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C H A P T E R

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Diversity in Health Care

Jean Gordon, RN, DBA

Learning OutcomesAfter completing this chapter, the student should be able to:

1. Define diversity. 2. Define cultural competency.3. Define diversity management.4. Understand why changes in US demographics affect the healthcare

industry.

■ OVERVIEWDemographics of the US population have changed dramatically in thelast three decades. These changes directly impact the healthcare indus-try in regard to the patients we serve and our workforce. By 2050, theterm “minority” will take on a new meaning. According to the US CensusBureau, by mid-century the white, non-Hispanic population will compriseless than 50 percent of the nation’s population. As such, the healthcareindustry needs to change and adopt new ways to meet the diverse needsof our current and future patients and employees.

The American Heritage Dictionary of the English Language (4th ed.)defines diversity as: (1) the fact or quality of being diverse; difference, and

Dr. Jean Gordon is Associate Professor in the Department of Management at St. Thomas University,Miami, Florida. Dr. Gordon received her DBA and MS/Human Resources Management from NovaSoutheastern University and her BSN from the University of Miami. Dr. Gordon is a reviewer for theMalcolm Baldridge Award and actively involved with the American Society of Training and Developmentand the Society for Human Resource Management.

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16 CHAPTER 2 DIVERSITY IN HEALTH CARE

(2) a point in which things differ. Dreachslin (1998) provided us with amore specific definition of diversity. She defined diversity as “the fullrange of human similarities and differences in group affiliation includ-ing gender, race/ethnicity, social class, role within an organization, age,religion, sexual orientation, physical ability, and other group identities”(p. 813). For our discussions, we will focus on the following diversitycharacteristics: (1) race/ethnicity, (2) age, and (3) gender.

This chapter will be presented in three parts. First, we will discuss thechanging demographics of the nation’s population. Second, we will ex-amine how these changes are affecting the delivery of health services fromboth the patient and employee perspectives. Because diversity challengesfaced by the healthcare industry are not limited to quality-of-care andaccess-to-care issues, the third part of our discussions will explore howthese changes will affect the health services workforce, and more specifi-cally the current and future leadership within the industry.

■ CHANGING US POPULATIONThere is no doubt that the demographic profile of the US population hasundergone significant changes within the past 10 years regarding age,gender, and ethnicity (see Table 2-1).

During the 1990s, the combined US population of black non-Hispanic,Native Americans, Asians, Pacific Islanders, and Hispanics/Latinos grewat 13 times the rate of the white non-Hispanic population (United StatesDepartment of Commerce, 2000). In addition, for the first time respon-dents to the 2000 US Census were allowed to choose more than one racialcategory. In fact, 1.6 percent of the US population (6.8 million people)did so by identifying with and choosing two or more races (United StatesDepartment of Commerce, 2003, p. 24). It is predicted that the numberof Americans reporting themselves or their children as multi-racial is ex-pected to increase. In addition to the changing ethnic and racial compo-sition of America, another issue is the aging population. According to theUS Census Bureau, 35 million people (12.4 percent of the US popula-tion) are 65 years of age or older. This is 3.8 million more people thanin 1990 (see Figure 2-1).

Although this was the first time in the history of the census that thepopulation aged 65 and over did not grow faster than the total popula-tion, it is predicted that the trend will reverse as the baby boomers (thoseborn between 1946 and 1964) reach age 65 starting in 2011 (see Figure2-2).

In addition to the increasingly older population, there is a decliningnumber of young people in America. From 1950 to 2000, the percent-age of the American population under the age of 18 fell from 31 percentto 26 percent (United States Department of Commerce, 2003, p. 23).

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This decline in America’s younger population will have a direct effect onthe industry’s ability to recruit healthcare professionals to provide suffi-cient services in the future. Young people of all ethnicities must be attractedto the healthcare industry as a career choice in order to meet the health-care needs of the country’s growing population.

Although males and females are almost evenly divided, representing50.9 percent and 49.1 percent, respectively, in the population under 25years, males dominate females with 105 males for every 100 females.However, among older adults, the male–female ratio changes, with womenoutnumbering men. For people 55 to 64 years old, the male–female ratiois 92 to 100, but for those 85 and over, the ratio decreases to only 41 menfor every 100 women (United States Department of Commerce, 2003).

Race/EthnicityThe US population has continued to diversify during the last 30 years,as minority populations continue to increase at a faster rate than thewhite, non-Hispanic population. Although the white, non-Hispanic

Changing US Population 17

Table 2-1 Resident Population of the United States by Age, Gender,Race/Ethnicity, and Region

1990 2000Number Percent Number Percent

Total population 248,709,873 100.0 281,421,906 100.0Under age 18 63,604,432 25.6 72,293,812 25.7Ages 18 to 64 153,863,610 61.9 174,136,341 61.9Ages 65 and over 31,241,831 12.6 34,991,753 12.4Males 121,239,418 48.7 138,053,563 49.1Females 127,470,455 51.3 143,368,343 50.9White, non-Hispanic* 188,128,296 75.6 194,552,774 69.1Black, non-Hispanic* 29,216,293 11.7 33,947,837 12.1Hispanic 22,354,059 9.0 35,305,818 12.5Asian, non-Hispanic* 6,968,359 2.8 10,476,678 3.7American Indian, non-Hispanic* 1,793,773 0.7 2,068,883 0.7Some other race, non-Hispanic* 249,093 0.1 467,770 0.2Two or more races, non-Hispanic N/A N/A 4,602,146 1.6

N/A�Not Available.*For 2000, excludes people who identified with two or more races.Source: AmeriStat, August 2001.Citations:U.S. Census Bureau, Census 2000 Redistricting Data (PL 94-171) Summary File for States, Tables PL1, PL2, PL3, andPL4, accessed at www.census.gov/population/www/cen2000/phc-t1.html (August 17, 2001); U.S. Census Bureau,“Table DP-1. Profile of General Demographic Characteristics for the United States: 2000,” accessed at www.census.gov/Press-Release/www/2001/tables/dp_us_2000.xls (August 17, 2001); and U.S. Census Bureau, “TableDP-1. Profile of General Demographic Characteristics for the United States: 1990,” accessed atwww.census.gov/Press-Release/www/2001/tables/dp_us_1990.xls (August 17, 2001).

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population still represents the largest group (69 percent) of the US pop-ulation, this is down from 83 percent in 1970 (United States Departmentof Commerce, 2003).

