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Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

Oriana handtke.

Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Benjamin Schilgen

Mike mösko, associated data.

All relevant data are within the manuscript and its Supporting Information files.

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

Methods and findings

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare–Individual level; Components of culturally competent healthcare–Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

Introduction

The United Nations state “the world is on the move, and the number of international migrants today is higher than ever before.” [ 1 ]. The associated growing diversification of societies offers many opportunities for societal and economic growth but often presents a challenge for receiving countries. Consequences can include inequalities and discrimination in different areas [ 2 ]. The European Union (EU) and the Constitution of the World Health Organization (WHO) ratified the universal right to health as a fundamental human right. Nevertheless, inequalities in access to healthcare exist worldwide and are related to the legal and socioeconomic status of each individual and the laws and policies of each country [ 3 , 4 ]. In fact, culturally and linguistically diverse patients (CLDP) access healthcare services less than the host populations and are confronted with different barriers [ 3 – 7 ]. These barriers include the organization and complexity of healthcare systems, legal restrictions on access to certain health services, linguistic and cultural barriers, discrimination and limited competencies or unawareness of providers. These are often intertwined with individual factors such as low health literacy, employment status, fear of stigma, language barriers or differences in health beliefs and behaviors [ 2 – 7 ]. Betancourt identified three levels of sociocultural barriers to healthcare: organizational barriers, structural barriers and clinical barriers. Organizational barriers, which affect availability and acceptability of healthcare for CLDP, refer for instance to the degree to which the population’s cultural and linguistic diversity is represented in the leadership and workforce of healthcare organizations. Structural barriers emerge from the complexity and bureaucracy of healthcare systems. Specifically, the absence of interpreter services and of culturally and linguistically adapted materials, increased wait times among CLDP populations and problems in referrals to specialist care cause dissatisfaction and inequalities. Clinical barriers occur in patient/provider interactions and can be seen as sociocultural differences which are not identified, accepted or understood. These can lead to mistrust, dissatisfaction, decreased adherence and poorer health outcomes [ 8 ].

The implementation of cultural competence in healthcare facilities seemed to be the answer to these disparities, and traditional receiving countries have been working towards it [ 8 – 12 ]. Indeed, the demand for culturally competent healthcare systems has reached the political levels of diverse countries. The National Culturally and Linguistically Appropriate Service Standards (CLAS Standards) were introduced in 2000 in the United States [ 13 ], and in 2005 the Australian government published “Cultural competency in health: A guide for policy, partnerships and participation” [ 14 ]. In 2007 the “cultural opening” of healthcare facilities was demanded by a representative of the German federal government [ 15 ] and the NHS has offered the migrant health guide since 2014 [ 16 ].

There are different definitions, names and implementation guidelines for the concept of cultural competence or cultural competency [ 12 , 17 ]. The most commonly used definition is the one by Cross et al. (1989): „Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations” [ 18 ]. This definition emphasizes that cultural competence is implemented on different levels of care. Corresponding to their identified barriers, Betancourt et al. (2003) differentiate between three levels of interventions: organizational, structural and clinical cultural competence interventions [ 8 ]. Fung et al. (2012) take a systemic approach and define cultural competence on macro, meso (institutional and programmatic) and micro levels, by which macro reflects the societal level, meso the organizational and micro the individual clinical level [ 10 ]. The German concept of “cultural opening”describes the process of adapting or “opening”facilities and is hence a process of organizational development which includes interventions on different levels within facilities [ 19 ].

Existing systematic reviews have focused on defining theoretical concepts [ 8 , 9 , 20 ] or on the effectiveness of cultural competence interventions [ 11 , 12 , 17 , 21 , 22 ]. Individual cultural competence among healthcare providers was examined most frequently [ 12 , 20 ]. A systematic review of reviews on cultural competence in healthcare found moderate positive effects of individual cultural competence trainings on provider outcomes (knowledge, skills, attitudes) and on access and utilization outcomes but only weak effects on patient outcomes (satisfaction, health status) [ 12 ]. Other interventions that were often identified by authors of existing reviews were the recruitment of bilingual staff, the use of interpreters and the translation of treatment materials [ 9 , 11 , 12 , 20 ]. All together these reviews were not able to determine the effectiveness of interventions because of the lack of comparative studies and objective outcome measures [ 11 , 12 , 17 , 21 – 23 ]. A number of systematic reviews were conducted which often focused on conceptual models and definitions or broad categories of cultural competence and derived interventions or strategies from those. We chose a bottom-up approach in order to extract culturally competent components or strategies from healthcare interventions designed to be culturally competent. The methodology of a scoping review appears appropriate for capturing the presumed diversity of components and strategies to provide culturally competent healthcare to CLDPs.

This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for CLDPs within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

The review was guided by the question “What are components or strategies extracted from evaluated culturally competent healthcare interventions that were designed to provide healthcare for culturally and linguistically diverse patients (CLDP) in healthcare organizations?”

Search strategy

A systematic literature search was carried out in following databases: Pubmed, PsycINFO and Web of Science. The search was conducted in August 2016 and updated in January 2017 to include studies published during/after August 2016. No restrictions were set. Furthermore, lists of references of relevant articles were manually examined for the purpose of identifying further eligible studies.

The PICO criteria were adapted [ 24 ] in order to formulate the research question and to systematically choose relevant search terms. We concentrated on the criteria Population (e.g., migrants, culturally and linguistically diverse patients), Intervention (e.g., program, standard, strategy) and Outcome (e.g., increasing cultural competences or cross-cultural opening). The search string is available in the S1 File . More precisely, we searched for studies which evaluated cultural competence interventions quantitatively or qualitatively in order to increase cultural competence in healthcare facilities. Additionally, we included the criterion Setting (e.g., hospitals, clinics, health centers) because we were exclusively interested in interventions implemented in healthcare facilities. Analyses of Medical subject Headings (MeSH) and of key terms of related articles were used to identify search terms. These were discussed by the authors and combined to a search string, which was adapted for each database. As recommended by Arksey and O’Malley (2005) we started the search with a wide approach in order to create a comprehensive map of the field.

Eligible criteria and assessment

The selection process was divided into two screening phases. First, a screening of titles and abstracts was conducted followed by full text screening.

In the first screening phase, studies evaluating interventions located at healthcare organizations and aiming to improve cultural competence of healthcare facilities and/or healthcare for CLDP were included. Studies reporting the existing level of cultural competence of healthcare facilities or studies evaluating interventions in other facilities (e.g., schools, community centers) were excluded. In the event that the setting of the intervention was not identifiable in title or abstract, studies were nonetheless included in order to be examined in full text screening. Studies evaluating cultural competence trainings on an individual provider level were excluded because systematic reviews have already shown their positive effect on provider outcomes (e.g., knowledge, skills and attitudes) and their satisfying effect on patient outcomes (e.g., satisfaction, health status) [ 12 ]. At this stage all study types as well as all publication types except for reviews and meta-analysis studies were deemed eligible.

The title and abstract screening was carried out by three independent raters. Prior to this first screening phase all raters screened 100 randomly chosen articles each and reached an interrater reliability of ĸ = 0.7 (main author—first rater) and ĸ = 0.8 (main author—second rater). Disagreement was discussed in regular meetings and screening criteria were specified along the screening process.

Eligible criteria for full text screening were specified and iteratively adapted during the second screening phase [ 25 ]. The criteria were divided into the following categories: Design, Recipient Population, Content, Method and Context. The category Design (criterion 1) included only studies with a sample size of more than two and only studies using primary data. Hence, reviews, meta-analysis studies, study protocols and letters to the editors were excluded. The Recipient Population consisted of migrants, CLDP, ethnic minorities (e.g., Latino population, Native Americans, South Asian Americans) or refugees (criterion 2). In order to be considered eligible regarding their content, studies had to examine interventions that aim to improve healthcare utilization, provision or treatment for CLDP and/or cultural competence in healthcare facilities (criterion 3). Additionally, they needed to be evaluated with quantitative or qualitative research methods (Method; criterion 4). Furthermore, studies that only focus on (psychometric) evaluation of instruments were not eligible. Interventions had to be implemented explicitly in inpatient or outpatient settings such as hospitals; health or medical centers; health facilities; health organizations; (medical) trusts or sites or clinics in order to meet the Context criterion (criterion 5). If study participants were recruited in healthcare facilities, but the intervention was located elsewhere, these studies were excluded. Studies located in general practice or community centers were excluded, as well. Only studies published in English or German and meeting all criteria were included. Detailed screening criteria are available in the S1 Table .

In the full-text screening the remaining articles were screened by two independent researchers. They reached an interrater reliability of k = 0.8, which was considered to be satisfying. Both raters met on a regular basis throughout the screening process to ensure a high level of consensus and to discuss any uncertainties.

Data extraction and summary

Data extracted from the studies were summarized into two spreadsheets. One spreadsheet describing the characteristics of healthcare interventions included following information: Authors, name and location of the intervention, target group and components of the interventions. ( S2 Table ) [ 26 ]. The second spreadsheet incorporated study characteristics and results: outcome measures, study type, study participants (N, ethnicity) and main results ( S3 Table ). To assure the accuracy of extracted data, they were verified by two independent researchers. Single components and strategies for providing culturally competent healthcare extracted from studies were clustered and organized into a model. In order to determine their effects, studies were checked for results relating to single components. Descriptive statistics were used to summarize the data.

Study selection

The initial search in the databases provided a total of 10,701 citations. Through the update in January 2017, an additional 542 publications were found. Four articles were added from a manual search. After adjusting for duplicates 8,801 records remained for the title and abstract screening, and 455 studies met criteria for inclusion in the first selection phase. 23 articles then had to be discarded because the full-text publications of the studies were not available. 432 articles were finally included for the full-text screening. Of these, 67 met the inclusion criteria in the second selection phase and were eligible to be included in the final synthesis ( Fig 1 ).

General study characteristics

The general characteristics of included studies are summarized in Table 1 . Studies included in the final synthesis were published between 1990 and 2017 and were all written in English.

a 33 studies included more than one ethnic group

The majority of studies were conducted in the United States (n = 51; 76%). 28% of the interventions were implemented in the mental health field including substance abuse and neuropsychology (n = 19), followed by 16.5% implemented in diabetes care/prevention (n = 11). Included studies applied a quantitative study design in 69%, a mixed method design in 21% and 10% were qualitative studies. Fourteen studies were randomized controlled trials (RCTs) [ 27 – 40 ] with two cluster randomizations [ 27 , 28 ]. RCTs compared one to three interventions with the control intervention, which was typically treatment as usual. Twelve studies were interrupted time series studies [ 41 – 52 ]. Other study types included controlled before and after studies [ 53 – 60 ], historically controlled studies [ 61 – 63 ], cross-sectional studies [ 64 – 67 ], cohort studies [ 68 , 69 ] and incidence studies [ 70 , 71 ]. All mixed methods studies used congruent triangulation [ 72 – 85 ], except for one that chose a sequential transformative design [ 86 ]. Qualitative studies included four case studies [ 87 – 90 ], and the methods of data collection used were interviews [ 90 – 92 ], focus groups [ 89 , 93 ] or open-ended questions [ 88 ]. The number of participants ranged from 6 [ 41 ] to 5963 [ 43 ] participants. Twenty-nine studies focused on one ethnic group [ 27 , 30 – 36 , 39 , 41 , 42 , 47 – 49 , 51 , 57 , 69 , 75 , 77 – 80 , 82 – 85 , 87 , 89 , 92 ] while thirty-three included more than one ethnic group [ 28 , 29 , 37 , 38 , 40 , 43 – 46 , 50 , 52 – 56 , 58 – 68 , 70 – 73 , 86 , 91 , 93 ] and five studies did not report the ethnicity of their participants [ 74 , 76 , 81 , 88 , 90 ].

Measured outcomes were patient outcomes, provider outcomes, organizational outcomes and utilization, coverage and access outcomes [ 12 ]. Psychological health outcomes such as reduction in symptoms of mental illness [ 28 , 33 , 35 , 36 , 47 , 48 , 52 , 59 , 61 , 85 ] and in regard to health, concepts such as self-efficacy [ 34 , 73 , 86 ] or distress [ 49 , 51 ] were assessed the most frequently.

Categorizations of identified culturally competent components and strategies

Extracted components and strategies of the 67 culturally competent healthcare interventions were clustered into 20 sub-categories of components, which were then grouped into four categories: (1) Components of culturally competent healthcare within facilities–Individual level; (2) Components of culturally competent healthcare within facilities–Organizational level; (3) Specific strategies to provide access to culturally competent healthcare; (4) Strategies to implement culturally competent healthcare within facilities. Descriptions of components and strategies including the references can be found in Table 2 . The components of identified culturally competent healthcare interventions and their assigned categories are available in the S4 Table . The component “Cultural and linguistic matching” was identified the most, more precisely in 29 studies, followed by “Use of culturally adapted/appropriate written or visual material”, which was found in 27 studies. The component “Involvement of the facilities’ leadership” as a strategy to implement culturally competent healthcare within facilities was identified the least, specifically in 3 studies. Almost 80% of the interventions were located in outpatient facilities. Only eleven studies collected data in inpatient settings.

Effects of identified components and strategies

Quantitative and qualitative results from studies implementing the identified components or strategies are reported below. Importantly, only the results which indicate a relation between an isolated component or strategy and an outcome measure are considered. Results related to the implementation of multiple components or strategies simultaneously are not reported because in this case the effects of single components or strategies on outcome measures cannot be confirmed.

Components of culturally competent healthcare–Individual level

Linguistically and cultural matching. After the recruitment of a bilingual Russian internist at the Denver Medical Center (USA) with the goal of improving diabetes care for Russian patients, there was a significant reduction in diastolic blood pressure and cholesterol (p < .0002) among Russian diabetes patients. HbA1c and systolic blood pressure also decreased, albeit not significantly [ 69 ]. The Portuguese-speaking patients of a clinic within an urban safety-net hospital system in the US where 95% of staff members spoke Portuguese, were more likely to receive adequate care with a difference of 28% compared with patients receiving care in other clinics. No differences were found for emergency room use and inpatient care [ 64 ]. Hispanic clients with severe mental illness treated by a Hispanic clinician in the context of assertive community treatment in the US, showed less improvement in symptoms of psychosis than those treated by a White clinician (p = .001). Interactions for other outcomes were not significant [ 59 ]. Patients in a culturally focused psychiatric consultation intervention program for Latino Americans with depression agreed that it is more important that their providers speak their language than that they have the same cultural background [ 82 ].

