percent
Valid 18-25 2 2.8 5.3
26-35 5 7.0 18.4
36-45 9 12.7 42.1
46-65 20 28.2 94.7
65+ 2 2.8 100.0
Total 38 53.5
Table 2.2. Scoring Key for Demographics Age.
The most common age category for respondents to this survey was between 46 and 65
years of age. The second most common age range was 36 to 45 years of age. The valid percent
represent an accurate picture of the distribution of the valid cases since these "valid" percentages
are not deflated by the inclusion of the missing cases in the denominator. In the state of Illinois,
the most common age category for respondents to this survey was between 46 and 55 years of
age (National Research Corporation, 2007).
18-25 = 1pt.
26-35 = 2pts.
36-45 = 3pts.
46-65 = 4pts.
65+ = 5pts.
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Figure 2.1 Trinity Demographic Age Range.
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Table 2.3. Illini Demographic Age Range.
Frequency N
Percent Cumulative Percent
Valid 18 - 25 years
3 4.2 6.4
26 - 35 years
11 15.5 29.8
36 - 45 years
17 23.9 66.0
46 - 65 years
16 22.5 100.0
Total 47 66.2
Total 100.0
Table 2.4. Scoring Key for Demographics Age.
The most common age category for respondents to this survey was between 36 and
45 years of age. The second most common age range was 46 to 65 years of age. The valid
percent represent an accurate picture of the distribution of the valid cases since these "valid"
percentages are not deflated by the inclusion of the missing cases in the denominator.
Scoring Key for Demographics Age
18-25 = 1pt.
26-35 = 2pts.
36-45 = 3pts.
46-65 = 4pts.
65+ = 5pts.
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Figure 2.2. Illini Demographic Age Range.
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Table 2.5. Illini and Trinity Race/Ethnicity of Nursing Workforce vs. Race/Ethnicity of Rock Island County Hospital Nurses.
a. Calculated from grouped data. b. Percentiles are calculated from grouped data
The racial identification question in the survey allowed respondents to indicate one or
more racial categories and for study purposes, the term race/ethnicity is used to clarify racial
identification. As shown in Table 2.4, almost all nurses (94.1%) identified White as their racial
group, followed by 2.4% who indicated Black or African American. There was not any racial
identification of nurses who were Native American/American Indian, Multiracial, or
Asian/Pacific Islander. As compared to the state of Illinois statistical data, the diversity of nurses
remains consistent.
Race/Ethnicity Response N Percentage Race/Ethnicity of
Rock Island County Hospital Nurses
Black/African American 2 2.4%
55
Hispanic/Non-White 3 3.5%
9
White 80 94.1% 491
Asian/Pacific Islander 0 0.0% 18
Native American/American Indian 0 0.0%
2
Multiracial 0 0.0% 0
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Table 2.6. Racial Demographics of Rock Island County Population.
Source: U.S. Census Bureau, 2006-2008 American Community Survey.
According to the completed demographic flysheets for each location (Tables 2.4 and 2.5),
the composite of the sample population did not accurately reflect the racial composite and
cultural diversity of Rock Island County. Ninety-four percent (n = 80) of the respondents were
White, which is indicative of the disparity in the racial composition of health care workforce in
Rock Island County, Illinois. Moreover, a culturally diverse nursing population in both locations
did not treat any patients in Rock Island County. This is a permutation of the health disparities
and cultural competence facing an underserved and under-represented patient population.
Rock Island County, Illinois
Estimate Margin of Error
Total: 146,800 *****
White alone 122,211 +/-1,112
Black or African American alone 11,771 +/-379
American Indian and Alaska Native alone 359 +/-150
Asian alone 2,862 +/-193
Native Hawaiian and Other Pacific Islander alone 33 +/-38
Some other race alone 6,376 +/-1,024
Two or more races: 3,188 +/-663
Two races including Some other race 1,123 +/-430
Two races excluding Some other race, and three or more races
2,065 +/-494
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Table 2.7. Study Participants’ Job Title/Level of Nursing.
Response Count Percentage
Nurse Practitioner 11 12.9%
RN 70 82.4%
LPN 4 4.7%
Table 2.8. Study Participants’ Years of Training (Schooling).
Response Count Percentage
1 year 2 2.4%
2 years 25 29.8%
3 years 18 21.4%
Graduate 39 46.4%
Most of the LPNs, RNs, and NPs who participated in this survey indicated their years of
education at Associate’s degree (2 years) followed by a Graduate degree. This pattern was
consistent with the findings of The 2007 Illinois Nursing Workforce Survey (NRC, 2007), RNs
were employed at a higher rate, with 67.8% of responding nurses completing 3 or more years of
college.