In 2002, the Hispanic population became the largest minority in theUnited States, representing 13.5 percent of the population. This is upfrom 4.5 percent in 1970, the first census in which Hispanic origin wasidentified. The remaining population is comprised of approximately 13percent black non-Hispanics, 4 percent Asians and Pacific Islanders, 1percent American Indians and Alaska Natives, and 2.4 percent of thepopulation identified themselves as belonging to more than one race.Interestingly, of the 6.8 million people reporting two or more races, 42percent were under 18 (United States Department of Commerce, 2003)

The Asian population in the United States is increasing faster than thetotal population. From 1990 to 2000, the population of those peoplewho identified themselves as being Asian (either alone or in combina-tion with another race) grew 72 percent, while the total population grewonly 13 percent (United States Department of Commerce, 2003).

Aging PopulationAccording to the 2000 US Census, people aged 85 and over showed thehighest percentage increase of the country’s population. This group rep-


199065 to 74 years 75 to 84 years 85 years and over

10,165

7,942

18,107

2000 1990 2000 2000

10,088

8,303

18,391

6,289

3,766

10,055

7,482

4,879

12,361

1990

3,080858

2,222

4,2401,227

3,013

MenWomen

Figure 2-1 Population 65 Years and Over by Age and Sex: 1990 and 2000(Numbers in thousands. For information on confidentiality protection, nonsampling er-ror, and definitions, see www.census.gov/prod/cen2000/doc/sfl.pdf)Source: U.S. Census Bureau, Census 2000 Summary File I: 1990 Census of Population, General PopulationCharacteristics, United States (1990 CP-1-1).

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resented 9.9 percent in 1990 and increased to 12.2 percent of the “older”population in 2000. It is estimated that this group will represent 5 per-cent of the total US population by 2050 and will represent 31 percent ofthe older population.

One of the most striking characteristics of the older population is thechange in the ratio of men to women as people age (United StatesDepartment of Commerce, 2003). In 2000, for the group aged 65 andover, there were 70 men for every 100 women, and 41 men for every 100women in the group over 85. It is predicted that in 2050 men will rep-resent 37 percent of the 85 and over group, and 46 percent of the 65 andover group. Therefore, in the future the elderly population will be 46percent men and 54 percent females.

The elderly comprise a nonhomogeneous population. The racial com-position of the older population differs from the racial composition of theUS population as a whole. In 2000, the US population, as a whole, included69 percent white non-Hispanic, 12 percent black non-Hispanic, 12 per-cent Hispanic, 4 percent Asian, and approximately 3 percent other races.A much higher proportion of the population over 65 is white non-Hispanic(more than 86 percent). Eight percent of the older population is black non-Hispanic and 5 percent is Hispanic. Asians make up just over two percentof this group, with other races forming the remainder. This racial compo-sition will change over the next two decades. By 2030, it is predicted thatblack non-Hispanic, Hispanic, and Asian populations will show the great-est population increase (United States Department of Commerce, 2004).

Changing US Population 19

0

20

40

60

28.5

59 6057.2

54.2 53.6 53.4

20.7

26

20.4

25.9

19.6

26.2

16.3

26.4

13

26.9

12.4

2000 2010 2020Years

2030 2040 2050

0–19

20–64

65–85�

Figure 2-2 Projected Population of the United States by Age 2000–2050Source: U.S. Census Bureau, Population Division, Population Projections Branch. Last Revised May 18, 2004.

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GenderAs previously noted, according to the US Census Bureau, in 2000 50.9percent of the US population was female, and 49.1 percent was male.That translates to 96 men for every 100 women. However, the ratioof men to women varies significantly by age group. There were about105 males for every 100 females under 25 in 2000, reflecting the factthat more boys than girls are born every year and that boys continueto outnumber girls through early childhood and young adulthood.However, the male–female ratio declines as people age. For men andwomen aged 25 to 54, the number of men for each 100 women in 2000was 99. Among older adults, the male–female ratio continued to fallrapidly, as women increasingly outnumbered men. For people 55 to64, the male–female ratio was 92 to 100, but for those 85 and over,there were only 41 men for every 100 women (United States Departmentof Commerce, 2003). These male/female ratios reflect a new trend oc-curring since 1980. From 1900 to 1940, there were more males.Beginning in 1950, there were increasingly more females due to re-duced female mortality rates. This trend reversed between 1980 and1990 as male death rates declined faster than female rates and as moremen immigrated to the United States than women did (United StatesDepartment of Commerce, 2003).

When we look at education, it appears that females are outpacingmen. Among the population aged 25 and over, 84 percent of both menand women were high school graduates. However, in this age group, 28percent of men had graduated from college as compared to 25 percentof women. But in the 25 to 29 age group, more college graduates arewomen than men, with 30 percent of women holding a bachelor’s degreeor higher, in comparison to 28 percent of men. However, even with col-lege degrees, a high number of women continue to be employed in ad-ministrative support positions. Therefore, it is not surprising that only5.5 percent of working women reported earnings of $75,000 or more ascompared to 15.8 percent for men.

■ IMPLICATIONS FOR THE HEALTHCARE INDUSTRYThe changing demographics of America’s population affect the healthcareindustry two-fold. First, healthcare professionals need to have cultural com-petence to provide effective and efficient health services to diverse patientpopulations. However, before we continue our discussion, we need to de-fine what is meant by cultural competence (see Hofstede’s CulturalDimensions, Exhibit 2-1). Although the literature provides many defini-tions of cultural competence, such as “ongoing commitment or institu-tionalism of appropriate practice and policies for diverse populations”


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Implications for the Healthcare Industry 21

Exhibit 2-1 Hofstede’s Cultural Dimensions

One of most extensive cross-cultural surveys ever conducted isHofstede’s (1983) study of the influence of national culture on or-ganizational and managerial behaviors. National culture is deemedto be central to organizational studies because national cultures in-corporate political, sociological, and psychological components.

Hofstede’s research was conducted over an 11-year period, withmore than 116,000 respondents in more than 40 countries. The re-searcher collected data about “values” from the employees of amultinational corporation located in more than 50 countries. Basedon his findings, Hofstede proposed that there are four dimensionsof national culture, within which countries could be positioned, thatare independent of each other. Hofstede’s (1983, pp. 78–85) four di-mensions of national culture were labeled and described as:

• Individualism – Collectivism. This dimension measures culturealong self-interest versus group interest scale. Individualismstands for a preference for a loosely knit social framework in so-ciety wherein individuals are supposed to take care of themselvesand their immediate families only. Its opposite, Collectivism,stands for a preference for a tightly knit social framework in whichindividuals can expect their relatives, clan, or other in-group tolook after them in exchange for unquestioning loyalty. Hofstede(1983) suggested that self-interested cultures (e.g., Individualism)are positively related to the wealth of a nation.