Incorporation of culturally specific concepts. At the Martha Eliot Health Center (USA) Latino/a patients with anxiety participating in an allocentric (“the tendency to define oneself in relationship to others”) relaxation intervention, which was considered more appropriate for the Latin culture, practiced allocentric imagery exercises significantly (p < .01; M = 3.1, SD = 1.8) more often than idiocentric imagery exercises (M = 2.1, SD = 2.2) [ 48 ]. No group changes in postpartum depressive symptoms were identified compared to treatment as usual after a preventive postpartum depression intervention that put value on integrating different aspects of Latino culture at a public sector women’s clinic (USA). Nonetheless, long-term rates of major depression were lower (14% vs. 25%) representing a small effect size (h = 0.28) [ 36 ]. Aviera (1996) noted that the use of dichos, Spanish language proverbs, in a therapy group for Spanish speaking psychiatric in-patients in the US are useful for “building rapport, decreasing defensiveness, enhancing motivation and participation in therapy, improving self-esteem, focusing attention, facilitating emotional exploration, articulating feelings, developing insight, and exploring cultural values and identity” [ 87 ] for Spanish-speaking patients. The CEVE is a “one-session clinical intervention that integrates the use of shared observations of videotaped interactions with the cultural framing of the family’s problem in a culturally congruent manner”. Families receiving the CEVE at an outpatient clinic in the US reported significantly higher ratings for therapeutic alliance and perceived therapist cultural competence (F(1,15) = 10.03; p < .01) [ 40 ]. The Cultural Formulation Interview, “a cross-cultural assessment tool”, was considered useful in eliciting data to determine the nature of the problem from patients’ perspectives, developing and maintaining the therapeutic relationship and communication, educating the patient and in implementing treatment plans at New York Presbyterian Hospital (USA) [ 91 ].

Use of culturally and linguistically adapted/appropriate written or visual material. Watching characters with the same cultural background in an educational telenovela intervention for diabetes patients in the context of the SHL-program (Sugar, Heart, and Life) at four community health centers in the US led to a mix of low and high levels of viewer identification among participants and to improved feelings of self-efficacy: 17% indicated general optimism or motivation for engaging in diabetes self-care, and 10.5% indicated a specific plan for behavior change [ 34 ].

Involvement if families. Parental satisfaction with a family-centered intervention for children within the Pediatric Resident Continuity clinic at the Mattel Children’s Hospital (USA) were 8.5 points higher for Spanish-speaking families then for English-speaking families, albeit not significantly ( p = .003) [ 65 ]. In the context of a community based approach to diabetes control at multiple heath centers in the US, focus group discussions suggest that through family involvement patients from African American, Latino or Asian background “felt they were better able to treat their disease, that they were more comfortable talking about their diabetes with their families and friends, and that they felt more confident and in control of their lives”. [ 73 ].

Components of culturally competent healthcare–Organizational level

Cultural competence trainings for providers. In a patient-centered culturally sensitive healthcare intervention program based in two community-based primary care clinics in the US cultural sensitivity ratings of providers’ behaviors and attitudes by African American patients increased significantly ( F (1, 14) = 4.549, p = .05) after provider training and more at the intervention clinic than at the control clinic, however, the differences were not significant [ 55 ]. Also, significant increases in providers’ self-rated knowledge ( t (34) = -7.96, p < .001), awareness ( t (34) = -6.79, p < .0019) and skills ( t (34) = - 4.49, p < .001.) in cultural competence was observed after a bilevel cultural competence intervention at a community mental health center in the US [ 45 ]. Furthermore, providers receiving training within the National Center for Healthcare Leadership Diversity demonstration project in two US hospitals presented greater changes on all three individual level competencies–increase in diversity attitudes, decrease in implicit bias, and increase in racial/ethnic identity–than providers in the control hospital [ 60 ].

Human resources development. Two interventions focused on the integration of qualified oversea nurses and midwives in Australia and the UK. The authors described the integration process of oversea nurses and offered support from the recruiting organizations. More than 90% of the questioned oversea nurses found the support strategies useful, especially personal support and a welcoming atmosphere upon arrival and orientation. All nurses who were supported by the program remain employed [ 67 ]. Stakeholders found that the program was resource-intensive and questioned the cost-effectiveness of this method for meeting employment needs. Senior nurses and many ward managers thought it beneficial to promote the ethnic diversity of the nursing workforce [ 93 ]. Another study concentrated on the expansion of the role of pharmacists in treating five minor pediatric conditions in a pediatric clinic (USA). Service provided by pharmacist was comparable to the service provided at the standard acute care clinic; patients were more likely to have shorter wait time (<15-minute wait) and were more likely to receive written information than patients evaluated by physicians. In addition, patient satisfaction was high [ 66 ].

Integration of interpreter services. Bekaert reports that even though a language and advocacy services was installed at Horton General Hospital (UK), relatives were still translating for patients due to costly systems [ 88 ]. Furthermore, some patients in a culturally focused psychiatric consultation intervention program for Latino Americans with depression reported that even though interpreters were available, waiting for interpreters or having interpreters involved in private medical conversations was challenging [ 82 ].

Adaption of the organization’s social and physical environment. After the implementation of a Cambodian menu for postpartum women at Saints Medical Center (USA) in combination with a staff training program on breastfeeding, there were no significant difference between breastfeeding initiation rates among Cambodian women and non-Cambodians (66.7% Cambodian vs.68.9% non-Cambodian p = .874), although before its implementation Cambodian mothers were significantly less likely to initiate breastfeeding than non-Cambodian mothers (16.7% Cambodian vs. 60.6% non-Cambodian p = .003) [ 63 ]. The option of having an ethnic meal was not chosen because patients did not trust the mechanism of provision at Horton General Hospital (UK) [ 88 ], and it was considered enjoyable but not essential by women refugees at an ambulatory healthcare facility [ 75 ]. The installment of a sweat lodge on hospital property, where traditional ceremonies were held, improved care for Native Americans, which resulted in increased admissions of this population (4.77% to 7.50%) [ 70 ].

Data collection and management. Bekaert et al. (2000) reports that at Horton General Hospital (UK) “data collection was still not carried out regularly because staff felt it would be an imposition.”

Strategies for providing access to culturally competent healthcare

Integration of community health workers (CHW) to educate patients during home or clinic visits. CHW were generally bicultural/bilingual and were also able to conduct minor medical procedures. Culica et al. (2008) found significant reductions (p < .05) in mean HbA1c levels of culturally diverse diabetes patients from baseline to six months (8.14% to 7.36%) and 12 months (8.14% to 7%) after attending educational clinic visits carried out by a CHW at an urban community clinic (USA). In the context of a clinic-based colorectal cancer screening promotion program (USA), the integration of a CHW in combination with mailed educational material on colorectal cancer screening increased the number of screenings to 31% compared to 26% in the control group among Hispanic patients but the differences were not significant (p = .28) [ 30 ]. In the study by Tu et al. (2006), a culturally competent clinic-based educational program promoting fecal occult blood testing (FOBT) screenings among Chinese patients including motivational videos on colorectal cancer screening and carried out by a trilingual and bicultural health educator increased the screening rate to 69.5% compared to 27.6% in the treatment as usual condition [ 39 ]. A culturally and linguistically tailored health coach intervention for Chinese-American diabetes patients at two outpatient medical care units, in which patients were closely accompanied by their health coach during and after treatment, resulted in decreased mean HbA1c levels at follow-up (-0.40%) compared to the treatment as usual group (+0.04%), however this difference was not statistically significant [ 57 ]. Black or Latina navigators were integrated at Capital Breast cancer Center (USA) for women with abnormal mammogram results to ensure follow-up screenings among a population with low screening rates. Due to the intervention, 80% of women in need of further screening returned within a median time interval of 39 (range: 6–400) days which is below the recommended time of 60 days [ 68 ]. The advocates or liaisons who are integrated into the clinic team work lower stress for patients and providers through improved communication, increased safety of treatment, improved understanding, trust and connectedness, which in turn leads to higher efficacy of treatment and greater improvements in applying health recommendations in an outpatient oncology clinic (USA) as well as in primary care community clinics (Israel) [ 74 , 79 ].

Telemedicine. Psychiatric treatment offered by a bilingual psychiatrist via webcam led to a significant reduction in symptom severity and disability ratings as well as improvements in quality of life over time (p>.001) among Hispanic patients at a community health center (USA), but differences to treatment as usual delivered by a primary health provider were not significant [ 35 ]. The ratings of acceptability on a five-point-Likert scale ranged between 3.19 to 4.69, showing a high acceptability among Korean-speaking patients who were treated by a Korean-speaking psychiatrist via webcam at two mental health centers in the US [ 84 ]. Multilingual educational videos were significantly more beneficial than usual care (p>.001) for Punjabi and Chinese patients at a university-based pulmonary medicine clinic in Canada [ 37 ].

Outreach methods. An RCT by Coronado (2011) shows that a culturally competent mailed colorectal screening packet led to a 26% screening rate compared to 2% in clinic-based usual care (p < .001) and to a 31% screening rate if combined with telephone reminders and an educational home visit by a health promoter and a medical assistant (p < .001). Additionally, patients assigned to a home-based educational program on Iiving donor kidney transplantation in addition to a clinic based program at Shands Hospital at the University of Florida (USA) were more likely to have had living donor inquiries (OR:1.7; CI = 1.2–3) and a living donor evaluation (OR:2.7; CI = 1.4–5.4) and live donor kidney transplantation (OR: 3.0; CI = 1.5–5.9) than patients in the clinic-based program only [ 38 ]. Watkins et al. (1990) developed a strategy of early case finding by visiting women enrolled in their project and providing them with guidelines to identify culturally diverse pregnant farmworker women and referring them to a migrant health center in North Carolina (USA), which increased prenatal visits from a mean of 7.4 to a mean of 9.7 over one year and decreased the number of children with low birth weight from 13 to 6 over 2 years.

Creating community health networks. In order to improve healthcare for CLDP, health facilities engaged in activities concentrating on cooperation and exchange with other institutions within communities. In the context of a health clinic for refugees in Canada, initial intake assessments and basic services were performed at the reception house by case workers and trained professionals, while comprehensive care was provided at the refugee health clinic and more specialist services by community providers. Language support was also provided by the reception house. As a result, the likelihood of an individual requiring a physician specialist went down 45% as a result of seeing a refugee health clinic physician (OR = .55; p = .004) and refugees’ wait time to see a healthcare provider decreased from 30 to 21 days (Ratio of mean = .70; p < .001) [ 50 ]. A regional health collaborative formed by New York Presbyterian aimed to create a “medical village” by transforming clinics into patient-centered medical homes in a large Hispanic community. Patient-centered medical homes included multidisciplinary care teams, patient education, electronic health records system with up-to-date patient information and, disease registry and were linked to other providers and community institutions. This led to a 9.2% decrease of mean visits per patient to the emergency department following implementation of the model (p = 0.001). During the same period, hospitalizations for the cohort dropped by 5.8% (p = 0.25) [ 43 ].

Strategies for implementing culturally competent healthcare

Promoting changes within the organization. In order to improve healthcare for migrants, the “Migrant Friendly Hospital Initiative” in Geneva (Switzerland) decided to give to all new staff members a brief presentation of the initiative and about interpreter services during their mandatory orientation day. Aside from distributing brochures on the “Health for all Network”, migrant friendly services and information on the work with an interpreter, the hospital also organized numerous public events to raise awareness for its initiative. Hospital staff was significantly more likely to use the service of interpreters and other migrant friendly structures at the hospital. Overall, providers’ awareness increased and difficulties working with migrant patients decreased significantly [ 46 ]. The “Sick-Kids Cultural Competence Initiative” at the Hospital for Sick Children (Canada) established a Champion program in which cultural competence champions obtained advanced cultural competence education and became designated change agents and role models. Over 2,100 hospital staff members attended the workshops. Participants fulfilled 78% of the documented commitments to change and planed on realizing another 16% of commitments. Commitments to change were related to changes in practice, beliefs or attitudes and to continuing education related to culture and culturally competent care. Following a Cultural Competence Initiative promoting interpreter services, a significant increase in the use of face-to-face interpretation and a doubling of the number of minutes of telephone interpretation use was observed [ 76 ].

Model of culturally competent healthcare provision

Extracted components and strategies were organized into a model, the “Model of culturally competent healthcare provision” ( Fig 2 ). Importantly, the model is embedded in the legal context of a given country’s health system that regulates the organization of the system and the access to healthcare for individuals depending on their legal status in the country in question. Then again, the legal context is shaped by the political and social context of a country. In conclusion, the possibilities and usefulness of implementing identified strategies and components depend on the health system in which they are implemented as well as on the legal, social and political context of the country or region.

This review systematically searched for evaluated culturally competent healthcare interventions from which components and strategies for providing culturally competent healthcare to CLDP were collected and their effects on outcome measures were examined. Twenty categories of components were identified and clustered into four groups. A model integrating those interventions is proposed. Data on the effects of identified components and strategies were not available for all categories because in most studies a combination of multiple strategies and components was implemented simultaneously, and therefore statements about the effects of single categories were not possible. However, for fifteen categories qualitative and/or quantitative data were available, but synthesis of data was difficult because of the diversity of studies and outcome measures. In general, the effects of identified components and strategies were positive but often small or not significant compared to treatment as usual. Qualitative data suggest that these components and strategies were appreciated and found helpful by patients and providers. Furthermore, they confirmed many of the components and strategies proposed by existing conceptual models or frameworks of cultural competence [ 8 – 10 , 21 ]. Existing models and reviews have already mentioned implementing the following strategies: providing care in different languages, recruiting bicultural/bilingual healthcare professionals, training healthcare staff in cultural competence, integrating community health workers, including individual patients’ families into care, adapting the environment by offering ethnic meals and, written material in different languages, collaborating with minority communities and monitoring of the organizational development. Nonetheless, this review identified strategies used to improve healthcare for CLDP which are not included in existing models. These are primarily related to improving access to culturally competent healthcare for CLDP: telemedicine, outreach methods and the creation of community health networks. In fact, it appears that these strategies address the socioeconomic differences often associated with culturally and linguistically diverse backgrounds, rather than the actual cultural backgrounds themselves (e.g., Outreach methods for Hispanic farmworkers). Some strategies are integrated in conceptual frameworks but were not often found in empirical studies. These include adapting policies and integrating traditional healers into care.

Reported evidence is limited in this review because the majority of studies implemented multiple components or used different strategies simultaneously, and outcomes could therefore not be attributed to one specific component or strategy. Other authors noted that the methodological quality of included studies is often insufficient to support the effectiveness of culturally competent interventions [ 9 , 11 , 12 , 21 , 22 ]. Truong’s systematic review of reviews on cultural competence outlined that most reviews only found weak evidence for improvements in patient outcomes and moderate improvement in provider outcomes and utilization rates [ 12 ]. Diaz et al. state in their scoping review that the main cultural competence interventions in 57 of 83 studies were declared beneficial for the primary outcome as well as for secondary outcomes in 13 studies. In 12 interventions no effects were observed compared with standard care [ 22 ]. The effectiveness of organizational system-level interventions was not confirmed because interventions were “context-specific, there were too few comparative studies and studies did not use the same outcome measures” [ 11 ]. In this review comparative studies were available but generally compared an innovative culturally competent health intervention to treatment as usual. This approach is problematic, because it gives no information on whether the health intervention, the culturally competent components or a combination of both can be determined to be effective. Anderson at al. (2003) stated in their review that no sufficient evidence was found to determine the effectiveness of workforce diversity, use of interpreter services, patient-provider matching, use of culturally and linguistically appropriate health education materials and culturally specific settings. In the present review, moderate effects on patient outcomes were found for patient-provider matching. A systematic review on race and racial concordance on patient-physician communication studies demonstrated that racial discordance is related to poorer communication [ 94 ]. Brach and Fraser (2000) highlighted that even though a relationship between communication, adherence and outcomes exists, it has not been demonstrated specifically for linguistic matching. They found some evidence that the provision of professional interpreter had positive effects on utilization and satisfaction and reduced disparities in healthcare [ 9 ], which could not be verified in this review. Integrating community health workers had again positive but modest effects on patient outcomes and utilization rates, which has also been confirmed by Brach and Fraser (2000).