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Table 2.9. Study Participants’ Years in the Nursing Profession.
Response Count Percentage
1-5 years 17 20.0%
6-10 years 13 15.3%
11-15 years 17 20.0%
16-20 years 6 7.1%
More than 20 years 32 37.6%
Health Resources and Services Administration (HRSA, 2004)
The majority of nurses were employed in the same setting in 2004 as they were in 2003.
Eighty-nine percent (88.8 percent) of registered nurses who were working in a hospital in 2004
were also working in a hospital in 2003. In order to get more data on job market conditions for
RNs, the NSSRN asked the nurses whether they had changed employers or positions between
2003 and 2004. Results show that 62.4 percent of those in the RN population in March 2004
were employed both years in the same position. Sixteen percent of nurses (16.1 percent or
467,566) were employed both years but changed employers and/or positions. Of all RNs who
reported making an employer or position change within the past year, a large proportion, 82.7
percent, cited a workplace issue as a reason for the change (Health Resources and Services
Administration HRSA, 2004), indicating a problem with retaining trained nursing staff.
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Table 2.10. Number and Percentage of Black Patients Treated in Rock Island County.
Response (both locations) Count Percentage
Less than 10% 13 15.9%
10%- 25% 37 45.1%
26%-40% 24 29.3%
41%-55% 5 6.1%
56%-70% 2 2.4%
More than 71% 1 1.2%
Blacks and Hispanics had 13 percent fewer follow-up consultations than whites. Forty
percent of Black patients were less likely to be referred for angioplasty or by-pass surgery.
Blacks had fewer follow-up consultations and received lower cardiac performance measures over
five years (Bozzette, S., Ake, C., Tam, H., Chang, S., Louis, T., (2003). The percentage of Black
patients treated is related to the quality and number of cultural encounters of each nurse. This
percentage reflects the amount of intercultural learning each nurse participant has experienced
(Table 2.9). In comparison to the racial distribution of the county, the nursing workforce in
Rock Island County is primarily White. The representation of other ethnic/racial groups is
minimal to nonexistent.
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Figure 2.3. Percentage of Black Patents Treated.
Key
1.00 = <10%
2.00 = 10% - 25%
3.00 = 26% - 40%
4.00 = 41% - 55%
5.00 = 56% - 70%
6.00 = > 71%
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Questionnaire Results
All answers to the questionnaire were categorized into sets to score each level/degree of
responses according to the scoring key (Campinha-Bacote, 2002). The sets of responses to the
questions were scored using the Likert Scale in Table 2.10 to convert into numbers. Each scored
response was categorized to represent each of the constructs of cultural
competency.
The final cultural competency scores were compiled and categorized into the following levels:
1) Culturally Proficient 91 – 100 points 2) Culturally Competent 75 – 90 points 3) Culturally Aware 51 – 74 points 4) Culturally Unaware 25 – 50 points
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The scoring key can be found in the book “The Process of Cultural Competence in the Delivery of Health Care Services” 2002), available through most libraries.
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I hypothesized that cardiovascular health care providers in Rock Island County perceive
themselves as culturally competent. This perception of cultural competence is self-reported
since it was not directly observed and only an assessment at the institutional level and not an
actual measurement. The self-reported cultural competence levels as measured by the
questionnaire are not as high as perceived. The findings were consistent with this hypothesis; the
cardiovascular health care providers sampled at both locations using self-reporting on the
questionnaire are primarily culturally aware, but not culturally competent or proficient.
The results of cultural competency scores for Trinity Regional Health System are;
1) Culturally Proficient 0
2) Culturally Competent 7
3) Culturally Aware 37
4) Culturally Incompetent 1
Total 45
The results of cultural competency scores for Genesis Medical Center, Illini Campus are;
1) Culturally Proficient 0
2) Culturally Competent 7
3) Culturally Aware 39
4)
Culturally Incompetent 1
Total 47
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Table 2.11. Cultural Competency Scores for Trinity Regional Health System.
N 45.00
Mean 67.69
Median 67.50(a)
Mode 70.00
Skewness 0.09
Std. Error of Skewness 0.35
Range 41.00
Minimum 46.00
Maximum 87.00
Percentiles 25 62.90(b)
50 67.50
75 71.20 a. Calculated from grouped data. b. Percentiles are calculated from grouped data
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Figure 2.4. Cultural Competency Scores for Trinity Regional Health System.