• Power Distance. This is the measure of how a society deals withphysical and intellectual inequalities, and how the culture appliespower and wealth relative to its inequalities. People in large PowerDistance societies accept hierarchical order in which everybodyhas a place, which needs no further justification. People in smallPower Distance societies strive for power equalization and de-mand justification for power inequalities. Hofstede (1983) indi-cated that group interest cultures (e.g., Collectivism) have largePower Distance.

• Uncertainty Avoidance. This dimension reflects the degree towhich members of a society feel uncomfortable with uncertaintyand ambiguity. The scale runs from tolerance of different behav-iors (i.e., a society in which there is a natural tendency to feel se-cure) to one in which the society creates institutions to createsecurity and minimize risk. Strong Uncertainty Avoidance soci-eties maintain rigid codes of belief and behavior and are intoler-ant toward deviant personalities and ideas. Weak Uncertainty

continues

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Exhibit 2-1 continued

Avoidance societies maintain a more relaxed atmosphere in whichpractice counts more than principles and deviance is more eas-ily tolerated.

• Masculinity versus Femininity. This dimension measures the divi-sion of roles between the genders. The masculine side of the scaleis a society in which the gender differences are maximized (e.g., needfor achievement, heroism, assertiveness, and material success).Feminine societies are ones in which there are preferences for re-lationships, modesty, caring for the weak, and the quality of life.

Hofstede proposed that the most important dimensions for orga-nizational leadership are Individualism/Collectivism and PowerDistance, and the most important for decision making are PowerDistance and Uncertainty Avoidance. Uncertainty Avoidance playsan integral part of a country’s culture regarding change. For example,Nahavandi and Malekzadeh (1999, pp. 495–496) point out that coun-tries such as Greece, Portugal, and Japan have national cultures thatdo not easily tolerate uncertainty and ambiguity. Therefore, the resultantbehavior emphasizes issue avoidance or the importance of plannedand well-managed activities. Other countries such as Sweden, Canada,and the United States are able to tolerate change because of thepotential for new opportunities that may come with change.

The question frequently asked is whether Hofstede’s (1983) cul-tural dimensions are still applicable today? Patel (2003) found thatthe characteristics of Chinese, Indian, and Australian cultures cor-roborated Hofstede’s study results. Patel’s study of the relationshipbetween business goals and culture, measured by correlating therelative importance attached to the various business goals with thenational culture dimension scores from Hofstede’s study, found thatalthough the four cultural dimension scores were nearly 20 years old,they were validated in this large, cross-national survey. In a studythat measured 1,800 managers and professionals in 15 countries, sta-tistically significant correlations with the Hofstede indices validatedthe applicability of the first study’s cultural dimension findings(Hofstede, Van Deusen, Mueller, & Charles, 2002). The findings fromthese studies suggest that Hofstede’s cultural dimensions continueto be robust and are still applicable measure components of na-tional culture differences.

Hofstede (1991) subsequently included an additional dimension based on Chinesevalues referred to ‘Confucian dynamism’. Hofstede renamed this dimension as a long-term versus short-term orientation in life.

(Brach & Fraser, 2000; Weech-Maldonado et al., 2002), for our discus-sions we adopted the definition used by the Office of Minority Health(OMH) of the US Department of Health and Human Services, which de-fines cultural competence as

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a set of congruent behaviors, attitudes and policies that come to-gether in a system, agency or among professionals that enables ef-fective work in cross-cultural situations. ‘Culture’ refers to integratedpatterns of human behavior that include the language, thoughts, com-munications, actions, customs, beliefs, values, and institutions ofracial, ethnic, religious or social groups. ‘Competence’ implies hav-ing the capacity to function effectively as an individual and an or-ganization within the context of the cultural beliefs, behaviors andneeds presented by consumers and their communities. (HHS Officeof Minority Health, 1999)

Second, due to changing demographics of the nation’s population, thehealthcare industry needs to ensure that the healthcare workforce mir-rors the patient population it serves, both clinically and managerially. Asnoted by Weech-Maldonado et al. (2002), healthcare organizations mustdevelop policies and practices aimed at recruiting, retaining, and man-aging a diverse workforce in order to provide both culturally appropri-ate care and improved access to care for racial/ethnic minorities.

Diversity Issues within the Clinical SettingConsider the following:

Scenario One: An insulin-dependent, indigent black non-Hispanicmale was treated at a predominantly Hispanic border clinic. Later,he was brought back to the clinic in a diabetic coma. When he awoke,the nurse who had counseled him asked if he had been following herinstructions. “Exactly!” he replied. When the nurse asked him toshow her, the monolingual Spanish-speaking nurse was startled whenthe patient proceeded to inject an orange and eat it.

Scenario Two: As Maria (an elderly, monolingual Hispanic fe-male) was being prepared for surgery, which was not why she cameto the hospital, her designated interpreter (a young female relative)is told by an English-speaking nurse to tell Maria that the surgeonis the best in his field and she’ll get through this fine. The young in-terpreter translated, “the nurse says the doctor does best when he’sin the field and when it’s over you’ll have to pay a fine!”

These may seem rather humorous misunderstandings, but real-life ex-periences such as these happen every day in the United States (Howard,Andrade & Byrd, 2001). For example, a recent survey by the Common-wealth Fund (2002) found that black non-Hispanics, Asian Americans,and Hispanics are more likely than white non-Hispanics to experiencedifficulty communicating with their physician, to feel that they are treatedwith disrespect when receiving health care, to experience barriers to ac-cess to care such as lack of insurance or not having a regular physician,and to feel they would receive better care if they were of a different race


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or ethnicity. In addition, the survey found that Hispanics were more thantwice as likely as white non-Hispanics (33% vs 16%) to cite one or morecommunication problems such as not understanding the physician, notbeing listened to by the physician, or not asking questions they neededto ask. Twenty-seven percent of Asian Americans and 23 percent of blacknon-Hispanics experience similar communication difficulties.

Cultural differences between providers and patients affect the provider–pa-tient relationship. For example, Fadiman (1998) related a true and poignantstory of cultural misunderstanding within the healthcare profession. Fadimandescribed the story of a young female epileptic Hmong immigrant whoseparents believed that their daughter’s condition was caused by spirits called“dabs,” which had caught her and made her fall down, hence the name ofFadiman’s book The Spirit Catches You and You Fall Down. The patient’sparents struggled to understand the prescribed medical care that only rec-ognized the scientific necessities but ignored their personal belief about thespirituality of one’s soul in relationship to the universe. From a unique per-spective, Fadiman examined the roles of the caregivers (physicians, nurses,and social workers) in the treatment of ill children. She studied the way themedical care system responded to its own perceptions that the family wasrefusing to comply with medical orders without understanding the mean-ing of those orders in the context of the Hmong culture, language, andbeliefs.