The strength of this review lies in its overall approach. The use of a scoping review methodology with a systematic literature search allowed for a broad overview on studies implementing culturally competent health interventions in healthcare facilities. A bottom-up approach was used, and components and strategies have been extracted from practice instead of deriving interventions from theoretical concepts of cultural competence. In this way we created a model based on feasible and actually implemented interventions. Compared to existing models, this model summarizes a variety of strategies on different levels. The “Analytic framework used to evaluate the effectiveness of healthcare system interventions to increase cultural competence” by Anderson et al. (2003) included five strategies, while the conceptual model by Brach and Fraser (2000) identified nine major cultural competency techniques. Fung et al. (2012) proposed strategies in 24 subdomains organized in eight domains for implementing organizational cultural competence, but these only concentrated on the organizational level. This model provides 20 strategies on four different levels. In addition to strategies on the individual and organizational level, the model points out how change within healthcare organization can be implemented and how patients can better access culturally competent healthcare, which was not as thoroughly considered by previous models. In combination with the detailed description of the strategies and components in Table 2 , this review provides researchers, facility leaders and policy or decision makers with a unique catalogue of feasible strategies aiming to battle healthcare disparities and enhance healthcare for all patients. Importantly, it highlights that health systems and facilities are integrated into specific social, cultural, legal and political contexts that affect one another and influence the possibilities of implementing chosen strategies.

Some limitations must be considered. We included in our search different groups of culturally and linguistically diverse patients, such as migrants including refugees and asylum seekers but also racial or ethnic groups and minorities. Obviously, these groups are very heterogeneous and their needs and perceived barriers to healthcare may differ substantially. Nevertheless, we chose to include all different groups to create a broad overview of generally possible strategies. When implementing strategies, their appropriateness for the specific target group must be considered. In addition, interventions needed to be located explicitly in a healthcare organization, otherwise they were excluded from the review. Notably, interventions for CLDP are often implemented in community institutions such as community centers, churches or schools, but the focus if this review was to identify strategies implemented in healthcare organizations. Only studies published in English or German were considered to be included in the review, which may have caused a selection bias, and some relevant studies in other languages may have been excluded.

The majority of studies (76%) were from the US, and almost all studies were from industrialized countries. The US hosts the largest number of international migrants in the world with approximately 53% of migrants from Latin America, 25% from Asia, 14% and from Europe [ 95 ]. This is also reflected in the targets groups of identified studies, of which 48% were designated for Hispanics or Latinos. Interestingly, only 9% of studies were from the European countries of the UK, the Netherlands and Switzerland, even though Germany, Spain, the UK and France accommodate the highest numbers of approximately 31.9 million non-European Union (EU) nationals in Europe [ 96 ]. The high number of studies from the US is understandable but it limits the generalizability of the results and possibly the transferability to other health systems and groups. Importantly, the developed model does not claim to be comprehensive or completed but rather serves as an empirical baseline that needs to be verified and further developed. In this context it would be an asset to identify connections between target groups, types of implemented strategies, the respective health systems’ organization and perhaps even the legal, social and political context in chosen countries.

Despite the limitations of this review it provides a unique overview and categorization of culturally competent healthcare provision. Unfortunately, the effectiveness of identified components and strategies could not be confirmed and was even often impossible to evaluate because either no control group was available or the chosen control group did not give any information on the effectiveness of the culturally competent components but rather on the health intervention in combination with culturally competent elements. This presents a challenge for future research on the effectiveness of cultural competence in healthcare. An option would be to simplify or reduce the number of implemented components and to choose more appropriate control groups. Another option would be to improve the research methods in order to be able to evaluate single components of complex interventions. Using qualitative study designs might help to better understand what strategies are helpful to overcome healthcare disparities why and for whom. It is essential to keep the heterogeneity among CLDP in mind and to carefully consider interactions between societal, cultural, health related and personal factors to explain and reduce healthcare disparities.

Supporting information

Funding statement.

The study was funded by the Verein zur Förderung der Rehabilitationsforschung in Hamburg, Mecklenburg-Vorpommern und Schleswig-Holstein (vffr) ( http://www.reha-vffr.de ). OH and MM received the funding. The funders did not play any role in the study design, data collection, decision to publish, or preparation of the manuscript.

Data Availability

Understanding Cultural Diversity in Healthcare

Case Studies

See culture in action.  Case studies bring you up close and personal accounts from the front lines of American hospitals and other countries on the issues of cultural diversity in healthcare.

The following case studies are presented by topic and contain quick recaps of some common cultural misunderstandings. More detailed information can be found in Caring for Patients from Different Cultures.

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• Stereotyping
• Communication
• Time Orientation
• Religious Beliefs and Customs
• End of Life
• Mental Health
• Traditional Medicine
• Additional Case Studies

Lamar Johnson, a thirty-three-year-old African American patient had been deemed a “frequent flyer” (a term used to describe those who keep coming to the hospital for the same reason, often assumed to be drug seekers) by the nurses and doctors in the emergency department. Each time he came in complaining of extreme headaches he was given pain medication and sent home. On this last admission, he was admitted to the ICU, where Courtney, a nurse, had just begun working. When she heard him described as a frequent flyer, she asked another nurse why he was thought to be a drug seeker. She was told, “He has nothing else better to do; I’m not sure why he thinks we can supply his drug habits.” Although Courtney says her instincts told her that something else was going on, she saw his tattoos, observed his rough demeanor, and went along with what everyone else was saying. While she was wheeling him to get a CT scan, Mr. Johnson herniated and died. It turned out that he had a rare form of meningitis and truly was suffering from severe headaches. If some of the staff had not stereotyped him as a drug seeker on one of his earlier visits, perhaps his life could have been saved. This incident left a lasting impression on Courtney, who vowed not ever to judge a patient on his looks, and to trust her instincts, rather than let others influence her nursing care.

While taking a course on cultural diversity, Anike Oghogho, a nurse from Nigeria, recognized his tendency to stereotype. He related an example of an African American male patient who presented with a swollen left foot. The patient, Jefferson Bell, kept ringing the call light and asking for more pain medication. Anike said that in the past, he would have assumed Mr. Bell was merely seeking pain meds. This time, however, he reassessed the patient. He discovered that Mr. Bell’s fourth and fifth toes were more red and swollen and had pus. Anike summoned the physician and Mr. Bell was eventually taken to the operating room for incision and drainage of his left foot. Stereotyping could have severely harmed the patient; fortunately, Anike had learned the lesson of not stereotyping in his class.

Hilda Gomez, a monolingual Spanish-speaking patient, came in to the clinic three days in a row to complain of abdominal pain. The first two times, the staff used her young, bilingual daughter to translate. They then treated Mrs. Gomez for the “stomach ache” she described. The staff didn’t understand why she kept returning with the same problem. Finally, on her third visit, the nurse located a Spanish-speaking interpreter. It turned out that Mrs. Gomez needed treatment for a sexually transmitted disease, but was too embarrassed to talk about her sexual activity with her daughter as interpreter. It taught the staff an important lesson.

Helena became very frustrated while caring for Gwon Chin, a seventy-nine-year-old Korean man who had recently suffered a stroke. Her frustration and impatience were aimed at Mr. Gwon’s wife and daughter. Since Mr. Gwon spoke only Korean, she had asked his bilingual daughter to tell her father not to get out of bed because his gait was unsteady. Helena was afraid he would fall and hurt himself. Throughout the day, however, Mr. Gwon continued to attempt to get out of bed. He became very agitated and his wife and daughter seemed almost afraid of him. When Helena questioned the daughter about it, she would only say that her father was “confused.” Eventually Helena called on a Korean nurse to help her. When the nurse told Mr. Gwon not to get out of bed because he might fall, he asked in a surprised tone, “Why would I fall?” When the nurse explained that he was unsteady from the stroke, the patient was shocked. “I had a stroke?!” Helena was in disbelief. He had been on the unit for two days; how could he not know he had had a stroke? When she questioned Mr. Gwon’s daughter about this, she explained that her brother has been out of town. He would be back today and tell him. When Helena, stunned by this, asked the daughter why she didn’t tell her father, she replied, “I could never tell my father what is wrong with him and what he can or can’t do. It would be disrespectful for me to do that when he has always told me what to do and what was wrong.”

Although Helena was angry that Mr. Gwon’s daughter preferred having her father possibly fall and hurt himself than tell him why he was in the hospital and that he must stay in bed, Helena remained silent. She asked the Korean nurse to explain to the patient how the numbness on his left side would make walking difficult so he should remain in bed. She also added that his son would be in later that day and would explain everything to him. After that, the patient remained calm and stayed in bed.  [For more discussion, see Chapter 2 of Caring for Patients From Different Cultures .]

Juanita Avelar was a forty-nine-year-old Mexican woman with kidney failure and diabetes. She relied on her niece and nephew to drive her to the clinic and was often late. In Mexican culture, the needs of the family typically take precedence over those of an individual. The nurses learned to take this into account when scheduling her appointments, and they allowed plenty of time for the family to discuss Mrs. Avelar’s condition as a family. When certain tests and medications required specific timing for accuracy and effectiveness, they stressed the importance of clock time.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “ Aye! Aye! Aye ! Mucho dolor ! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez’s dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.

She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.

Bobbie, a nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony.

Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her. [For more discussion, see Chapter 5 of Caring for Patients From Different Cultures .]

Pepe Acab, a Filipino patient, was being discharged on Coumadin, a blood thinner, to prevent clotting. Vitamin K reverses the effect of the drug and must be avoided. Normally, Libby, his nurse, would tell such patients to avoid foods like liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and any green, leafy vegetables. She suddenly realized, however, that there might be other foods he should avoid. She spoke with Mr. Acab and his wife, and got a list of foods he commonly ate. She then did some research and discovered that two foods on the list—soybeans and fish liver oils—are very high in Vitamin K. She was then able to educate him properly on what to avoid.

Susi Givens, a thirty-seven-year-old woman with two children, was horseback riding one day when a snake startled her horse. She was thrown off and landed on a stump, resulting in massive internal injuries. She was rushed to the hospital, where the surgical team discovered that there was a large amount of blood in her abdomen and that she needed to have a kidney removed.

Mrs. Givens had a medical alert card identifying her as a Jehovah’s Witness and stating that under no circumstances was she to receive blood. Her physician knew this but felt impelled by his oath to save lives to give her a blood transfusion. The hospital was unable to locate her husband, so the physician decided to transfuse her.

His actions saved her life; however, she was not grateful. She sued her doctor for assault and battery and won a $20,000 settlement. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Sol and Deborah Meyers, an Orthodox Jewish couple, came to the hospital late Friday night when Deborah was in active labor. When she gave birth at midnight, the nurses suggested that Sol accompany her to the postpartum unit and then return home to rest. He thanked them, then explained that he could not drive home because it was the Sabbath. The nurses suggested that he call a friend or relative to pick him up. Sol replied that he could not use the phone on the Sabbath, and even if he made a call, no one would answer because all his friends and relatives were also Sabbath-observant. The nurses understood and arranged for him to stay in his wife’s room, but were left wondering why Sol could drive to the hospital but not drive back home.

In the morning, a nurse noticed that Deborah had not received breakfast and was instead eating snacks from the bag she had brought from home. The nurse asked if she needed help ordering food, and Deborah explained that the hospital-provided meals did not adhere to kosher dietary laws. The nurse, trying to be helpful, suggested that Sol purchase kosher food from the gift shop on the first floor, but was told that due to the laws of the Sabbath, Sol was forbidden to ride in an elevator or handle money. The nurse left the room, confused but glad the couple had brought some food of their own.  

Later that afternoon, the nurse returned to check on Deborah, and made friendly conversation by asking how the baby’s nursery was decorated at home. She was surprised to learn that in Orthodox tradition, minimal preparations are made before a baby’s birth, and the baby’s room was not set up at all. Intrigued, she asked Sol to explain some of the laws of Sabbath observance. She learned that the couple had been able to drive to the hospital because, according to halacha (Jewish law), childbirth is considered an emergency requiring the breaking of the Sabbath, but that once the birth was over, they were not allowed to drive home due to the absence of an emergency.

Raj Singh, a seventy-two-year-old Sikh from India, had been admitted to the hospital after a heart attack. He was scheduled for a heart catheterization to determine the extent of the blockage in his coronary arteries. The procedure involved running a catheter up the femoral artery, located in the groin, and then passing it into his heart, where special x-rays could be taken. His son was a cardiologist on staff and had explained the procedure to him in detail.

Susan, his nurse, entered Mr. Singh’s room and explained that she had to shave his groin to prevent infection from the catheterization. As she pulled the razor from her pocket, she was suddenly confronted with the sight of shining metal flashing in front of her. Mr. Singh had a short sword in his hand and was waving it at her as he spoke excitedly in his native tongue. Susan got the message. She would not shave his groin.

She put away her “weapon,” and he did the same. Susan, thinking the problem was that she was a woman, said she would get a male orderly to shave him. Mr. Singh’s eyes lit up again as he angrily yelled, “No shaving of hair by anyone!”