Key
1) Culturally Proficient 91 – 100 points 2) Culturally Competent 75 – 90 points 3) Culturally Aware 51 – 74 points 4) Culturally Unaware 25 – 50 points
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Table 2.12. Cultural Competency Scores for Genesis Medical Center, Illini Campus. N 47.00
Mean 66.98
Median 66.00(a)
Mode 66.00
Variance 55.60
Skewness 0.03
Std. Error of Skewness 0.35
Range 44.00
Minimum 43.00
Maximum 87.00
Percentiles 25 62.75(b)
50 66.00
75 71.10 a. Calculated from grouped data. b. Percentiles are calculated from grouped data.
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Figure 2.5. Cultural Competency Scores for Genesis Medical Center, Illini Campus.
Key 1) Culturally Proficient 91 – 100 points 2) Culturally Competent 75 – 90 points 3) Culturally Aware 51 – 74 points 4) Culturally Unaware 25 – 50 points
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Table 2.13. Illini and Trinity Cultural Competency Scores.
N 92.00
Mean 67.30
Median 66.50(a)
Mode 66.00
Std. Deviation 7.48
Variance 56.05
Skewness 0.06
Std. Error of Skewness 0.25
Range 44.00
Minimum 43.00
Maximum 87.00
Percentiles 25 62.85(b)
50 66.50
75 71.13 a. Calculated from grouped data. b. Percentiles are calculated from grouped data.
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Figure 2.6. Illini and Trinity Cultural Competency Scores.
Key
1) Culturally Proficient 91 – 100 points 2) Culturally Competent 75 – 90 points 3) Culturally Aware 51 – 74 points 4) Culturally Unaware 25 – 50 points.
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CHAPTER IV
CONCLUSION
The purpose of this study was to examine the level of cultural competence of the health
care providers treating Black patients with cardiovascular disease and the resulting comorbid
conditions, based on The Inventory for Assessing the Process of Cultural Competence Among
Healthcare Professionals-Revised [(IAPCC-R), ]. This chapter will discuss the
results based on the analysis of the questionnaire for each of the constructs of cultural
competency, cultural mistrust and racism, and perception of these barriers to quality health care
services for treatment and management of cardiovascular disease affecting the Black/African
American patient population in Rock Island County, Illinois. Recommendations will be included
in the discussion that nursing departments can implement to potentially increase cultural
understanding and competency to address the needs of a rapidly changing diversity within their
patient population.
In comparing this study results to several similar research studies, Teresa Seright (2007)
describes a similar population of nurses, who had indicated that they were culturally competent.
The nurses were evaluated using the Campinha-Bacote method; results were a mean score of
68.1. Noble, Noble and Hand (2009) report their findings of one hundred twenty eight (n=128)
surveyed healthcare professionals, twenty-nine (n=29) of the nurses achieved a score of cultural
competence (75-90 points). The combined mean score of Trinity and Genesis nurses was 66.98,
which correlates to the Campinha-Bacote category of merely “culturally aware” (range score of
51-74 points), not culturally competent (range score of 75-90 points).
Discussion
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This study found that nurses at both locations, who had fewer years of nursing experience
and graduate level of nursing education did not score at the cultural proficient (90 – 100 points),
which supports the hypothesis. Compared with Cooper Braithwaite’s (2006) research study,
regression analysis showed that nurses with fewer years of nursing experience and higher level
of education had a weak association with increased cultural knowledge and cultural competence.
Nurses' personal and professional characteristics influenced their response to an educational
intervention to improve their cultural knowledge and cultural competence. This study results
found that although age and years of nursing experience were a factor in nurses being culturally
aware, none achieved the level of cultural proficiency (91 – 100).
According to this study, the majority of responding nurses reported that 10%-25% of total
patients treated for cardiovascular conditions were Black. The Center for Disease Control and
Prevention (CDC, 2010) reports that from 2003-2006, 39% percent of Black men 20 years and
over were diagnosed with hypertension. In the same period, 43% of Black women 20 years and
over were reported to have hypertension. This indicates that the Black population is not seeking
treatment for cardiovascular conditions, or that more interventions of outreach and education are
needed for this target population in Rock Island County, Illinois. This is also indicated for the
entire Quad Cities area which is composed of Rock Island, Moline, East Moline, and Silvis in
Illinois; Davenport and Bettendorf in Iowa Scott County.
When comparing the cultural competency scores with the percentage of Black patients
treated, there is the overall recognition and understanding that Black (minorities) do not always
receive an equal level of health care compared to White patients. According to a report by
Michele Late (2003), 65 percent of Blacks recognize this statistical fact, while only 30 percent of
Whites admit the problem. Racism is incompatible with democratic ideals, yet both are deeply
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characteristic of the US society (James and Arbor, 2003). Cooper Braithwaite’s (2006) research
study examined how nurses' personal and professional characteristics influenced their response
to an educational intervention to improve their cultural knowledge and cultural competence
(n=76). Regression analysis showed that fewer years of nursing experience and higher level of
education had a weak association with increased cultural knowledge and cultural competence but
learning style and age were not associated with the outcomes.