Because of our increasingly diverse population, healthcare profes-sionals need to be concerned about their cultural competency, which ismore than just cultural awareness or sensitivity. Although formal cul-tural training has been found to improve the cultural competence ofhealthcare practitioners, a recent study found that only 8 percent of USmedical schools and no Canadian medical schools had formal courses oncultural issues (Kundhal, 2003).

However, changes are occurring within the industry to reduce thehealthcare disparities among different minority groups (see Exhibit 2-2)by assisting healthcare practitioners in developing their cultural compe-tences as they encounter more diverse patients.

One leader in this effort has been the Commonwealth Fund. TheCommonwealth Fund (2003), in addition to funding initiatives regard-ing quality of care for underserved populations, has also initiated an ed-ucational program that assists healthcare practitioners in understandingthe importance of communication between culturally diverse patientsand their physicians, the tensions between modern medicine and culturalbeliefs, and the ongoing problems of racial and ethnic discrimination.The goals of this program are for clinicians to:

1. Understand that patients and healthcare professionals often havedifferent perspectives, values, and beliefs about health and illnessthat can lead to conflict, especially when communication is limitedby language and cultural barriers.

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2. Become familiar with the types of issues and challenges that are par-ticularly important in caring for patients of different cultural back-grounds.

3. Think about each patient as an individual, with many different so-cial, cultural, and personal influences, rather than using generalstereotypes about cultural groups.

4. Understand how discrimination and mistrust affect the interactionof patients with physicians and the healthcare system.

5. Develop a greater sense of curiosity, empathy, and respect towardpatients who are culturally different, and thus be encouraged to de-velop better communication and negotiation skills through ongoinginstruction.

In addition to the Commonwealth Fund, the W.K. Kellogg Foundationhas led efforts to lessen the recognized disparity of racial and ethnic minoritygroups’ representation among the nation’s health professionals. It was theKellogg Foundation that requested the recent Institute of Medicine’s (2004)study entitled In the Nation’s Compelling Interest: Ensuring Diversity inthe Health Care Workforce. The Institute of Medicine found that racial andethnic diversity is important in the health professions because:

1. Racial and minority healthcare professionals are significantly morelikely than their peers to serve minority and medically underserved


Exhibit 2-2 Unequal Treatment

A study in 2002 by the Institute of Medicine entitled UnequalTreatment: Confronting Racial and Ethnic Disparities in Health Care,found that a consistent body of research demonstrates significantvariation in the rates of medical procedures by race, even when in-surance status, income, age, and severity of conditions are compa-rable. This research indicated that US racial and ethnic minoritiesreceive even fewer, routine medical procedures, and experience alower quality of health services than the majority of the population.For example, minorities are less likely to be given appropriate car-diac medications or to undergo bypass surgery, and are less likelyto receive kidney dialysis or transplants. By contrast, they are morelikely to receive certain less desirable procedures, such as lowerlimb amputations for diabetes and other conditions.

The study’s recommendations for reducing racial and ethnic dis-parities in health care included increasing awareness about dispar-ities among the general public, health care providers, insurancecompanies, and policy-makers.

Source: Smedley, B. D., Stitch, A. Y. & Nelson, A. R. (eds) (2002). Unequal Treatment:Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: NationalAcademy of Sciences, Institute of Medicine Committee on Understanding and EliminatingRacial and Ethnic Disparities in Health Care, p. 3.

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communities, thereby helping to improve problems of limited mi-nority access to care.

2. Minority patients who have a choice are more likely to select health-care professionals of their own racial or ethnic background. Moreover,racial and ethnic minority patients are generally more satisfied withthe care that they receive from minority professionals, and minoritypatients’ ratings of the quality of their health care are generally higherin racially concordant than in racially discordant settings.

3. Diversity in healthcare training settings may assist in efforts to im-prove the cross-cultural training and competencies of all trainees.

In addition to the Commonwealth Fund and the W.K. KelloggFoundation, other organizations have begun to bridge cultural differencesin the attempt to lessen health disparities due to cultural differences. Forexample, the OMH has developed a list of 14 standards for Culturally andLinguistically Appropriate Services (CLAS), which healthcare organiza-tions and practitioners should use to ensure equal access to quality healthcare by diverse populations. The 14 standards are:

1. Promote and support the attitudes, behaviors, knowledge, and skillsnecessary for staff to work respectfully and effectively with patientsand each other in a culturally diverse work environment.

2. Have a comprehensive management strategy to address culturally andlinguistically appropriate services, including strategic goals, plans, poli-cies, procedures, and designated staff responsible for implementation.

3. Utilize formal mechanisms for community and consumer involvementin the design and execution of service delivery, including planning,policy making, operations, evaluation, training and, as appropriate,treatment planning.

4. Develop and implement a strategy to recruit, retain, and promotequalified, diverse, and culturally competent administrative, clinical,and support staff that are trained and qualified to address the needsof the racial and ethnic communities being served.

5. Require and arrange for ongoing education and training for ad-ministrative, clinical, and support staff in culturally and linguisti-cally competent service delivery.

6. Provide all clients with Limited English Proficiency access to bilin-gual staff or interpretation services.

7. Provide oral and written notices, including translated signage at keypoints of contact, to clients in their primary language, informingthem of their right to receive no-cost interpreter services.

8. Translate and make available signage and commonly used writtenpatient educational material and other materials for members of thepredominant language groups in service areas.


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9. Ensure that interpreters and bilingual staff can demonstrate bilingualproficiency and receive training that includes the skills and ethics ofinterpreting, and knowledge in both languages of the terms and con-cepts relevant to clinical or nonclinical encounters. Family or friendsare not considered adequate substitutes because they usually lackthese abilities.

10. Ensure that the clients’ primary spoken language and self-identifiedrace/ethnicity are included in the healthcare organization’s manage-ment information system as well as any patient records used byprovider staff.

11. Use a variety of methods to collect and utilize accurate demographic,cultural, epidemiological, and clinical outcome data for racial and eth-nic groups in the service area, and become informed about the eth-nic/cultural needs, resources, and assets of the surrounding community.

12. Undertake ongoing organizational self-assessments of cultural andlinguistic competence, and integrate measures of access, satisfaction,quality, and outcomes for CLAS into other organizational internalaudits and performance improvement programs.