Susan managed to calm him down by agreeing. She then called her supervisor and the attending physician to report the incident. The physician said he would do the procedure on an unshaved groin. At that moment, Mr. Singh’s son stopped by. When he heard what had happened, he apologized profusely for not explaining his father’s Orthodox Sikh customs. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Ricky, a five-year-old African American male with asthma, was supposed to take a controller medication (asthma inhaler #1, Steroid) twice a day as a preventative measure. When he was wheezing and/or having breathing problems, he was supposed to take asthma inhaler #2 (Albuterol) as an emergency medication. Dr. Arabel felt that she had given very clear instructions on how to use the two inhalers, but Ricky’s mother kept bring him back to the clinic with a lot of wheezing; his asthma was obviously not being well controlled. As it turned out, Ricky had not been using the inhalers as directed. His mother, who was enrolled in school, was overwhelmed and did not understand the significance of his asthma and the need to use the two inhalers properly. On one of the visits, Dr. Arabel learned that Ricky’s grandmother had accompanied them to the clinic. She brought the grandmother into the exam room, and explained everything to her. Once the grandmother became involved, everything changed. There were no more emergency room/urgent clinic visits and Ricky’s asthma was much better controlled. He only rarely needed the “emergency” Albuterol compared to earlier. Involving the grandmother had made a tremendous difference.  [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Julia was treating Mrs. Torres, an elderly Hispanic patient who was intubated. When she needed information, she would direct her questions to the eldest son. She assumed he would be the family spokesperson. However, he rarely had an answer for her. While in many cases the eldest son would be the decision-maker, in this case he was not. The youngest daughter held the durable power of attorney for medical decisions. It was several days before anyone even thought to ask the family who held power of attorney. The staff had made the mistake of stereotyping. Once Julia learned that the youngest daughter was responsible for making medical decisions for her mother, such decisions were reached more quickly and without unnecessary strain on the rest of the family. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Juan Martinez, a thirty-six-year-old Mexican man with second-degree burns on his hands and arms, posed a problem. The skin grafts had healed, and there was now danger that the area would stiffen and the tissue shorten. The only way to maintain maximum mobility was through regular stretching and exercise. The nurses explained to Mr. Martinez’s wife that feeding himself was an essential therapeutic exercise. The act of grasping the utensils and lifting the food to the mouth stretches the necessary areas. Mrs. Martinez seemed to understand the nurses’ explanation, yet she continued to cut her husband’s food and put it in his mouth.

When Linda, one of his nurses, observed this, she took the fork out of Mrs. Martinez’s hand and told Mr. Martinez to feed himself because he needed to exercise his arms and hands. Linda again explained to Mr. Martinez’s wife how important it was for him to do it himself. Mrs. Martinez appeared skeptical but did not argue. Mr. Martinez looked at Linda peevishly and made a feeble attempt at eating. His wife watched with pity. Linda knew from seeing Mr. Martinez when his wife was not around that he was perfectly capable of feeding himself. Linda left the room. When she looked in five minutes later, she saw Mrs. Martinez once again cutting her husband’s food and putting it in his mouth. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Before taking my course in cultural diversity, Jennifer, like all the nurses on her unit, tried to avoid taking care of Naser Assharj, a middle-aged Iranian Muslim patient, because the entire staff found his family to be very “uptight and demanding.” The nurses rotated care for this patient, because no one was willing to care for him more than one day at a time. When Jennifer learned a bit about Muslim culture, however, she understood why his family kept demanding a private room and made such a fuss over his meals. It was their way of showing love and care for their family member. He needed a private room so that, as devout Muslims, the family could pray together five times a day as commanded by Allah. It was also important that his food be halal , or follow the Muslim laws of what is permissible (see Chapter 5). Once Jennifer realized this, she contacted her supervisor and arranged to have the patient moved to a private room and spoke to the dietician regarding his food. The family members were very grateful for her efforts, and became much easier to deal with.

Amira Faroud was a three-year-old Middle Eastern patient, newly diagnosed with type 1 diabetes. Understanding the importance of involving the entire family in the patient’s care, Lisa tried to get the patient’s father, Mr. Faroud, to participate. She had seen other fathers reluctant to learn in the past, but eventually, they all were persuaded. But not Mr. Faroud. He would not even consider it. Eventually, Lisa changed the teaching plan to include Amira’s grandmother rather than her father, and all went well. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

A female resident could not get a Hispanic mother to sign consent for a procedure for her child; she, too, insisted on waiting for her husband. In this case, however, it was urgent that the procedure be done as soon as possible. The resident asked an older male physician to speak to the mother. Apparently, the combination of his age and gender were enough to convince her to sign consent without speaking first to her husband.

Amiya Nidhi was a young woman in her twenties who had recently immigrated to the United States from India. She was in the hospital to give birth. Her support person was her sister, Marala. Marala kept telling her to get an epidural, but Amiya said that even though she would like one, she could not get one; her husband would not allow it. Cindy, her nurse, overheard the conversation. Having learned that husbands are the authority figure in the traditional Indian household, she went to speak with Mr. Nidhi. She explained why an epidural would be advisable. She said that he seemed pleased that she came to him about it. He said he would think about it, and let her know. About thirty minutes later, he came to Cindy and told her that he would like his wife to have an epidural. Everyone was pleased. By using cultural competence, Cindy helped her patient get the care she wanted, while still respecting the authority structure within the family. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

An Iranian mother and father admitted their thirteen-month-old child, Ali, to the pediatrics unit. After three days of rigorous testing and examination, it was discovered that Ali had Wilms’ tumor, a type of childhood cancer. Fortunately, the survival rate is 70 to 80 percent with proper treatment.

Before meeting with the pediatric oncologist to discuss Ali’s treatment, Mr. and Mrs. Mohar were concerned and frightened, yet cooperative. Afterward, however, they became completely uncooperative. They refused permission for even the most routine procedures. Mr. Mohar would not even talk with the physician or the nurses. Instead, he called other specialists to discuss Ali’s case.

After several frustrating days, the oncologist decided to turn the case over to a colleague. He met with the Mohars and found them extremely cooperative. What caused their sudden reversal in behavior? The fact that the original oncologist was a woman.

Several weeks later, it became necessary to insert a permanent line into Ali to administer his medication. The nurse attempted to show Mrs. Mohar how to care for the intravenous line, but Mr. Mohar stopped her. “It is my responsibility only. You should never expect my wife to care for it.” Throughout each encounter with the hospital staff, Mrs. Mohar remained silent and deferred to her husband. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

A twenty-eight-year-old Arab man named Abdul Nazih refused to let a male lab technician enter his wife’s room to draw blood. She had just given birth. When the nurse finally convinced Abdul of the need, he reluctantly allowed the technician in the room. He took the precaution, however, of making sure Sheida was completely covered. Only her arm stuck out from beneath the blankets. Abdul watched the technician intently throughout the procedure. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

Fatima, an eighteen-year-old Bedouin girl from a remote, conservative village, was brought into an American air force hospital in Saudi Arabia after she received a gunshot wound to her pelvis. Her cousin Hamid had shot her. Her family had arranged for her to marry him, as was local custom, but she wanted nothing to do with him. She was in love with someone else. An argument ensued, and Hamid left. He returned several hours later, drunk, and shot Fatima, leaving her paralyzed from the waist down.

Fatima’s parents cared for her for several weeks after the incident but finally brought her to the hospital, looking for a “magic” cure. The physician took a series of x-rays to determine the extent of Fatima’s injuries. To his surprise, they revealed that she was pregnant. Sarah, the American nurse on duty, was asked to give her a pelvic exam. She confirmed the report on the x-rays. Fatima, however, had no idea that she was carrying a child. Bedouin girls are not given any sex education.

Three physicians were involved in the case: an American neurosurgeon who had worked in the region for two years; a European obstetrics and gynecology specialist who had lived in the Middle East for ten years; and a young American internist who had recently arrived. No Muslims were involved. The x-ray technician was sworn to secrecy. They all realized they had a potentially explosive situation on their hands. Tribal law punished out-of-wedlock pregnancies with death.

The obstetrician arranged to have Fatima flown to London for a secret abortion. He told the family that the bullet wound was complicated and required the technical skill available in a British hospital.

The only opposition came from the American internist. He felt the family should be told about the girl’s condition. The other two physicians explained the seriousness of the situation to him. Girls in Fatima’s condition were commonly stoned to death. An out-of-wedlock pregnancy is seen as a direct slur upon the males of the family, particularly the father and brothers, who are charged with protecting her honor. Her misconduct implies that the males did not do their duty. The only way for the family to regain honor was to punish the girl by death.

Finally, the internist acquiesced and agreed to say nothing. At the last minute, however, he decided he could not live with his conscience. As Fatima was being wheeled to the waiting airplane, he told her father about her pregnancy.

The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatima’s brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, “She died.” Family honor had been restored. The ethnocentric internist had a nervous breakdown and had to be sent back to the United States.

Sofia Toledo, a sixty-five-year-old upper-class Mexican woman, refused to be dialyzed when she learned that her usual dialysis station was unavailable. She said she would wait until her next treatment, when she could have her customary place. Unfortunately, this was not a viable alternative. Missing a treatment could result in serious complications or even death. When Julia, the nurse, asked her why the new station was unacceptable, Mrs. Toledo was very vague.

Julia finally called Mrs. Toledo’s daughter, and together they solved the problem. Mrs. Toledo’s usual station was unusual in that neither the nurses nor the patients at the other dialysis stations could see it very well. The rest of the stations were very open, designed for high visibility by the nurses. To be dialyzed, the patient had to remove her pants and don a patient gown. Her underwear was exposed during the process. Mrs. Toledo’s sense of modesty, a quality very strong in Hispanic women, made the more open station intolerable.

Julia said that at the time she found Mrs. Toledo’s behavior annoying. She and the other nurses saw it as a delay that would prevent them from leaving on time. They did not want to have the extra work of moving machinery or remixing the dialysate. She did not understand the importance of modesty in Hispanic culture, but she did realize that it was important to Mrs. Toledo, a normally “compliant” patient. In this case, a screen or curtain might have alleviated the problem.

Kayla was a staff nurse on a medical-surgical floor when she first met Dr. Ling, an Asian physician. They got along well until Kayla transferred to the diabetes clinic. Clinic protocols allow nurses to order new medications, adjust medications, and order lab work as needed, as long as they get a physician to sign the order. When Kayla asked Dr. Ling for his signature, he would rudely question why she felt the medication was necessary, and on a few occasions refused to sign, stating that he disagreed with the medication she had ordered. After learning more about Asian culture in a cultural competence course, she realized he probably perceived her approach as showing a lack of respect, despite the fact that she was following clinic protocols. She then changed her approach. Rather than just asking him to sign the medication order, she would go to him, explain the situation with the patient, tell him what she was considering, and ask him what he would like done. Kayla reported that Dr. Ling was much more receptive to this approach, probably because it allowed him to feel respected and in control. Taking the extra time to do this repaired the lines of communication between them. Although it could be argued that Dr. Ling is the one who should have changed his behavior, that is probably less realistic than having Kayla apply her cultural knowledge to achieve the results that she wanted.

Josepha, a Filipina nurse, did not get along well with her coworkers. The nursing staff on her unit was composed of two Anglo Americans, two Nigerians, and Josepha. She felt her coworkers were taking advantage of her, because they would ask for assistance whenever they saw her. Josepha was angry over what she perceived as obvious discrimination. She cheered herself by reminding herself that she was a better nurse than the others; she could do her work without their help. In addition, she was not lazy like they were. She took care of her patients; the other nurses insisted that their patients take care of themselves.

One day, Rena, one of the Anglo nurses, was unusually friendly, so Josepha opened up to her. As they got to know each other better, Josepha shared her feelings of being taken advantage of. Rena explained that it was common procedure for the nurses to help each other with their work. Rena confided that the others thought Josepha was being snobbish and proud because she never asked for help. They saw what Josepha had interpreted as laziness on the part of the others as being team players. Rena also explained that American health care providers believe that independence is important and encourage self-care among their patients.

Josepha was stunned by Rena’s revelations. Rena offered to help bridge the communication gap between Josepha and her coworkers. She explained to the others that Josepha was trying to save face by never asking for help; she didn’t want them to think she couldn’t do her job. Josepha began to teach her patients self-care and to ask her coworkers for assistance. Over time, the cross-cultural misunderstandings were resolved, and Josepha’s coworkers became her best friends.

Leslie reported that her hospital had recently hired five new Korean nurses. Unfortunately, they did not get along well with the rest of the nursing staff. They rarely said “please” or “thank you” and were generally perceived as rude. Leslie was reading an earlier edition of this book and suddenly realized that the Korean nurses were older than the other nurses on the unit and probably felt that “please” and “thank you” were implicit. Leslie then showed the other staff nurses the section on “Please” and “Thank You.” She reported that morale on the unit is much improved. Sometimes, all it takes is a little understanding.

An American physician and professor, consulting in Japan, was about to address a group of university physicians; it was fully understood by all that he would give his talk in English. He nevertheless prepared a brief introduction in Japanese, concluding with the statement, “My Japanese is limited, so with your permission, I will continue in English.” When he asked his Japanese secretary if his statement was grammatically correct, she seemed uncomfortable. On further questioning she reluctantly admitted that, grammar aside, it was not appropriate for someone of his stature to ask the audience for permission, and that this would diminish the audience’s ability to respect anything else he said. Instead, she suggested, he should merely announce that he would continue in English. In this context “asking permission” was entirely pro forma in American culture; it would be seen as a polite gesture. In Japan, however, it was considered inappropriate from someone in a position of authority, and would likely result in a loss of respect for the person doing the asking. [For further discussion, see Chapter 8 of Caring for Patients From Different Cultures .]

A labor and delivery nurse reported that the most difficult patient she ever attended was Robabeh Farag, an Iranian woman, who yelled and screamed for the entire duration of her labor. After she delivered their child, her husband presented her with a three-karat diamond ring. When her nurse commented on the expensive gift, she responded dramatically, “Of course. He made me suffer so much!” Iranian custom is to compensate a woman for her suffering during childbirth by giving her gifts. The greater the suffering, the more expensive the gifts she will receive, especially if she delivers a boy. Her cries indicate how much she is suffering. A young Iranian doctor recently told me that when his wife has a baby, he will present her with a diamond ring or a watch. [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Naomi Freedman, an Orthodox Jewish woman, was in labor with her third child. She had severe pains, which were alleviated only by back rubs between contractions. Her husband asked Marge, a nurse, to remain in the room to rub his wife’s back. Because she had two other patients to care for, Marge began to instruct him on how to massage his wife. To Marge’s surprise, he interrupted her, explaining that he could not touch his wife because she was unclean. Marge, assuming he meant she was sweaty from labor, suggested that he massage her through the sheets. In an annoyed tone, he explained that he could not touch his wife because she was bleeding. Marge was further surprised when, while Naomi began pushing, her husband left the room and did not return until after their baby was born.

Marge later learned from Mrs. Freedman that in halacha (Jewish law), the blood of both menstruation and birth render a woman spiritually unclean and therefore physical contact between husband and wife was prohibited. Mrs. Freedman also explained that in some Orthodox communities, husbands are prohibited from being present at birth in non-emergency situations.