A study by Wittwer and Herbold (2009) found eighty-nine percent (n = 85) of
respondents knew fairly or very well the dietary choices/patterns of individuals they serve based
on cultural preferences. More than 50% (n = 60) never or seldom asked about the use of
traditional cultural practices, and 41% (n = 39) never or seldom asked about traditional remedies.
Forty-eight percent (n = 43) regularly modified health education materials to meet the linguistic
needs of individuals they serve, whereas 53% (n = 46) regularly modified materials to meet
literacy needs.
Survey research suggests that among White Americans, prejudicial attitudes toward
minorities remain more common than not, as over half to three-quarters believe that relative to
Whites, particularly African Americans, are less intelligent, more prone to violence, and prefer to
live off of welfare. It is reasonable to assume, however, that the vast majority of healthcare
providers find prejudice morally abhorrent and at odds with their professional values. But
healthcare providers, like other members of society, may not recognize manifestations of
prejudice in their own behavior.
While there is no direct evidence that provider biases affect the quality of care for
minority patients, research suggests that healthcare providers’ diagnostic and treatment
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decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity.
(Schulman, Berlin, Harless, Kerner, Sistrunk, Gersh et al., 1999).
These findings suggest that while the relationship between race or ethnicity and treatment
decisions is complex and may also be influenced by gender, providers’ perceptions and attitudes
toward patients are influenced by patient race or ethnicity, often in subtle ways.
The concept of managing diversity is founded in recognizing diversity and difference as
positive attributes of individuals and focuses on building the positives rather than seeking to
eliminate or reduce the negatives (Cortis, 2003). The principals of the managing diversity
approach are relevant to nursing because they offer less reliance on a legalistic approach, which
can easily become tokenistic, mere gestures, and does not respect or accept racial or cultural
differences, but address the issues at a level of organizational culture (Donald and Rattansi,
1992). This strategic approach is does more than tolerate differences and moves from the
paradigm of understanding culture as belonging to a different group, but as an integral concept of
individuality that is not static, not stereotypical.
Summary
Three mechanisms might be operative in healthcare disparities from the provider’s side of
the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting
with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or
health of minorities. Patients might also react to providers’ behavior associated with these
practices in a way that also contributes to disparities. Research on how patient race or ethnicity
may influence decision-making and the quality of care for minorities is still developing, and as
yet there is no direct evidence to illustrate how prejudice, stereotypes, or bias may influence care.
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In the absence of such research, the study committee drew upon a mix of theory and relevant
research to understand how these processes might operate in the clinical encounter.
Part of the problem is that health care professionals see some patients through a
stereotypical lens that cloud their diagnosis and treatment. Another part of the problem is the
collective memory among Blacks about their exploitation by the medical establishment (Gamble,
2002; Erlen, 2003). These memories cultivate fears of genocide and create barriers that impede
the process of health promotion within the Black population and other racial/ethnic populations.
One of the basic and essential roles of health promotion in public health is to address
racial and ethnic disparities in a straight forward manner due to the demographic changes that are
anticipated in the next decade (Campanelli, 2003; English and Videto, 1997). The success that is
achieved in improving the quality of health and the delivery of health care services will
significantly impact the future quality of health of the entire nation.
Cultural awareness was described as self-examination and in-depth exploration of one’s
own cultural background (Campinha-Bacote, 2003). Without this awareness, health care
providers may tend to engage in cultural imposition, which is described as imposing one’s own
cultural beliefs upon those from another culture (Campinha-Bacote) or cultural blindness.
Cultural awareness does not go far enough toward achieving the level of cultural competence
development that is required of health care providers and institutions to safely and effectively
care for diverse populations. Some health care providers may believe that by treating others
equally, regardless of cultural background that they are doing the right thing. Campinha-Bacote,
(2003) described this as racism, however; racism is not easily talked about in health care. The
American Nurses Association (2002) and the Institute of Medicine (2002) both described the
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existence of racism in healthcare and the detrimental effects on the health of patients (Seright,
2007).
Cultural competence plays an important role when addressing racial/ethnic health
disparities. Cultural competence is defined as a set of attitudes, skills, behaviors and policies that
enable health professionals to work effectively in cross-cultural situations and take into account
the health related beliefs, cultural values, disease prevalence, and treatment efficacy (Edwards
and Erwin-Johnson, 2003; Richardson and Jacobs, 2002; Health Disparities, 2004; Kim, Clark,
and Barton, 2001).