13. Develop structures and procedures to address cross-cultural ethicaland legal conflicts in healthcare delivery and complaints or grievancesby patients and staff about unfair, culturally insensitive or discriminatorytreatment, or difficulty in accessing services, or denial of services.

14. Prepare an annual progress report documenting the organization’sprogress with implementing CLAS standards, including informa-tion on programs, staffing, and resources.

Aging PopulationIn addition to the changing ethnic and racial composition of America, an-other area of concern is the growing elderly population. Technology hasgiven us the ability to enhance longevity; the challenge now is whetheror not the healthcare profession can learn how to best serve this grow-ing population of patients.

As our citizens grow older, more services are required for the treatmentand management of both acute and chronic health conditions. The pro-fession must devise strategies for caring for the elderly patient popula-tion. America’s older citizens are often living on fixed incomes, have smallor nonexistent support groups, and are facing the challenges of where andhow to obtain expensive medicines. Americans have begun obtainingprescription medications from Canada and Mexico, something that wouldhave been unheard of in previous years. While this may be considered anAmerican infrastructure dilemma, the reality is that medical profession-als must be able to understand and empathize with poor, sick, elderlypeople of all races, sexes, and creeds.


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Ageism can be defined as “any attitude, action, or institutional struc-ture, which subordinates a person or group because of age or any assign-ment of roles in society purely on the basis of age” (Traxler, 1980, p. 4).Healthcare professionals often make assumptions about their older patientsbased on age rather than on functional status. This may be due to the lim-ited training physicians receive in the care and management of geriatricpatients. For example, Warshaw (2002) related that only 10 percent of USmedical schools require coursework or rotation in geriatric medicine.Although medical schools offer geriatric courses as electives, fewer than3 percent of medical school graduates choose to take these courses. A re-port from the Alliance for Aging Research (2003) related that there con-tinue to be medical shortcomings in medical training, prevention screening,and treatment patterns that disadvantage older patients. The report out-lined four key recommendations to safeguard against ageist bias:

1. Increase training and education of healthcare providers and researchinto aging. The training infrastructure needs to be enhanced so physi-cians, nurses, pharmacists, and allied health professionals receiveappropriate exposure to geriatrics. Geriatrics competency and knowl-edge should be part of licensing and credentialing examinations wher-ever appropriate.

2. Include older patients in clinical trials. Older people are consistentlyexcluded from clinical trials, even though they are the largest usersof approved drugs.

3. Utilize appropriate screening and treatment methods. Older patientsare less likely than younger people to receive preventative care andare less likely to be tested or screened for diseases and other healthproblems. As such, proven medical interventions for older patients areoften ignored, leading to inappropriate or incomplete treatment.

4. Empower and educate older Americans. Older patients neglect tobring health problems to the attention of their care providers, con-tributing to the symptoms to old age.

■ DIVERSITY MANAGEMENTDiversity management is a challenge to all organizations. Diversity man-agement is “a strategically driven process whose emphasis is on buildingskills and creating policies that will address the changing demographicsof the workforce and patient population” (Svehla, 1994; Weech-Maldonado et al. 2002). A study by the National Urban League (2004)found that few American workers believed their companies had effec-tive diversity programs. The two-year study, entitled Diversity PracticesThat Work: The American Worker Speaks, surveyed more than 5,500American workers regarding their views on diversity. Although 45 per-cent believed that diversity was part of the organization’s corporate cul-


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ture of their respective employers, only 32 percent believed that theircompany had an effective diversity initiative. The study found that work-ers tended to have more favorable perceptions of diversity initiatives atcompanies where:

1. Leaders demonstrated a personal commitment to diversity and heldthemselves and others accountable.

2. Diversity training increased diversity awareness and provided a linkto improving business results.

3. There was an established track record for recruiting people of di-verse backgrounds.

4. Employees earned rewards for their contributions in diversity.

Studies on diversity within the healthcare industry reflect that it hasbeen slow to embrace diversity management. For example, a study byMotwani, Hodge, and Crampton (1995) found that only 27.7 percent ofhealthcare workers in six Midwest hospitals felt that their institutions hada program to improve employee skills in dealing with people of differentcultures and only 38.9 percent felt that management realized that culturalfactors were sometimes the cause of conflicts among employees. The health-care industry may be slow to embrace diversity management due to thelow percentage of demographic diversity in senior management positions.

Healthcare LeadershipThe American College of Healthcare Executives (ACHE), the NationalAssociation of Health Services Executives (NAHSE), and the Institutefor Diversity in Healthcare Management (IFD) released a study in 2003that measured the representation of black non-Hispanics, Hispanics,women, and other minorities in healthcare executive leadership roles.This study was a follow-up to similar studies completed in 1992 and1997. The study, completed in 2002, was based on a random-sample sur-vey of 1,621 healthcare executives. Respondents worked in a variety ofsettings—hospitals, healthcare provider organizations, government healthagencies, and consulting and educational institutes (see Table 2-2).

Although the results of the 1997 study reflected improvements in di-versity over the 1992 study, the 2002 results indicated that the healthcareindustry did not do as well in promoting minorities and women in positionsof chief executive officers, chief operating officers, and senior vice presidentsas in subsequent years. In the 2002 ACHE study (see Table 2-3), only 23percent of black non-Hispanic female respondents held senior manage-ment positions in 1997 as compared to 26 percent in 2002. Although whitenon-Hispanic female healthcare senior managers made progress, from 35percent in 1997 to 40 percent in 2002 (see Table 2-4), the gap betweenwhite non-Hispanic males and females holding senior healthcare manage-ment positions widened from 16 percent in 1997 to 22 percent in 2002.

Diversity Management 29

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Table 2-2 American College of Healthcare Executives 2002 Diversity StudyPopulation, Sample and Response Rates1

1992 1997 2002Native

Black White Black White Hispanic Asian Black White Hispanic Asian American

Population 795 17,775 1,6232 16,096 6623 235 2,0334 13,601 4495 240 1536

Sample 517 966 767 802 662 2.5 1,573 1,608 449 240 153Response 367 565 410 408 264 124 526 779 215 118 68Response Rate (%) 46.2 58.5 53.5 50.9 39.9 52.8 33.4 48.4 47.9 49.2 44.4Analyzed1 328 524 380 386 240 115 497 742 204 114 64Males 165 242 177 192 154 76 222 359 125 65 37

% 50.3 46.2 46.6 49.7 64.2 66.1 44.7 48.4 61.3 57 57.8Females 163 282 203 194 86 39 275 383 79 49 27

% 49.7 53.8 53.4 50.3 35.8 33.9 55.3 51.6 38.7 43 42.2

1Responses were analyzed if they were from employed healthcare executives who gave their gender.2Composed of 603 ACHE members, 375 of whom were sampled, and 224 of whom responded;and 1020 NAHSE members, 625 of whom were sampled, and 186 of whom responded (233 having proved unlocatable).3Composed of 296 ACHE members, 179 of whom responded, and 366 members and contacts of AHHE, 85 of whom responded.4Composed of 696 ACHE members, 539 of whom were sampled and 282 of whom responded and 1337 NAHSE members, 1034 of whom were sampled and 244 of whom responded.5Composed of 281 ACHE members, 159 of whom responded and 168 AHHE members, 56 of whom responded.6Composed of 51 ACHE members, 29 of whom responded and 102 EDLP members, 39 of whom responded.Source: American College of Healthcare Executives, Reprinted with permission.