[For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Maria Salazar was a thirty-two-year-old recent immigrant from Mexico with an infected incision from a caesarean section. She asked Tonya, her nurse, for some water. When Tonya grabbed the bedside pitcher to refill it, she discovered it was full. When Tonya pointed this out to her, she answered in Spanish, “Yes, but I have a fever and a cough. If I drink that cold water I will get even more sick.” Tonya, who spoke some Spanish, was taking a course in cultural diversity at the time and was elated to see hot/cold beliefs in action. She then emptied the ice water and refilled it with warm water. Curious, Tonya asked her if there were any changes she would like to see in her treatment. Mrs. Salazar nodded her head. She said she didn’t understand why the nurses kept insisting she do things that would make her ill—things like taking a shower. Didn’t they understand she had a fever and had just delivered a baby? And why did they want her to spend so much time walking, when she knew she should stay in bed and rest as much as possible? [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Raul Santiago was a Hispanic male in his seventies who had been in the hospital for seven months. He had been admitted for abdominal pain, but it soon became apparent that he had advanced stage pancreatic cancer. Mr. Santiago had 12 children, who all conspired to avoid using the word “cancer” in front of their father or to even acknowledge his fatal prognosis. Instead, they referred to his condition as “abdominal pain.” During the time he was in the hospital, Mr. Santiago became close to the nursing staff. One day while Tiffany was administering his pain medication, he looked directly at her and said with resignation, “I’m going to die, aren’t I?” Without waiting for her to respond, he continued. He explained to Tiffany that he didn’t want his children to suffer because of his illness, and he knew that if they knew that he knew he had cancer, it would cause them great distress. He told her that he was ready to be with his wife who had died two years earlier. He was content to pretend to be ignorant of his disease if it eased his family’s suffering. Whether or not it would have caused his children to suffer if they knew he knew, or if it would have been a relief is unknown. But the nurses honored his decision.

A fifty-two-year-old African American man named William Jefferson was admitted to the critical care unit with a diagnosis of pneumonia. On admission, he was offered an Advance Directive, which he refused, saying that God would help him with his illness. His lung cancer had gone into remission after radiation treatment; he believed that God had helped him through that illness, and would help him through the current one. He thought that signing a Do Not Resuscitate form or Advance Directive would be a sign of giving up or losing faith in God. Unfortunately, he died ten days later, after enduring a great deal of suffering. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Ngoc Ly, a twenty-five-year-old Vietnamese man, was hit by a car while riding his bicycle to work. Paramedics were able to resuscitate him, but the physician at the local trauma center determined that Mr. Ly was clinically brain dead. He placed him on life support until the family could be notified.

An interpreter explained Mr. Ly’s condition to his wife and parents. They nodded in understanding and quietly left the hospital. Normally, the staff neurosurgeon would then have pronounced Mr. Ly dead and removed him from the ventilator, but he was suddenly called to surgery.

Later that afternoon, Mr. Ly’s family met with Dr. Isaacs, the physician they had spoken to earlier. Dr. Isaacs intended to tell them of the plan to pronounce Mr. Ly dead and discontinue the ventilator, but the Lys had other plans. They informed him that they had consulted a specialist who said this was not the right time for him to die. Dr. Isaacs was confused. What kind of specialist would make such a recommendation? An astrologer who had read Ngoc Ly’s lunar chart advised that his death be postponed until a more auspicious date.

The physician had never encountered a situation like the one now facing him. Fearing legal repercussions if he did not abide by the family’s request, he agreed to keep Mr. Ly on life support until further notice. A little less than a week later, the Lys called to tell him that Ngoc could now die. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Canh Cao was a thirty-four-year-old Vietnamese woman who was treated by a medical student at a public health clinic. She had made several visits for various physical complaints—abdominal pain, backache, headaches. She was diagnosed with somatoform pain disorder—preoccupation with pain in absence of physical findings.

Several months later, Cao attempted suicide. She was sent for evaluation to a psychiatrist, who at that point diagnosed her with depression. She had been depressed all along, but the medical student was both inexperienced and unaware of cultural issues, so he missed it. [For further discussion, see Chapter 11 of Caring for Patients From Different Cultures .]

Amelia avoided a potential child abuse report with a Cambodian family, the Chhets. The child had suspicious burn marks on her body. Instead of assuming child abuse, she first interviewed both parents separately. Both explained that they had treated their child using cupping and coining to make her feel better and help her recover more quickly. Amelia then explained to her supervisor what she had learned from the parents, and they decided it was not a child abuse situation. The Chhets practiced the traditional form of cupping. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Mexican American mother refused to use cooling measures in caring for her febrile infant, despite medical instructions to do so. Mrs. Lopez had called the hospital because her infant’s temperature was very high. She was told to give the baby a mild analgesic and a cool bath and then to bring her in. Mrs. Lopez ignored both cooling instructions and, to the consternation of the medical staff, brought the child wrapped in several layers of blankets, outer garments, undershirt, and several pairs of socks. When asked why she did not follow the instructions given her, she replied, “He must sweat the fever out. Besides, he could get pneumonia from the night air and die.” [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Fariba was asked to interpret for Fereydoon Jalili, an Iranian man who had come to the hospital with gastrointestinal bleeding. Mr. Jalili spoke some English, and when the physician had asked him what medications he was taking, he told him he didn’t take any. When Fariba was brought in to interpret, she began talking to him about his health. During their conversation, he admitted that he took vitamins to stay healthy and he was very proud of the fact that he had never been sick. He also mentioned that he took two aspirins a day for his heart after seeing a commercial on television which said it prevented heart attacks. When Fariba asked him why he didn’t tell the doctor about the vitamins and aspirin, he said that he didn’t consider anything he bought over-the-counter to be a “real” medication. Once the physician learned what he had been taking, he educated Mr. Jalili on appropriate aspirin consumption, since that was the likely cause of his GI bleed. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Jen, a second-year medical student, was on a pediatrics visit learning how to perform a newborn exam. As she followed the attending into the patient’s room, she noticed that the baby’s mother was sitting on the side of the crib talking in Spanish to her husband. The attending started to explain to Jen what is important to notice about a baby and what to look for on the physical exam, and proceeded to ask her questions about the causes of pneumonia and meningitis in the newborn period. As they were talking, the infant’s mother came over to the crib. In an attempt to welcome her into their conversation, Jen said “hello,” and proceeded to compliment her on her beautiful child. As soon as she finished the sentence, the mother said “thank you,” but frowned, and her demeanor changed slightly—she stopped smiling, and looked nervous.

Jen wondered what she had done wrong, and suddenly realized that the family was Mexican, and her complimentary words, intended as a tool to gain the mother’s trust, resulted in causing her distress. Remembering what she had learned about Mexican culture and mal de ojo (evil eye), she touched the baby’s hand, and looked back at the mother. The change was remarkable—the mother smiled back at her, and nodded her head. She did not say anything, but her smile and nod tacitly communicated her gratitude for preventing mal de ojo. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

An eighty-three-year-old Cherokee woman named Mary Cloud was brought into the hospital emergency room by her grandson, Joe, after she had passed out at home. Lab tests and x-rays indicated that she had a bowel obstruction. After consulting with Joe, the attending physician called in a surgeon to remove it. Joe was willing to sign consent for the surgery, but it would not be legal; the patient had to sign for herself. Mrs. Cloud, however, refused; she wanted to see the medicine man on the reservation. Unfortunately, the drive took an hour and a half each way, and she was too ill to be moved. Finally, the social worker suggested that the medicine man be brought to the hospital.

Joe left and drove to the reservation. He returned three hours later, accompanied by a man in full traditional dress complete with feather headdress, rattles, and bells. The medicine man entered Mrs. Cloud’s room and for forty-five minutes conducted a healing ceremony. Outside the closed door, the stunned and amused staff could hear bells, rattles, chanting, and singing. At the conclusion of the ceremony, the medicine man informed the doctor that Mrs. Cloud would now sign the consent form. She did so and was immediately taken to surgery. Her recovery was uneventful and without complications. . [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Emma Chapman was a sixty-two-year-old African American woman admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.”

When Judy, her nurse, asked her what she thought had caused the problem, she said she had sinned and her illness was a punishment. According to her beliefs, illnesses from “natural causes” can be treated through nature (e.g., herbal remedies), but diseases caused by “sin” can be cured only through God’s intervention. Remember, treatment must be appropriate to the cause. In addition, Mrs. Chapman may have felt that to accept medical treatment would be perceived by God as a lack of faith.

Mrs. Chapman finally agreed to the surgery after speaking with her minister, whom Judy called to the hospital. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman.

Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by her physician. Anabel, using cultural competence, asked Mrs. Salcedo’s daughter to bring in the tea. Anabel paged the physician about the remedy and brought it to the pharmacist, who researched the ingredients. Because there was nothing contraindicated, the pharmacist contacted Mrs. Salcedo’s physician, who told her she could take the tea for her pain. The next day, Mrs. Salcedo was able to go to physical therapy and was much more motivated and positive in demeanor. Although it took some time to coordinate the effort, in the end, it resulted in a better patient outcome. Had Anabel not asked what she had been using to cope with her pain, it is likely Mrs. Salcedo would have delayed physical therapy and thus her recovery.

Jorge Valdez, a middle-aged Latino patient, presented with poorly managed diabetes. When Dr. Alegra, his physician, told him that he might have to start taking insulin, he became upset and kept repeating, “No insulin, no insulin.” Not until Dr. Alegra asked Mr. Valdez what concerns he had about insulin did he tell her that both his mother and uncle had gone blind after they started taking insulin. He made the logical—though incorrect—assumption that insulin caused blindness. In this case, the patient expressed his fears, and because the physician was competent enough to pick up on them and explore them, she was able to allay them. In many cases, however, unless the physician specifically asks about concerns, patients will say nothing and simply not adhere to treatment. By asking, the health care provider can correct any misconceptions that can interfere with treatment.

A 35-year-old Jewish woman went in for a baseline mammogram.  A lump was discovered.  When discussing it with the radiologist, the woman questioned him about all the possible treatments if it turned out to be cancerous, as well as all the side effects of the treatment.  The radiologist had little patience for her questions; he repeatedly told her they should wait until after they get the results of the biopsy before they start discussing the side effects of chemotherapy and radiation.  The woman, however, felt that she had to know everything possible about the potential negative outcome; only through knowledge could she feel a degree of control.  The lump turned out to be benign, but she went into the biopsy procedure much more relaxed than she would have had she not known every possible eventuality.

A 27-year-old pregnant Mexican woman who had been living in the US for two years went to see a genetic counselor at the urging of a friend.  XFAP tests indicated the possibility of Down syndrome in her unborn child.  She declined the offer of amniocentisis, however, based upon the manner of the genetic counselor, who told her not to be afraid and to do whatever she wanted.  The patient later said she interpreted the lack of directiveness as an indication that the positive screening was “no big deal” and that if there were any real danger, the counselor would have insisted on the test.

A middle-aged Mexican female patient suffering from acute liver cirrhosis with abdominal ascites, began to experience extreme shortness of breath. The physician, a liver specialist, asked her to sign consent for an abdominal tap.  The patient refused, saying, “I am going to wait until my husband arrives.”  The physician was not happy with her response as he felt it was necessary to do the procedure as soon as possible.  Fortunately, the patient’s husband arrived within an hour, the paracentesis was done, and her shortness of breath was minimized.

An African American man in his 40s, suffering from diabetes and hypertension presented to his physician, complaining of “feeling poorly”.  When questioned, he admitted that he was not taking his insulin regularly; only when he felt that his sugar was high.

A Chinese woman in her 60s was diagnosed with cancer and scheduled to receive chemotherapy.  She was unaware of her diagnosis, due to her son’s insistence.  The staff was uncomfortable with having to withhold this information from her, so they asked her whether she wanted to know her diagnosis and why she was receiving chemotherapy medication.  Her answer was no.  She said, “Tell my son; he will make all of the decisions.”  They resolved the matter by having hersign a Durable Power of Attorney, appointing her son as legal decision-maker.  They were thus able to remove the legal and ethical obstacles to her care.

Bobbie, the nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony. Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her.

Nurses usually report that “expressive” patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while “stoic” patients often come from Northern European and Asian backgrounds. As a young Chinese man told me, “Even since I was little boy, my family watched dubbed Chinese movies, and by watching many of the male protagonists state ‘I’d rather shed blood than my tears,’ it is imbedded in my mind that crying or showing pain shows my weakness.” However, simply knowing a person’s ethnicity will not allow you to predict accurately how a patient will respond to pain; in fact, there are great dangers in stereotyping, as the next case demonstrates.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “Aye! Aye! Aye! Mucho dolor! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

Reports from the Field

Field reports are submitted by students, peers and colleagues in the healthcare profession. Do you have field report to share?   Submit it here. Thank you!

A Filipino Case Study

Patient safety and satisfaction have always been a priority in nursing, but they can be compromised by nursing priority and time constraint. With higher patient to nurse ratios, increase patient acuity, managed health care system, and higher demands for quality patient care, nurses today are working harder.   Read More

Conditions in Kenya, Africa

HE DIDN’T ANSWER

Rounds have started. I move from bed to bed with the doctors, three patients at a time. Bed 3 contains Matu, Mugambi and Karanja. Matu’s spine is beginning to curve from six weeks of clutching his knees so he doesn’t touch the cold, contaminated floor. His spot at the foot of the bed is tinged yellow. He’s 4. He was treated for malaria and discharged two weeks ago, but with no family to claim him he’s still hereŠand getting sick again.   Read More

A Case of Polygamy

This is a case of a 49-year-old Hispanic male who was involved in a motor vehicular accident while not wearing a seat belt. He suffered multiple chest injuries, fractured ribs and humerus and sustained severe subdural bleeding. He was unconscious when brought to the Emergency Department, where a trauma work-up was done. His CT scan of the head revealed severe bleeding and was inoperable. His pupils were fixed and dilated.    Read More

I was on a pediatrics visit at Harbor-UCLA hospital learning how to perform a newborn exam. As I followed the Peds attending into the patient’s room, I noticed that the baby’s mom was sitting on the side of the crib talking in Spanish to her husband. The attending, I’ll call her Dr. Gabe, started to explain what is important to notice about a baby, what to look for on the physical exam, and proceeded to ask     Read More

Homelessness in our Hometown: The Hidden Community

In today’s society a person’s worth is determined by their material possessions, the size of their home, what kind of car they drive and how well they dress. How are you viewed by society if you have nothing and live on the streets? What kind of treatment do you receive if you chose to live this way?  Read More

Cultural Incompetence

Maria was a 4-month-old Hispanic infant with a history of Down’s syndrome and an ASD/VSD congenital anomaly. After her cardiac surgery, she had several complications that resulted in a lengthy ICU stay. During that time she had two cardio-pulmonary arrests, which resulted in the need to try to contact her parents. Her parents visited infrequently due to work obligations and the need to care for their other children.   Read More

A Vietnamese Death

I was invited to do a presentation on cultural competence to the hospice staff and a large, successful, and very white hospital. As part of my preparation, I visited the in patient hospice one afternoon. At the end of my visit I sat with the nurses as they debriefed the shift. One, a leader of some sort, said that she was pleased I would talk to them since she felt that she needed to know more.   Read More

Dangerous Dominican Powder

An article in the Nov. 6, 2003 issue of the New York Times, written by Richard Pérez-Peña, reported on a highly poisonous powder sold.   Read More

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A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

Vasquez Guzman, Cirila Estela PhD; Sussman, Andrew L. PhD, MCRP; Kano, Miria PhD; Getrich, Christina M. PhD; Williams, Robert L. MD, MPH

C.E. Vasquez Guzman is a family medicine postdoctoral fellow, Oregon Health & Science University, Portland, Oregon.