Turnock (2001) identified several enabling steps, from an Institute of Medicine (IOM)
report in 1988 that would guide the current health system to a more optimally functioning
system. These steps include; improving the statutory base of public health; strengthening the
structural and organizational framework; improving the capacity for action, including technical,
political, management, programmatic, and fiscal competencies of public health professionals;
and strengthening the linkages between academia and the practice of healthcare.
The time of day was a major limitation because shift change was the optimal time to
access the greatest number of nurses. The questionnaire was based on self-report of the nurse’s
personal beliefs and biases; there was no way to measure the effect of peer pressure in
completing the answers.
Study Limitations
The nursing profession will be required to develop culturally specific skills, attitudes, and
beliefs in order to effectively promote the interventions that are necessary to begin the process of
reducing the health disparities within this nation. The elimination of health disparities was a
Recommendations
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bold step forward from the goal of Healthy People 2000 (Spector, 2000), which was to reduce
disparities in health status, health risks, and use of preventative interventions within the
population groups. The elimination of disparities by the year 2010 requires new knowledge of
the cultural diversity within the nation starting with developing cultural competence of the
workforce of Public Health.
According to a report by Mail, Lachenmayr, Auld, and Roe (2004), a stronger
organizational commitment from groups like Society for Public Health Education (SOPHE) and
the American Public Health Association (APHA) is crucial to helping diverse practitioners
eliminate the continuing practices among health care professionals of racism, stereotyping, bias,
discrimination, and cultural and professional incompetence
The ability to evolve and adapt to the emerging culturally diverse population is a
challenge that is not just a necessity but also a requirement to address the goals of improving the
quality of health and equal access to and the delivery of health care services of the minority
populations of this nation. During the course of this research study, I have noted interaction
between nurses and Black patients; I developed a list of common cultural courtesy rules that
address some of the barriers when treating patients of another culture:
1. Unless they learn to become culturally sensitive, 90% to 95% of the current students
will probably fail many attempts to develop and implement any type of interventions
within a target population.
2. Do not assume you are familiar with the person/minority that you are addressing.
Show respect and address the person with; Yes Sir, No Sir, Yes Ma’am, and No
Ma’am. Age is not necessarily a proper guideline.
3. Do not assume anything about a particular culture, race, or ethnic group. Do the
research. If you do not know, ask questions.
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4. Remain nonjudgmental. The goal is to gain another perspective, not to express
your opinion. You are now the one who has to gain acceptance.
5. Step out of your comfort zone. Do not be afraid to learn, experience something
different or new, and what is accepted within the culture, race, or ethnic group.
6. Understand, what is accepted behavior by you, will possibly and can be perceived as
offensive and discriminatory by another culture, race, or ethnic group.
7. Do not assume. The media is a very powerful provider of misinformation.
Assumptions and stereotyping does not work or fit in reality.
8. Keep in mind that a goal you must obtain is trust. Without trust you will get
absolutely nowhere. Be truthful and sincere. Do not promise anything you cannot do
or give. You are the outsider and you must prove you can be trusted.
9. Do not dwell on cultural differences. Focus on similarities. Respect the cultural
differences.
10. Actions speak louder than words. Whether conscious or unconscious, body
language provides cues that send out powerful messages.
11. Capitalize on good listening skills. A large amount of information can be gained.
12. It would be wise to assess and identify your own personal prejudices and perceptions.
In essence, know and understand yourself before you try to know and understand
other cultures, races, or ethnic groups.
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APPENDIX A
DEMOGRAPHICS SHEET
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DEMOGRAPHICS
Age 18-25 26-35 36-45 46-65 65+
Race/Ethnicity Black/African American Hispanic/NonWhite White Asian/Pacific Islander Native American/American Indian Multiracial College 1year 2 years 3 years Graduate
Job Title Nurse Practitioner RN LPN
Years in healthcare 1-5 years 6 -10 11-15 16-20 More than 20 years Job Location Illini Trinity What is the percentage of Black patients do you treat? Less than 10% 10% - 25% 26% - 40% 41% -55% 56% -70% More than 71%
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APPENDIX B
GENESIS INSTITUTIONAL REVIEW BOARD
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67
APPENDIX C
TRINITY INSTITUTIONAL REVIEW BOARD
68
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APPENDIX D
UNIVERSITY OF IOWA INSTITUTIONAL REVIEW BOARD
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APPENDIX E
POSTERS /FLYERS
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