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Table 2-3 American College of Healthcare Executives 2002 Diversity StudyPosition by Race/Ethnicity and Year

Males1992 1997 2002

NativeBlack White Black White Hispanic Asian Black White Hispanic Asian American

CEO 23% 35%** 17% 26% 23% 16% 19% 37% 23% 11% 32%***COO/Senior

Vice President 48 65 43 51 47 36 44 62 47 34 46Vice President 20 16 19 23 19 21 24 19 23 20 16Department Head 20 10 27 13 21 28 22 10 20 31 30Department

Staff/Other 13 8 11 13 12 15 11 9 10 15 8100%1 100%1 100% 100% 100%1 100% 100% 100% 100% 100% 100%

n (163) (240) (168) (198) (145) (75) (216) (355) (123) (65) (37)Position Level In Hierarchy1 � CEO 29 37*** 17 26 24 18* 18 37 24 15 33***2 20 24 17 26 15 13 17 26 16 22 213 22 26 19 22 20 29 25 20 14 20 214 13 8 24 14 23 26 15 13 20 18 155� 17 5 22 13 18 13 24 4 26 25 9

100%1 100% 100%1 100%1 100% 100%1 100% 100% 100% 100% 100%n (152) (230) (149) (188) (136) (68) (206) (328) (111) (55) (33)

*Chi-square significant p�.05**Chi-square significant p�.01***Chi-square significant p�.0011Responses may not total to 100 due to rounding.

Source: American College of Healthcare Executives, Reprinted with permission.

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Table 2-4 American College of Healthcare Executives 2002 Diversity StudyPosition by Race/Ethnicity and Year

Females

1992 1997 2002Native

Black White Black White Hispanic Asian Black White Hispanic Asian American

CEO 13% 9%* 9% 10% 6% 5%* 11% 13% 9% 9% 12%***COO/Senior

Vice President 31 34 23 35 26 15 26 40 25 24 28Vice President 17 28 22 24 25 21 19 28 24 19 8Department Head 20 14 33 25 33 23 39 19 32 34 44Department

Staff/Other 32 24 22 16 16 41 17 14 20 26 20100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

n (161) (280) (203) (191) (80) (39) (266) (381) (76) (47) (25)Position Level In Hierarchy1 � CEO 12 9*** 10 12 7 6** 10 14 9 10 13***2 15 25 8 23 15 22 14 28 15 15 93 23 35 28 31 32 13 21 28 31 18 524 30 18 23 21 26 28 23 18 22 25 135+ 20 13 31 14 20 31 33 12 22 32 13

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%n (150) (266) (170) (173) (74) (32) (229) (353) (67) (40) (23)

*Chi-square significant p�.05**Chi-square significant p�.01***Chi-square significant p�.0011Responses may not total to 100 due to rounding.

Source: American College of Healthcare Executives, Reprinted with permission.

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Diversity Management 33

In 2003, the National Center for Healthcare Leadership (NCHL) com-missioned a study to identify specific strategies to advance careers of womenand racially/ethnically diverse individuals in health care management.Dreachslin and Curtis’s (2004, p. 456) literature review confirmed the find-ings of the 2002 ACHE report that career advancement of women andracially/ethnically diverse individuals in health care management was char-acterized by: (1) underrepresentation, especially in senior level manage-ment positions; (2) lower compensation, even controlling for educationand experience; and (3) more negative perceptions of equity and opportu-nity in the workplace. The researchers identified three areas that are keyorganization–specific factors for shaping career outcomes for women andracially/ethnically diverse individuals: (1) leadership and strategic orientation(i.e., senior management’s commitment for successful implementation ofdiversity initiatives), (2) organizational culture/climate (i.e., the depth andbreadth of the organization’s strategic commitment to diversity leadershipand cultural competence), and (3) human resources practices (i.e., estab-lishing best practices in advancing the management careers of women andracially/ethnically diverse individuals, such as formal mentoring programs,professional development, work/life balances, and flexible benefits).

Based on Dreachslin’s and others’ research, the NCHL, ACHE, IFD,and the American Hospital Association developed the Diversity andCultural Proficiency Assessment Tool for Leaders (see Exhibit 2-3). Theassessment tool begins the process of developing a cultural awarenessfor the organization’s workforce.

In order to best serve their patient base, healthcare organizations andproviders must be willing to invest the time, money, and effort needed toeducate all their employees. Educating senior staff is important, but sois educating the entire healthcare workforce. For healthcare managersto transform their organizations into an inclusive culture where all em-ployees feel the opportunity to reach their full potential, Guillory (2004,pp. 25–30) recommended a ten-step process:

1. Development of a customized business case for diversity for yourorganization. In other words, how does diversity relate to the over-all success of the organization?

2. Education and training for your staff to develop an understandingof diversity, its importance to your organization’s success, and diversityskills to apply on a daily basis.

3. Establishment of a baseline by conducting a comprehensive culturalsurvey that integrates performance, inclusion, climate, and work/lifebalance.

4. Selection and prioritization of the issues that lead to the greatestbreakthrough in transforming the culture.

5. Creation of a three- to five-year diversity strategic plan that is tiedto organizational strategic business objectives.

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Exhibit 2-3 A Diversity and Cultural Proficiency Assessment Tool for Leaders

CHECKLIST

As Diverse as the Community You Serve

• Do you monitor at least every three years the demo-graphics of your community to track change in gender,racial and ethnic diversity? YES NO

• Do you actively use these data for strategic and outreachplanning? YES NO

• Has your community relations team identified commu-nity organizations, schools, churches, businesses andpublications that serve racial and ethnic minorities foroutreach and educational purposes? YES NO

• Do you have a strategy to partner with them to work onhealth issues important to them? YES NO

• Has a team from your hospital met with community lead-ers to gauge their perceptions of the hospital and seektheir advice on how you can better serve them, both inpatient care and community outreach? YES NO

• Have you done focus groups and surveys within the pastthree years in your community to measure the public’sperception of your hospital as sensitive to diversity andcultural issues? YES NO

• Do you compare the results among diverse groups inyour community and act on the information?