A.L. Sussman is associate professor, Comprehensive Cancer Center and Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico.

M. Kano is assistant professor, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico.

C.M. Getrich is associate professor, Department of Anthropology, University of Maryland, College Park, Maryland.

R.L. Williams is Distinguished Professor, Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico.

Funding/Support: Research reported in this article was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award numbers R01MD006073 and P20MD004811.

Other disclosures: None reported.

Ethical approval: Approved by the University of New Mexico Institutional Review Board as well as institutional review boards at each participating school.

Disclaimers: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Correspondence should be addressed to Cirila Estela Vasquez Guzman, Family Medicine Postdoctoral Fellow and OHSU Fellowship for Diversity in Research, Oregon Health Science University, 3405 SW Perimeter Ct., Portland OR 97239; telephone: (503) 201-0061; email: [email protected] .

Purpose 

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

Method 

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012–2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students’ preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

Results 

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

Conclusions 

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

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Case Study: Integrating Cultural Competence and Health Equity in Nursing Education

• First Online: 03 July 2018

Cite this chapter

• Susan W. Salmond Ed.D., R.N., A.N.E.F., FAAN 4  

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Academic programs preparing nurses for the future must ensure that nurses are prepared to be culturally competent. Achieving this goal requires a multifaceted curricular, student, faculty, and infrastructure approach. This case study summarizes the strategies taken by one school to move from an implicit understanding of the importance of cultural competence to explicit changes that were made to achieve this outcome

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Kaiser Family Foundation (2016) Analysis of the 2016 ASEC supplement to the CPS. http://www.kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-wake-of-national-health-reform/view/footnotes/

Peterson Center on healthcare, Kaiser Family Foundation (2015) Health of the healthcare system: an overview. Peterson-Kaiser Health Tracker System. http://www.healthsystemtracker.org/chart-collection/health-of-the-healthcare-system-an-overview

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Salmond, S.W. (2018). Case Study: Integrating Cultural Competence and Health Equity in Nursing Education. In: Douglas, M., Pacquiao, D., Purnell, L. (eds) Global Applications of Culturally Competent Health Care: Guidelines for Practice. Springer, Cham. https://doi.org/10.1007/978-3-319-69332-3_36

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A case study of organisational cultural competence in mental healthcare

• Jean Adamson 1 ,
• Nasir Warfa 2 &
• Kamaldeep Bhui 2  

BMC Health Services Research volume  11 , Article number:  218 ( 2011 ) Cite this article

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Ensuring Cultural Competence (CC) in health care is a mechanism to deliver culturally appropriate care and optimise recovery. In policies that promote cultural competence, the training of mental health practitioners is a key component of a culturally competent organisation. This study examines staff perceptions of CC and the integration of CC principles in a mental healthcare organisation. The purpose is to show interactions between organisational and individual processes that help or hinder recovery orientated services.

We carried out a case study of a large mental health provider using a cultural competence needs analysis. We used structured and semi-structured questionnaires to explore the perceptions of healthcare professionals located in one of the most ethnically and culturally diverse areas of England, its capital city London.

There was some evidence that clinical staff were engaged in culturally competent activities. We found a growing awareness of cultural competence amongst staff in general, and many had attended training. However, strategic plans and procedures that promote cultural competence tended to not be well communicated to all frontline staff; whilst there was little understanding at corporate level of culturally competent clinical practices. The provider organisation had commenced a targeted recruitment campaign to recruit staff from under-represented ethnic groups and it developed collaborative working patterns with service users.

There is evidence to show tentative steps towards building cultural competence in the organisation. However, further work is needed to embed cultural competence principles and practices at all levels of the organisation, for example, by introducing monitoring systems that enable organisations to benchmark their performance as a culturally capable organisation.

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The relationship between ethnicity and mental health has been the focus of much debate and dispute for many years. International research has shown that Black and Minority Ethnic (BME) communities fear and mistrust mental health services, and that BME groups, as they are called in UK policy, feel alienated and generally misunderstood (Mohan et al. 2006 [ 1 ]; Bhui et al. 2003 [ 2 ]; Leese et al. 2006 [ 3 ]; Fearon et al. 2006 [ 4 ]; Warfa et al 2006 a [ 5 ]; Warfa et al 2006 b [ 6 ]). This literature also shows that patients from ethnic minority backgrounds are less likely to attend their GP, and more likely to be placed on compulsory treatment orders. Another area of disparity has manifested itself through pathways into mental health care; service users from some specific ethnic groups are more likely to be admitted via the criminal justice system. A large number of these studies have suggested that action should follow demonstrable ethnic differences in relation to diagnosis, rates of inpatient admissions, care pathways and compulsory detention. Another group of studies examines racial discrimination and mental illness (e.g., Bhui et al. 2005 [ 7 ]; Karlsen et al. 2005 [ 8 ]; Bhugra & Ayonrinde, 2001 [ 9 ]). A smaller set of studies has focused on acculturation and mental illness. (e.g., Bhui et al. 2005 [ 10 ]; Berry, 1988 [ 11 ], 1997 [ 12 ]). However, very few studies have investigated the issue of organisational CC, with the exception of Siegel et al. (2000 [ 13 ], 2003 [ 14 ]) and Stork et al. (2001 [ 15 ]) in the US. From these limited studies, there is some evidence to support the notion that there is a relationship between the CC of health practitioners and the CC of organisations. For example, Organisations that incorporate CC into their strategic planning and operational policies are more likely to develop health practitioners and leaders that are culturally competent (Paez et al. 2007 [ 16 ]). In the UK, the concept of cultural competence has developed from within the diversity framework and was initially applied within the US health and social care systems. It is suggested that the term came into use because it fits with work-based frameworks for competencies in a number of areas, an approach that has been used to train and maintain a competent professional workforce.

Cultural Competence begins with understanding the strengths and weaknesses of the healthcare organisation and the unique needs of the population being served. Cross et al. (1989 [ 17 ]) defined cultural competency as "a set of congruent behaviours, attitudes, and policies that come together in a system, agency or among professionals and enables that system, agency or those professionals to work effectively in cross cultural situations" . In other words, the concept of cultural competence (CC) has evolved as multicultural societies have grown and mental health services are required to respond to a range of cultural needs from the communities that they serve. CC is based on the premise that culturally appropriate care aids the recovery process; therefore, a skilled workforce has become central to the development of cultural competence in organisations.

There are numerous models of cultural competence. Davis (1997 [ 18 ]) postulated that at an operational level cultural competence is the ability to integrate knowledge about individuals and groups into specific standards, policies, practices and attitudes, which are used to improve the quality of health care and ultimately produce better outcomes. Cross et al's (1989) model identifies a continuum of cultural competence from cultural proficiency at one end through to cultural destructiveness at the other. It is a process of increasing proficiency gained from informal and formal cross-cultural experiences rather than an endpoint that is achieved. Culturally competent organisations actively design and implement services that are relevant to the needs of their service users. Within the organisational context, CC can be sought at various levels; including direct clinical care, operational management and corporate managerial levels. In this study we address all of these levels by taking into account the perceptions of staff across the organisation.

In the UK, Black and Minority Ethnic (BME) groups have largely encompassed those from African, Caribbean and Asian origins as well as 'racialised' white people, for example, East Europeans, the Irish and Gypsy and travelling communities. Research has shown that BME groups feel alienated, and generally misunderstood (Breaking the Circles of Fear, Sainsbury Centre for Mental Health 2002 [ 19 ]). The campaign for improving mental health services for BME populations emerged from three key UK government publications: Inside Outside (NIMHE 2003 [ 20 ] ), Delivering Race Equality (DoH 2005 [ 21 ] ) and Race Equality Training in Mental Health Services in England (DoH 1999 [ 22 ]). Inside Outside (NIMHE 2003) describes a programme for reform of mental health services for (BME) communities in England. It builds on standards set out in the Mental Health National Service Framework (MHNSF) and the NHS Plan. The MHNSF (DoH 1999 [ 23 ]) recognised that services were not adequately meeting the needs of BME service users; whilst the NHS Plan sets out a blueprint for high quality care in the twenty first century. Inside Outside's change initiatives focussed on actions both 'inside'- within the services- and 'outside' - within the communities; cognisant of the need for collaboration between BME communities, voluntary and statutory sector services to develop services that are appropriate and responsive to the needs of minority ethnic communities. Two key components of the strategic plan were to reduce and eliminate ethnic inequalities in mental health service experience and outcome and to develop the cultural competence of mental health services through education and training.

Since much of the research on cultural competence has taken place in North America, it is reasonable to question the relevance of findings to the UK setting. There are apparent parallels evidenced in the increasing diversity of the population; the similarity in ethnic health inequalities and the growing demand for cultural competence in health care systems. In the US and UK, ethnic and racial disparities in health care form the basis for actions to develop culturally competent practice; in recent years these issues have come to the forefront of healthcare policy and research, not least as these inequalities persist, indeed in the UK the ethnic disparities in compulsory admission are sustained such that the Care Quality Commission (a regulating body) has decided to stop collecting the data and reporting on these through other data sources five yearly rather than annually. This is ironic given the lack of progress, but perhaps belies the underlying organisational narratives and a failure of achieving organisational cultural competence. These inequities are well documented in the literature, some of which is reviewed in this paper and reported in a systematic review (Bhui et al. 2007 [ 24 ]). All of the studies in the systematic review, with the exception of one, were North American; the nature of health inequalities experienced in health care, nevertheless, are not dissimilar from those experienced in the UK, although there are some fundamental differences between the UK and US healthcare systems and the specific histories and cultural influences and life events that lead to social exclusion and mental illness.

The context in which health care is delivered differs in the UK due to the welfare system and in particular the NHS; which is free at the point of delivery. In the US, healthcare is largely privatised and 'managed care' functions to gate keep healthcare services; hence healthcare is related not only to patients' needs but also affordability, a pattern which is becoming evident in the UK as the costs of NHS care are rising. So universally, health inequalities are related to socioeconomic status and ethnicity; however, health care will inevitably be influenced by the health care system. In this context, given the lack of studies from the UK and studies of organisations, this paper reports on a three level cultural competence needs analysis that examines whether CC principles are embedded in organisational systems.

Mixed methods were used to conduct a cultural competence needs analysis of a large London based NHS provider organisation (called a NHS Trust). The areas served by the NHS Trust are the most culturally diverse and deprived areas in England and therefore provide significant challenges for the provision of mental health services. The provider organisation's local services cater for a multi-ethnic population of 710,000 and forensic services are provided to a population of 1.5 million.

Measures of Cultural Competence

Culturally competent practice is not limited to individual professional practice; rather there is an organisational component that comes with a statutory obligation to ensure that its workforce and service users can expect to be treated in a way that is appropriate and responsive to their cultural needs. Such measures are not instead of existing standards of care quality but in addition to in order to eliminate inequalities. Siegel et al., (2000) developed a conceptual framework with interacting domains of CC; six domains of CC were identified: needs assessment, information exchange, services, human resources, policies/procedures and CC outcomes. In a follow up study Siegel et al., (2003) benchmarked a selection of these performance measures in several mental health facilities. The six CC domains were utilised in this study to develop the data collection tools. Prior to the study, the questionnaire was piloted within the provider organisation; which brought a helpful response and revisions were made to the format and style of the questionnaire. Using these tools, cultural competency was measured across three levels of the organisational structure: corporate, operational and direct care. Culturally competent activities in these domains were hypothesised to lead to positive outcomes for multicultural and multiracial clients. The domains are defined below:

1 . Needs Assessment - availability of information on characteristics of population in treatment , i.e. demography, socioeconomic status, languages spoken, literacy levels, cultural beliefs & practices.

2 . Information Exchange - Exchange of information between local communities & the Trust , i.e. concerns of multicultural and multiracial groups and information from the organisation to the community re: services offered.

3 . Human Resources - CC training; recruitment of cultures representative of the community and who speak the languages of the target population of the area. KSF should reflect adherence to CC principles.

4 . Services - Service users and carers need to be involved in the development of services . Services are responsive to cultural needs.

5 . Policies/Procedures - Trust wide CC plan should be formulated with representation from local community then disseminated to all sites (inpatient & community services). Information systems include cultural and ethnic characteristics.

6 . Cultural Competence Outcomes - Desirable outcomes for service users are evidenced by clinical change, increased social functioning and recovery.

The provider organisation was divided into three levels using the following definitions:

Corporate level

The mental health authority that has organised and administers the care system. It comprises key functions of the organisation i.e. Information Technology, Human Resources etc .

Operational level

Those employed by the mental health authority responsible for operations and service delivery i.e. Senior managers based on hospital sites and in the community setting .

Direct Care Level

Those employed by the mental health authority responsible for provision of direct care i.e. nurses, doctors .

Procedure for authorisation to undertake staff survey

The provider organisation's ethics committee approved this project subject to a few amendments. Concerns raised by the ethics committee related to the use of Americanised terminology and the perceived sensitivity of some questions. Necessary amendments were made, and prior to the survey, the audit and evaluation tool was piloted for face validity and feedback obtained on style, format and content.

Three samples were selected, one for each of the corporate, operational and direct care levels. The direct care level sample was selected using the stratified sampling method, and comprised 336 clinical staff of which two thirds were nurses. Others included doctors, occupational therapists, psychologists, social therapists and healthcare support workers. In addition, a purposive sample of 36 staff was taken for the operational and corporate level participants. Thirty operational level staff selected included directors and senior nurse managers. At corporate level, six department heads and directors were selected representing key functions of the Trust.

Data Collection

For this study, two questionnaires were devised based on the six domains; one questionnaire was used in a postal survey, at operational and direct care levels. The second questionnaire was used at corporate level and asked the same questions, but in an open-ended style to allow exploration of issues for the semi-structured interviews. A participant information sheet was incorporated into the tool outlining the participant's right to withdraw and ethical considerations such as confidentiality and anonymity. For consistency and clarity in the postal survey, the concept of 'cultural competence' was defined and explained before the questions. Cultural Competence was defined as "the set of behaviours, attitudes, skills, policies and procedures that come together in a system, agency, or individuals to enable mental health care givers to work effectively and efficiently in multicultural situations" .

The aim of the evaluation at the corporate level was to elicit understanding of CC and organisational engagement, and given the methods were open-ended interviews, a standard CC definition was not deemed necessary as answers were to be qualified by respondents and so intended meaning could be checked at interview. Respondents were asked to report their ethnicity, job title and work location.