YES NO

• Are the individuals who represent your hospital in thecommunity reflective of the diversity of the commu-nity and your organization? YES NO

• When your hospital partners with other organizationsfor community health initiatives or sponsors commu-nity events, do you have a strategy in place to be cer-tain you work with organizations that relate to thediversity of your community? YES NO

• As a purchaser of goods and services in the commu-nity, does your hospital have a strategy to ensure thatbusinesses in the minority community have an oppor-tunity to serve you? YES NO

• Are your public communications, community reports,advertisements, health education materials, Websites, etc. accessible to and reflective of the diversecommunity you serve? YES NO

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Culturally Proficient Patient Care

• Do you regularly monitor the racial and ethnic diversity ofthe patients you serve? YES NO

• Do your organization’s internal and external communica-tions stress your commitment to culturally proficient careand give concrete examples of what you’re doing?

YES NO

• Do your patient satisfaction surveys take into account thediversity of your patients? YES NO

• Do you compare patient satisfaction ratings among di-verse groups and act on the information? YES NO

• Have your patient representatives, social workers, dis-charge planners, financial counselors and other key pa-tient and family resources received special training indiversity issues? YES NO

• Does your review of quality assurance data take into ac-count the diversity of your patients in order to detect andeliminate disparities? YES NO

• Has your hospital developed a “language resource,”identifying qualified people inside and outside yourorganization who could help your staff communicatewith patients and families from a wide variety of na-tionalities and ethnic backgrounds? YES NO

• Are your written communications with patients andfamilies available in a variety of languages that re-flects the ethnic and cultural fabric of your commu-nity? YES NO

• Based on the racial and ethnic diversity of the patientsyou serve, do you educate your staff at orientationand on a continuing basis on cultural issues importantto your patients? YES NO

• Are core services in your hospital . . . such as signage,food service, chaplaincy services, patient informationand communications attuned to the diversity of thepatients you care for? YES NO

• Does your hospital account for complementary and al-ternative treatments in planning care for your patients? YES NO

continues

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Exhibit 2-3 continued

Strengthening Your Workforce Diversity

• Do your recruitment efforts include strategies to reach out to the racial and ethnic minorities in your community?

YES NO

• Does the team that leads your workforce recruitment initia-tives reflect the diversity you need in your organization?

YES NO

• Do your policies about time off for holidays and religiousobservances take into account the diversity of your work-force? YES NO

• Do you acknowledge and honor diversity in your em-ployee communications, awards programs and other in-ternal celebrations? YES NO

• Have you done employee surveys or focus groups tomeasure their perceptions of your hospital’s policies andpractices on diversity and to surface potential problems?

YES NO

• Do you compare the results among diverse groups inyour workforce? Do you communicate and act on theinformation? YES NO

• Have you made diversity awareness and sensitivitytraining available to your employees? YES NO

• Is the diversity of your workforce taken into account inyour performance evaluation system? YES NO

• Does your human resources department have a sys-tem in place to measure diversity progress and reportit to you and your board? YES NO

• Do you have a mechanism in place to look at em-ployee turnover rates for variances according to di-verse groups? YES NO

• Do you ensure that changes in job design, workforcesize, hours and other changes do not affect diversegroups disproportionately? YES NO

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Expanding the Diversity of Your Leadership Team

• Has your Board of Trustees discussed the issue of the di-versity of the hospital’s board? Its workforce? Its manage-ment team? YES NO

• Is there a Board-approved policy encouraging diversityacross the organization? YES NO

• Is your policy reflected in your mission and values state-ment? Is it visible on documents seen by your employeesand the public? YES NO

• Have you told your management team that you are per-sonally committed to achieving and maintaining diversityacross your organization? YES NO

• Does your strategic plan emphasize the importance of di-versity at all levels of your workforce? YES NO

• Has your board set goals on organizational diversity, cul-turally proficient care and eliminating disparities in careto diverse groups as part of your strategic plan?

YES NO

• Does your organization have a process in place to ensurediversity reflecting your community on your Board, sub-sidiary and advisory boards? YES NO

• Have you designated a high-ranking member of yourstaff to be responsible for coordinating and implement-ing your diversity strategy? YES NO

• Have sufficient funds been allocated to achieve yourdiversity goals? YES NO

• Is diversity awareness and cultural proficiency train-ing mandatory for all senior leadership, managementand staff? YES NO

• Have you made diversity awareness part of your man-agement and board retreat agendas? YES NO

• Is your management team’s compensation linked toachieving your diversity goals? YES NO

• Does your organization have a mentoring program inplace to help develop your best talent, regardless ofgender, race or ethnicity? YES NO

• Do you provide tuition reimbursement to encourageemployees to further their education? YES NO

• Do you have a succession/advancement plan for yourmanagement team linked to your overall diversitygoals? YES NO

• Are search firms required to present a mix of candi-dates reflecting your community’s diversity?

YES NO

Source: Institute for Diversity in Health Management (2004). Reprinted with permission.

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6. Leadership’s endorsement of and financial commitment to the plan.7. Establishment of measurable leadership and management objectives

to hold managers accountable to top leadership for achieving theseobjectives.

8. Implementation of the plan, recognizing that surprises and setbackswill occur along the way.

9. Continued training in concert with the skills and competencies nec-essary to successfully achieve the diversity action plan.

10. Survey one to one and a half years after initiation of the plan to de-termine how inclusion has changed.

The Future WorkforceAs part of diversity management, healthcare managers need to devisestrategies for attracting younger workers to enter the healthcare fieldwhile maintaining positive relationships with older workers. As Barney(2002, p. 83) points out,

employers are realizing that Generation X-ers (people born between1963 and 1977) are more concerned with meaningful work thanhigh pay, impressive titles, and fancy offices. They reject paternal-istic workplaces and want managers who listen, consider their ideas,and treat them as peers. They want to be part of the decision-makingprocess and want to be flexible in their work environment becausethey value their time and freedom.

Healthcare organizations need to be flexible to change to meet these chal-lenges. The greatest barrier to the industry’s success may be its inabilityto understand and appreciate the increasing diversity within our popu-lation whether relating to patients or employees.

End-of-Chapter Discussion Questions

1. Discuss what the term diversity means.2. Explain the meaning of cultural competency.3. What do we mean when we say “diversity management”?4. Explain why and how changes in US demographics affect the health-

care industry.

Exercise 2-1You have been asked recently to join the hospital’s task force for de-

veloping a plan to increase the organization’s workforce diversity fromits current 10 percent level to 30 percent over the next five years. Whatrecommendations would you make as a member of the task force?

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Exercise 2-2Cross Cultural Interview and AnalysisInterview a healthcare professional who was born and raised in

a country other than your own. Focus on the following topics:

• Family background• Cultural background• Educational background• Community• Religious background

Analysis: List some of the major differences between your back-ground and the interviewee. What are some of the similarities?Discuss what you believe some of the major challenges will be inhealth care in raising the profession’s awareness of diversity.

ReferencesAlliance for Aging Research. (2003). Ageism: how healthcare fails the elderly,

http://www.agingresearch.org.American College of Healthcare Executives (ACHE), Chicago, IL. (2002). A

race/ethnic comparison of career attainments in healthcare management,Summary Report – 2002, http://www.ache.org.

Barney, S. M. (2002, March/April). A changing workforce calls for twenty-firstcentury strategies. Journal of Healthcare Management, 47(2), 61–65.

Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial and eth-nic racial health disparities? A review and conceptual model. Medical CareReview, 57, Supplement 1, 181–217.

Commonwealth Fund. (2003). Worlds apart: A film series on cross-cultural healthcare, http://www.cmwf.org.

Commonwealth Fund. (2002). International health policy survey of adults withhealth problems, http://www.cmwf.org.

Dreachslin, J. L. (1998). Conducting effective focus groups in the context of di-versity: Theoretical underpinnings and practical implications. QualitativeHealth Research, 8(6), 813–820.

Dreachslin, J. L., & Curtis, E. F. (2004, Fall). Study of factors affecting the careeradvancement of women and racially/ethnically diverse individuals in healthcaremanagement. The Journal of Health Administration Education, 21(4), 441–484.

Fadiman, A. (1998). The spirit catches you and you fall down. New York, NY:Farrar, Straus and Giroux.

Guillory, W. A. (2004, July/August). The roadmap to diversity, inclusion, andhigh performance. Healthcare Executive, 19(4), 24–30.

HHS Office of Minority Health. (1999). Assuring cultural competence in health-care: Recommendations for national standards and outcomes-focused re-search agenda, http://www.omhrc.gov/CLAS.

Hofstede, G. (1983). The cultural relativity of organizational practices and the-ories. Journal of International Business Studies, 14(2), 75–89.

Hofstede, G., Van Deusen, C. A., Mueller, C. B., & Charles, T. A. (2002). Whatgoals do business leaders pursue? A study in fifteen countries. Journal ofInternational Business Studies, 33(4), 785–803.

References 39

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Howard, C., Andrade, S. J., & Byrd, T. (2001, January). The ethical dimensionsof cultural competence in border healthcare settings. Family and CommunityHealth, 23(4), 36–49.

Institute for Diversity in Health Management. (2004). Strategies for leadership:Does your hospital reflect the community it serves?, http://www.diversity-connection.org/.

Institute of Medicine. (2004). In the nation’s compelling interest: Ensuringdiversity in the health care workforce. Washington, DC: National AcademyPress.

Kundhal, K. K. (2003, January 1). Cultural diversity: An evolving challenge tophysician-patient communication. Journal of the American Medical Association,289(1), 94.

Motwani, J., Hodge, J., & Crampton, S. (1995, March). Managing diversity inthe healthcare industry. The Healthcare Supervisor, 13(3), 16–25

Nahavandi, A., & Malekzadeh, A. R. (1999). Organizational behavior: Theperson-organization fit. Upper Saddle River, NJ: Prentice Hall.

National Urban League (2004). Diversity practices that work: The Americanworker speaks, http://www.nul.org.

Patel, C. (2003). Some cross-cultural evidence on whistle-blowing as an internalcontrol mechanism. Journal of International Accounting Research, 2, 69–96.

Svehla, T. (1994). Diversity management; key to future success. Frontiers ofHealth Services Management, 11(2), 3–33.

Traxler, A. J. (1980). Let’s get gerontologized: Developing a sensitivity to aging.The multi-purpose senior center concept: A training manual for practitionersworking with the aging. Springfield, IL: Illinois Department of Aging.

United States Department of Commerce, Bureau of the Census. (2000). Currentpopulation reports: Population projections of the United States by age, sex,race, and Hispanic origin: 1995 to 2050, http://www.npg.org/facts/us_pop_projections.htm.

United States Department of Commerce, Bureau of the Census. (2003). Chartbookon trends in the health of Americans. Retrieved March 21, 2004 from InfoTracon-line database.

United States Department of Commerce, Bureau of the Census. (2004). US in-terim projections by age, sex, race, and Hispanic origin. http://www.census.gov/ipc/www/usinterimproj/, Internet Release Date: March 18, 2004.

Warshaw, G. A. (2002). Academic geriatrics programs in US allopathic and os-teopathic medical schools. Journal of the American Medical Association, 288,2313–2319.

Weech-Maldonado, R., Dreachslin, J. L., Dansky, K. H., DeSouza, G., & Gatto,M. (2002). Racial/ethnic diversity management and cultural competency: thecase of Pennsylvania hospitals. Journal of Healthcare Management, 47(2),111–124.

Suggested ReadingHealth management students need a full understanding of diversity andits effect on healthcare outcomes. Below is a listing of various websitesand publications for suggested reading.

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1. The Institute of Medicine’s 2004 Report: In the Nation’s CompellingInterest: Ensuring Diversity in the Healthcare Workforce. This textis available in two locations:

a. http://www.iom.edu/event.asp?id=17856 Gives an overview ofthe public briefing held on February 5, 2004.

b. http://www.nap.edu/catalog/10885.html A copy of the full textof the study can be found at this website.

2. A full list of reference texts discussing cultural beliefs and influences,issues, and how to identify/develop materials can be found athttp://www.culturalhealing.com/patientedu.htm.

3. A discussion of cultural issues involved in providing health care tointernational students can be found at http://www.healthcenter.unt.edu/internat/culture.htm.

4. An interview with author Anne Fadiman discussing her book The SpiritCatches You and You Fall Down can be found at http://www.beatrice.com/interviews/fadiman/. A complete review of thebook can be found at http://www.spiritcatchesyou.com.

5. Discover how language and culture affect the delivery of quality ser-vices to ethnically diverse populations at http://www.diversityrx.org/.

Suggested Reading 41

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