Excel software was used to calculate descriptive statistics. The framework approach (Miles & Huberman 1984) was used to analyse the semi-structured interviews. This approach is based on matrix based methods of analysis, and it is both inductive and deductive in nature. The analytic process is linked to the aims and objectives of the study; whilst also being rooted in the original accounts and observations of the people studied. This method was chosen for its transparency and procedures that are replicable and valuable in policy and practice research. The researcher acquired an intimate knowledge of the raw data. The process of familiarisation with the data began on conducting the semi-structured interviews. The collection of data and the analysis of data were not entirely discrete activities, since themes began to emerge during the data collection phase. The analysis moved iteratively through stages of data management, description and explanation. Several themes were identified and then numbered and named using short descriptive text. Distilled summaries were taken from the original data and charted onto an Excel spreadsheet, according to the appropriate part of the thematic framework to which they related. The process of mapping and interpretation of the data was influenced by the original research objectives as well as the themes that emerged from the data itself.

Seventy-three of 336 staff from the direct care sample responded to the postal questionnaire. Two thirds of the respondents were nurses, mostly of Black African ethnic origin; this was in accord with the proportional of Black African nurses employed in the Trust. White British and Black Africans represented 82% of all respondents (Table 1 ). Fourteen of 30 staff from the operational sample responded to the questionnaire, almost half were White British and the remainder were from BME groups (Table 2 ).

Operational & Direct Care Levels

There was a tendency for operational and direct care level staff to agree in their response to questions pertaining to frontline CC practices. However, they were divided on issues such as whether someone is appointed with responsibility for CC in the organisation and if reference is made to CC in the Trust mission statement (Table 3 ). This may be an indication that messages about CC are not filtering through to direct care staff.

Corporate Level

A list of emerging themes were noted and then categorised into sub-groups and coded for easy retrieval. They were further refined to the point where four broad themes were conceptualised under the following headings, conveying the key ideas and forming the thematic framework :

Perceptions of cultural competence

Participants had a tendency to describe cultural competence in terms of understanding differences in the cultural context, and the ability to change and adapt clinical practice to meet the client's cultural needs. The need to be aware of one's own prejudices and biases was seen as prerequisite for that change to take place. Views expressed supported the idea that cultural competence training is not transferable; but rather, that it should be contextual and relevant to the type of service being delivered. Collectively, participant discourse mainly focused on the individual practitioner's responsibility for cultural competence practice, with the organisational responsibility largely ignored. The provider organisation had recently implemented a race equality cultural competence (RECC) programme; which is mandatory for all clinical staff. This is in addition to the equality & diversity training that all new staff received on the induction programme.

Equality in the workforce

Under-representation of BME staff in senior management and at board level, in particular, is problematic. Targeted recruitment of local communities was identified as an initiative to attract greater numbers of ethnic minorities; however it was also recognised that the campaign was designed to fill lower graded posts in the organisation rather than senior management positions. Poor quality data on ethnicity of the workforce had weakened the organisation's ability to understand how issues of equality impact on its staff. Other ongoing initiatives included training of career advisors as a resource for employees, and the promotion of programmes for BME staff seeking career succession into senior management and director level positions.

Patient Information

The provider organisation owns a substantial amount of service user data collected through patient assessment systems. There is inconsistency between data that has been collected on paper and data that is collected electronically, with little understanding about types of information held on the patient information database. Disparate accounts were expressed about the utilisation of patient data; although it was apparent that participants' views about utilisation of data were consistent with statutory legislation about improving ethnicity data. The provider organisation had not made comparisons of the representativeness of BME inpatients in relation to local population statistics, although relevant data is available for such analysis to take place. There was evidence though, that steps had been taken to acquire demographic data to support service planning. The Trust had recently commissioned a report to map the age, ethnicity and religion of its local population with predictive patterns for the coming years.

Race Equality in Organisations

Delivery of Race Equality encapsulates a multitude of activities that emanate from statute, and which are pivotal for the reform of mental health services. Many change initiatives were identified by participants. Less was known about the duties levied by race equality legislation. On the topic of race equality there was a tendency to defer to staff that lead on cultural competence. Accountability for race equality was not seen as a shared responsibility, but was articulated as the domain of specialist staff, conveying a lack of ownership and the location of responsibility for any action to a small group of staff often in relatively junior positions.

The findings of this study indicate that the provider organisation has taken several definite steps towards building the cultural competence of the organisation. Issues around recruitment & retention, improving data, engaging faith communities, training, challenging stigma, impact assessing policies and systems were ongoing. Structures were in place to facilitate engagement with multicultural and multiracial communities. Although the provider organisation had been slow to embrace the cultural competence agenda, and had yet to embed cultural competence principles at all levels of the organisation; our data suggest that the cultural relevance of services had moved up on the agenda.

Cultural Competence should not only reflect competence in delivering interventions to culturally diverse populations but also the development of interventions to engage and help recovery where existing models of treatment are ineffective or lead to non-adherence. Given the complexity of care services, cultural competent practice must be effective across organisational systems in general. It is argued that CC ought to be integral to policy, administrative practices and service delivery, and should be informed through service user and community involvement. Whilst CC training has focused on cultural difference and encompasses a wide range of activities designed to improve cultural awareness, knowledge and understanding; fewer CC activities highlight the adaptation of specific clinical practices or procedures for improved take up and recovery; and few studies investigate cultural considerations in prescribing practice.

From our study, commonly expressed views of CC comprise a discourse that focuses largely on diversity, cultural awareness and cultural sensitivity. Cultural competence training was described in terms of changing of attitudes & behaviour, self-reflection, acquisition of skills, knowledge and increasing awareness. Culturally competent outcomes could not be formally identified anywhere within the Trust; nor were performance measures used or applied by commissioners or providers or regulators. The NHS staff appraisal system offers a competency based assessment of staff performance. Although one of its core dimensions is Equality and Diversity, respondents observed that there is insufficient guidance on what skills/knowledge constitutes CC.

Overall, it was apparent that there was greater convergence in the views of corporate and operational level staff than corporate and direct care clinical staff; notwithstanding corporate level staff were less well informed about cultural competence initiatives happening in clinical practice. For example, most corporate managers interviewed demonstrated scant awareness of culturally appropriate services or their provision in the provider organisation.

The Trust sets out its vision in the annual plan and it appears on their website. Strategic objectives outline the development of a culturally capable workforce, the need for culturally sensitive services and recruitment of staff that are locally representative. However, the organisation's Board of Directors and its Senior Management Team is not representative of the cultural and racial diversity of local communities. A particular form of cultural competence (RECC) training is mandatory for all clinical staff; however the same does not apply to senior managers and directors. The nature of this mandatory training does not address clinical practice, but issues of race awareness and communication. It has been suggested that CC training may not adequately meet the needs of senior managers and directors; indeed, recent reports indicate that managers would benefit from training with an interpersonal focus on managing BME staff.

Corporate managers described CC in the context of understanding cultural differences and shared a narrow interpretation of cultural competence. This finding is consistent with literature that shows that cultural competence training has tended to focus on understanding difference, rather than reducing inequalities that affect BME groups. Little attention was paid to how culture impacts upon clinical presentation and the acceptability of specific interventions. Consensus indicated that CC principles were not adequately represented in the staff performance management framework. The local academic provider established an MSc in Transcultural Mental Healthcare to support workforce development ( http://www.wolfson.qmul.ac.uk/psychiatry/courses/tmh [ 25 ]), a cultural consultation club as a resource for staff, and more recently, a cultural consultation service for work with narratives of recovery among commissioners, providers, and staff. ( http://www.culturalconsultation.org.uk [ 26 ]).

Although this is a case study, there are broader implications of these findings for other provider organisations in the UK; especially with regards to training, policy making and strategic planning in general. CC Training should form part of a wider framework for reducing race inequality and address the needs of the organisation and its staff. It is not enough for direct care practitioners to undergo training; those who administer the provider organisation should educate itself on the dynamics of difference and develop cultural knowledge in order to make decisions that are not ethnocentric. Strategically, it is essential to develop a CC plan and define CC outcomes so that organisational self-assessment can take place. The policy making process should assess the impact on diverse communities. These strategic activities require input from local communities if services are to reflect diverse needs of service users. Accordingly, future research can build our understanding of CC further by eliciting the service user perspective.

Strengths and limitations of study

The use of mixed methods in this study has produced a greater yield over and above a qualitative study or quantitative study undertaken independently. The interviews with corporate managers in the organisation allowed for richer and deeper insights into attitudes towards cultural competence; and most crucially offered insight into the sense of ownership felt by influential individuals.

The meaning attached to this study needs to be understood in the national context. There has been resistance to delivering race equality reforms; much criticism has been levelled at government agencies including mental health provider organisations around the UK (Bhui K, Ascoli M, Nuamh O: The Place of Race and Racism in Cultural Competence; the English Experience about the Narratives of Evidence and Arguments, submitted). Other factors that may introduce potential biases include the use of selective sampling; the local focus of the study, and the limited response rate to the study questionnaire.

Since there were no validated CC assessment tools in use in the UK, the questionnaire used in this study was modelled on performance measures developed in North America where health care systems are characteristically different from the UK; this in itself imposes a limitation in terms of the validity of the questionnaire for a UK study.

Change occurs in a complex interplay between practice and policy set in the context of narratives of change and the culture of the system. Cultural competence is a developmental process and takes time, commitment and sustained effort at each level of the organisation. In recent years, the provider organisation has progressed in putting in place infrastructure to enhance its cultural competence; however, there is no strategy or policy to build cultural competence or dedicated strategic planning in the organisation, despite the local population being one of the most diverse in the country. Culturally inappropriate care practices and perceptions of injustice and inequity are likely to continue in the absence of a whole systems approach.

Mohan R, Mone P, Szmutler G, et al: Ethnic differences in mental health service use among patients with psychotic disorders'. Social Psychiatry, Psychiatric Epidemiology. 2006, 41: 771-776. 10.1007/s00127-006-0094-7.

Article   Google Scholar  

Bhui K, Stansfeld S, Hull S, et al: Ethnic variations in pathways to and use of specialist mental health services in the UK. British Journal of Psychiatry. 2003, 182: 105-116. 10.1192/bjp.182.2.105.

Article   PubMed   Google Scholar  

Leese M, Thornicroft G, Shaw J, et al: Ethnic differences among patients in high security psychiatric hospitals in England. British Journal of Psychiatry. 2006, 388: 380-385.

Fearon P, Kirkbride J, Morgan C, et al: Incidence of schizophrenia and other psychoses in ethnic minority groups: Results from the MRC AESOP study. Psychological Medicine. 2006, 36: 1541-1550. 10.1017/S0033291706008774.

Warfa N, Bhui K, Craig T, Mohamud S, Stansfeld S, McCrone T, Thornicroft G, Curtis S: Post-migration residential mobility, mental health and health service utilization among Somali refugees in the UK: A Qualitative Study. Health & Place. 2006, 12: 503-515. 10.1016/j.healthplace.2005.08.016.

Warfa N, Bhui K, Phillips K, Nandy K, Griffiths S: Comparison of live events, substance misuse, service use and mental illness among African-Caribbean, Black African and White British men in East London: a qualitative study. Diversity in Health and Social Care. 2006, 3: 111-21.

Google Scholar  

Bhui K, Stansfeld S, McKenzie K, et al: Racial/ethnic discrimination and common mental disorders among workers: Findings from the EMPIRIC study of ethnic minority groups in the UK'. American Journal of Public Health. 2005, 95: 496-501. 10.2105/AJPH.2003.033274.

Article   PubMed   PubMed Central   Google Scholar  

Karlsen S, Nazroo J, McKenzie K, et al: Racism, psychosis and common mental disorder among ethnic minority groups in England. Psychological Medicine. 2005, 35: 1795-1803. 10.1017/S0033291705005830.

Bhugra D, Ayonrinde O: Racism, racial life events and mental ill health. Advances in Psychiatric Treatment. 2001, 7: 343-349. 10.1192/apt.7.5.343.

Bhui K, Lawrence A, Klineberg E, et al: Acculturation and health status among African-Caribbean, Bangladeshi and White British adolescents. Social Psychiatry, Psychiatric Epidemiology. 2005, 40: 259-266. 10.1007/s00127-005-0890-5.

Berry J, Kim U: Acculturation and mental health. Health and Transcultural Psychology: Towards Applications. 1988, 207-238. Dasen PR, Berry JW, Sartorius N

Berry J: Immigration, acculturation and adaptation. Applied Psychology: An International Review. 1997, 46: 5-68.

Siegel C, Davis Chambers E, Haugland G, et al: Performance Measures of Cultural Competency in Mental Health Organisations. Administration and Policy in Mental Health. 2000, 28: 91-106. 10.1023/A:1026603406481.

Article   CAS   PubMed   Google Scholar  

Siegel C, Haugland , Davis Chambers E, et al: Performance measures and their benchmarks for assessing organisational cultural competency in behavioural health care service delivery. Administration and Policy in Mental Health. 2003, 31: 41-170.

Stork E, Scholle S, Greeno C, Copeland VC: Kelleher, Monitoring and Enforcing Cultural Competence in Medicaid Managed Behavioural Health Care. Mental Health Service Research. 2001, 3 (3): 169-177. 10.1023/A:1011575632212.

Article   CAS   Google Scholar  

Paez K, Allen J, Carson K, Cooper L: Provider and Clinic Cultural Competence in a Primary Care Setting. Social Science & Medicine. 2007, 5: 1204-16.

Cross TL, Bazron BJ, Dennis KW, Isaacs MR: Towards a culturally competent system of care. A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. 1989, Washington DC: Georgetown University Child Development Centre, 1.

Texas Department of Health National Maternal & Child Health Resource Center on Cultural Competence (1997).

Sainsbury Centre for Mental Health: Breaking the Circles of Fear. 2002

NIMHE: Inside Outside: Improving mental health services for black and minority ethnic communities in England. 2003, Leeds: National Institute for Mental Health in England

DH: Delivering Race Equality in Mental Health Care. An action plan for reform inside and outside services and the Government's response to the independent inquiry into the death of David Bennett. 2005, London: Department of Health

Sainsbury Centre for Mental Health: Race Equality Training in Mental Health Services in England. 1999

DH: National Service Framework for Mental Health: Modern standards and service models. 1999, London: Department of Health

Bhui K, Warfa N, Edonya P, et al: Cultural competence in mental health care: A review of model evaluations. BMC Health Services Research. 2007, 7: 15-10.1186/1472-6963-7-15.

MSc Transcultural Mental Healthcare. [ http://www.wolfson.qmul.ac.uk/psychiatry/courses/tmh ]

Cultural Consultation Service. [ http://www.culturalconsultation.org.uk ]

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Acknowledgements

We would like to express our gratitude to colleagues who kindly advised and supported us in undertaking this project; with a special thank you extended to those who participated in the research.

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Jean Adamson

Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London, EC1M 6BQ, England, UK

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Competing interests.

'KB is Director MSc Transcultural Mental Healthcare, MSc Psychological Therapies, Director of Cultural Consultation Service in Tower Hamlets London.'

NW is senior lecturer, deputy director and MSc programme coordinator

The MSc programme has received support from the Local Mental Health Trust

NW is on the executive committee of the Cultural Consultation Club

Authors' contributions

JA undertook the service evaluation supervised by KB and NW. All authors contributed to the consecutive versions of the paper. All authors have read and approved the final manuscript.

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Adamson, J., Warfa, N. & Bhui, K. A case study of organisational cultural competence in mental healthcare. BMC Health Serv Res 11 , 218 (2011). https://doi.org/10.1186/1472-6963-11-218

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DOI : https://doi.org/10.1186/1472-6963-11-218

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• Using Case Studies to Teach (Boston University Center for Teaching & Learning)
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Writing your own case studies?  Remember to use  these alternatives  to commonly used sexist labels.

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• Cracking the Codes: The System of Racial Inequality Using interviews with racial justice leaders, this document aims to shift the conversation about racial inequality from the individual level to the institutional level ( full description from the producer).  
• Hold Your Breath  Documentary of the story of Mohammad Kochi, an Afghan immigrant who faces possible death from stomach cancer and his American doctors’ attempt to provide culturally competent care (an expanded version of the story that appears in the Worlds Apart series; full description from distributer).  
• Unnatural Causes  (also available electronically to insert in your D2L course; contact  [email protected] ) A seven-part documentary series exploring racial & socioeconomic inequalities in health ( full description from the producer).  
• Gen Silent  The story of six LGBT seniors and the personal choices they make in the face of discrimination by caregivers and peers ( full description from the producer).  
• The Waiting Room  A behind the scenes look at an ER in a United States public hospital struggling to serve a diverse community ( full description from the producer).  
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• Madeleine Leininger: Cultural Care Diversity & Universality An interview with nurse theorist Madeleine Leininger in which she talks about her theory of culturally congruent care. 

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Case Study in Cultural Competence

Post By Eric Craypo

A case study submitted to ASCO by Berkeley Optometry Resident Dr. Quan Dao titled,  When the Patient Puts You in Check: Navigating the Grey Area of Mental Illness in Healthcare , has been selected as the grand prize winner of the Case Studies in Cultural Competence competition! Entrants were asked to describe a single patient-based encounter in detail, in any aspect of clinical education, and how cultural competency played a role.

Dr. Dao’s paper explores the implicit biases in healthcare towards patients who are suffering from mental health problems. In her study, Dr. Dao says “It takes mental effort to unlearn the implicit bias, to make it a habit, to build discipline, and to be more inclusive”.

Congratulations to Dr. Dao on this noteworthy accomplishment.

Read the case study here .

Project READY: Reimagining Equity & Access for Diverse Youth

A free online professional development curriculum

Module 8: Cultural Competence & Cultural Humility

After working through this module, you will be able to:

• Define cultural competence  and cultural humility and give examples of these concepts in action.
• Describe why cultural competence and cultural humility are important to creating equitable and inclusive library services.
• Set personal goals for moving from cultural competence to cultural humility.

Introduction

Becoming culturally competent and practicing cultural humility are central to serving youth of color and Indigenous youth. As Dr. Nicole A. Cooke (2017) argues, cultural competence and cultural humility compel us to act – to move beyond simply being aware of or sensitive to people’s cultural differences. Library staff who are culturally competent and practice cultural humility collect materials, provide programs, design instruction, and build technology tools that reflect the various cultures represented in their communities.  They also actively work to identify and address systemic inequities. In this module, we will develop a shared understanding of the terms culturally competent and cultural humility, explore why an understanding of these two concepts is important to creating equitable and inclusive library services, and create personal goals to guide your journey to cultural competence and cultural humility.

What does it mean to be culturally competent?

Culturally competent librarians and educators understand, communicate with, and effectively interact with people across cultures. Cultural competence encompasses:

• being aware of one’s own world view
• developing positive attitudes towards cultural differences
• gaining knowledge of different cultural practices and world views
• developing skills for communication and interaction across cultures

Underlying cultural competence are the principles of trust, respect for diversity, equity, fairness, and social justice ( Rhonda Livingstone ).

While there is no single checklist that identifies the attributes of culturally competent educators or librarians, the following attitudes, skills and knowledge are commonly identified in the literature:

• understands and honors the histories, cultures, languages, and traditions of diverse communities
• values the different abilities and interests of youth
• respects differences in families’ home lives
• builds on the different ways of knowing and expertise found in different cultures and communities
• recognizes that diversity contributes to the richness of our society and provides a valid evidence base about ways of knowing
• understands that a strong sense of cultural identity and belonging is central to developing a positive self-esteem
• identifies and challenges their own cultural assumptions, values and beliefs
• demonstrates an ongoing commitment to developing their own cultural competence

Who is…

Dr. Nicole A. Cooke

Dr. Nicole A. Cooke is an Associate Professor and the Augusta Baker Endowed Chair at the School of Library and Information Science at the University of South Carolina. In this role she focuses on issues of diversity, equity, inclusion, and social justice in the profession.

To learn more about Dr. Cooke and her work:

• Watch this webinar in which Dr. Cooke discusses power, diversity, and cultural competency in LIS.
• Read one of Dr. Cooke’s texts (we recommend starting with Information Services to Diverse Populations: Developing Culturally Competent Library Professionals) .

In this short video produced by NEA, academic experts from across the United States define cultural competence and share their thoughts on the importance of cultural competence for today’s educators. As you watch, consider these questions:

• What are primary premises of cultural competence?
• What issue is cultural competency designed to address? How does it address this issue?

Review these definitions of Cultural Competency. In your journal , make a list of the key ideas that stand out for you in these definitions. Use those ideas to develop your own definition of cultural competence.

• “the ability of an individual or organization to understand, interact, and engage with people who have different values, culture, languages, lifestyles, and traditions based on their distinctive heritage and social relationships” ( SAMHSA 2023 )
• “a congruent set of behaviors, attitudes, and policies that enable a person or group to work effectively in cross-cultural situations; the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each” (National Association of Social Workers, 2001).
• “the ability to recognize the significance of culture in one’s own life and in the lives of others; and to come to know and respect diverse cultural backgrounds and characteristics through interactions with individuals from diverse linguistic, cultural, and socioeconomic groups; and to fully integrate the culture of diverse groups into services, work, and institutions in order to enhance the lives of both those being served by the library profession and those engaged in service” (Overall, 2009, 189-190).
• “the ability to successfully teach students who come from cultures other than our own. It entails developing certain personal and interpersonal awareness and sensitivities, developing certain bodies of cultural knowledge, and mastering a set of skills that, taken together, underlie effective cross-cultural teaching” (Diller & Moule, 2005).
• “high levels of respect for and knowledge of other cultures; actively working for and with diverse groups” (Cooke, 2017, 18).

What is cultural humility?

The concept of cultural humility was developed by Melanie Tervalon and Jann Murray-Garcia in 1998 to address inequities in the healthcare field. It is now used in many fields, including education, public health, social work, and library science, to increase the quality of interactions between workers (i.e. library staff and educators) and their diverse community members.  Cultural humility goes beyond the concept of cultural competence to include:

• A personal lifelong commitment to self-evaluation and self-critique
• Recognition of power dynamics and imbalances, a desire to fix those power imbalances and to develop partnerships with people and groups who advocate for others
• Institutional accountability (Tervalon & Murray-Garcia, 1998)

In this YouTube video excerpt, Melanie Tervalon, a physician and consultant, and Jann Murray-Garcia, a nursing professor at UC Davis, discuss the philosophy and function of cultural humility. The full video (29 minutes) can be viewed here . As you watch this video, consider the following questions:

• What are primary premises of cultural humility?
• How do Tervalon and Murray-Garcia distinguish cultural humility from cultural competency? Why do they think this distinction is important?

In your response journal , reflect on what you learned about culture in Module 7 and what you’ve learned about cultural competency and cultural humility in this module. Then answer this question: Why should library staff and educators care about cultural competency and cultural humility?

When you’re done, click here to see what the research says.

• Youth are more diverse than ever. The 2016 Kids Count data from the Annie E. Casey Foundation shows that 49% of youth in the U.S. between the ages of 0-18 identify as non-White.
• The fields of librarianship and education remain primarily white and female, suggesting a cultural mismatch between library staff, educators, and the communities they serve (ALA, 2012; U.S. Department of Education, 2016).
• Culture plays a critical role in learning. By incorporating youths’ historical knowledge and analysis into library programs and services, youth may feel that they are validated and that their culture is relevant to the learning experience (Mestre, 2009; Sheets, 2005).
• Cultural competence & cultural humility lead to more authentic and effective interactions with youth and their families. Incorporating youths’ cultural backgrounds into all aspects of library services can help youth feel accepted and better connected to the library as a place where they belong (Kumasi, 2012; Mestre, 2009).
• Research suggests that low cultural relevance is one factor that contributes to lack of library use by people of color (Overall, 2009)
• Culturally competent educators and library staff value diversity, are adaptable and able to embrace varying levels and types of diversity (Cooke, 2017).
• Since libraries provide free and added value services, if people do not feel welcome or represented in the library they may choose not to use them (Cooke, 2017).

Images of Practice

What happens when cultural competence isn’t enough? In the video below, Adilene Rogers (a Bilingual Youth Services Librarian at Sacramento Public Library) discusses how cultural humility has improved her work with Spanish-speaking youth and their families.

Becoming Culturally Competent and Practicing Cultural Humility

Becoming culturally competent and practicing cultural humility are ongoing processes that change in response to new situations, experiences and relationships. As Cooke (2017) points out “each community is distinct and has its own needs; there are also communities within communities, all of which deserve recognition and special attention” (p. 18). Knowing about one community does not make us culturally competent about all communities. Additionally, communities are dynamic and change over time. Maintaining cultural competency and practicing cultural humility require continuous and intentional work.

Cultural humility “stretches the idea of cultural competence,” challenging library staff to not only recognize power dynamics and imbalances, but to redress these imbalances. Nicole A. Cooke, 2017, 20

As the diagram below shows, cultural competence is a necessary foundation for cultural humility.

Both cultural competence and cultural humility require:

• Becoming aware of your own cultural norms, attitudes, beliefs, and behaviors
• Identifying & examining your own personal biases, stereotypes, and prejudices
• Considering the impact cultural differences might have on your interactions with BIYOC, their families, and their communities
• Being comfortable with “not knowing” – Balancing your expert knowledge with being open to learning from the community and their lived experience
• Being curious about other cultures – Asking questions, reading #ownvoices texts about other cultures, viewing #ownvoices films & documentaries, studying another language, attending classes & workshops about other cultures, etc.
• Attending cultural events and festivals
• Establishing trusting relationships with community confidants or connectors who are able to provide insights into cultural norms, family practices, communication styles, traditions, etc.
• Conducting an asset-based community analysis or community walk (see Module 17b )

Cultural humility also requires:

• Studying the history of race and racism in the U.S. and understanding how it disproportionately impacts BIPOC
• Completing racial equity training
• Learning to develop and evaluate culturally relevant and appropriate programs, materials, and interventions
• Serving on the library or school equity team
• Collecting and analyzing data about library practices, programs, services, and community partnerships through an equity lens
• Analyzing library policies for bias and rewriting them to make them reflective of the cultures, customs, behaviors and information needs of various community members

Now that you’ve explored the concepts of cultural competence and cultural humility it’s time to get to work. Complete the Cultural Competence Self-Evaluation Checklist [PDF] to identify areas that need attention. This self-assessment tool is designed to help you: (1) think about your skills, knowledge, and awareness in interactions with others and (2) identify areas of strength and areas that need further development. After you’ve completed the assessment, make a list of the areas where you need further development (those you rated a 1 or 2).

Now set three goals for becoming culturally competent and practicing cultural humility: one short-term goal that you can accomplish immediately, one medium-term goal that you can accomplish over the next several weeks, and one long-term goal that you can accomplish over the next year. Use the  Goals for Becoming Culturally Competent & Practicing Cultural Humility template [PDF] to write these goals down. Post these goals somewhere in your library. Once you have achieved a goal, replace it with another one.

In this section, we address common questions and concerns related to the material presented in each module. You may have these questions yourself, or someone you’re sharing this information with might raise them. We recommend that for each question below, you spend a few minutes thinking about your own response before clicking the arrow to the left of the question to see our response.

While engaging in this work, keep in mind that some BIYOC and BIPOC may be uncomfortable sharing aspects of their culture with you. There may also be elements of their culture that are not meant to be shared with outsiders. Be respectful of their preferences and keep in mind that it is not their role to teach you.

• If you have another question you'd like us to address in this section, suggest it here.

References and Image Credits

American Library Association (2012). Diversity Counts 2012 Tables. Retrieved from http://www.ala.org/offices/sites/ala.org.offices/files/content/diversity/diversitycounts/diversitycountstables2012.pdf .

Cooke, N.A. (2017). Information services to diverse populations: Developing culturally competent library professionals. Santa Barbara, CA: Libraries Unlimited.

Diller, J.V. and Moule, J. (2005). Cultural competence: A primer for educators. Belmont, CA: Thomas Wadsworth.

Kumasi, K. (2012). Roses in the concrete: A critical race perspective on urban youth and school libraries. Knowledge Quest, 40 (4): 12-17.

Mestre, L.S. (2010). Culturally responsive instruction for teacher-librarians. Teacher Librarian, 36 (3), 8-12.

National Association of Social Workers. (2015). Standards and indicators for cultural competence in social work practice. Washington, DC: National Association of Social Workers. Retrieved from https://www.socialworkers.org/LinkClick.aspx?fileticket=PonPTDEBrn4%3D&portalid=0 .

Overall, P. M. (2009). Cultural competence: A conceptual framework for library information science professionals. The Library Quarterly, 79 (2), 175-204.

Sheets, R. H. (2005). Diversity pedagogy: Examining the role of culture in the teaching-learning process. Boston: Pearson Education, lnc.

Tervalon, M., and Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Undeserved, 9, 117-125.

U.S. Department of Education, Office of Planning, Evaluation and Policy Development, Policy and Program Studies Service. (2016). The State of Racial Diversity in the Educator Workforce , Washington, D.C. Retrieved from https://www2.ed.gov/rschstat/eval/highered/racial-diversity/state-racial-diversity-workforce.pdf .

Cultural Competence Case Study

by Theresa Steckel | May 18, 2018 | Nursing Case Studies

Using case studies in the classroom to teach cultural competence to nursing students can create animated discussion, and encourage teamwork as student nurses work together to solve complex nursing problems.

This case study addresses:

• Communicating with peers using CUS.
• Explaining FSBS to a patient.
• Health Disparities.
• Cultural Competence.

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Diversity in Nursing

by Theresa Steckel | Clinical Tools , Nursing Case Studies

How do we teach student nurses to relate to and have meaningful interactions with patients and members of the healthcare team that are different than themselves? Our understanding of the world is shaped by our interactions and life experiences. Nurses interact with...

Ethical Dilemmas in Nursing

by Theresa Steckel | Ethical , Nursing Case Studies

Post Conference Activity: Ethical Dilemmas in Nursing Have you heard this before? “That’s not how we do it in the real world!” I am certain you have faced the same challenge I have; nurses who deviate from expected best practices and the students they leave behind....

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