02 – Principles for Culturally Competent Care

PRINCIPLES FOR CULTURALLY COMPETENT CARE

 

The United States has always been represented by a culturally diverse society. However, the volume of cultural groups entering our country is increasing rapidly. Professional nurses must provide care to persons of various cultures who have different values, beliefs, and perceptions of health and illness. This chapter explores cultural phenomena, including environmental control, biologic variations, social organization, communication, space, and time in relation to major cultural groups. It also examines different views toward health, illness, and cure. Federally defined minority groups, which include African-Americans, Asians, Hispanics, and Native Americans, are emphasized, although the needs of marginalized populations such as the homeless, refugees, and the elderly also are addressed. The need for diversity in the health care force is explored, and strategies for recruiting and retaining minorities in health care are suggested. Strategies that nurses can use to increase their own cultural competence also are given.

POPULATION TRENDS

The demographic and ethnic composition of the U.S. population has experienced marked change in the past 100 years. The United States always has been a multicultural society, although changes in immigration laws have increased the number of cultural groups entering the United States (Stanhope and Lancaster, 2000). “Federally defined minority groups have grown faster than the population as a whole” (Nies and McEwen, 2001). If migration trends continue, by mid twenty-first century the minority populations will outnumber the Caucasian population. Approximately one in every three Americans will be an ethnic minority. In some cities in the United States the number of persons from diverse cultural groups is increasing at such a rapid pace that minorities comprise more than half the population. It is predicted that at the end of this decade some states will have no majority group, only multiple minority subcultures (Meleis et al., 1995).

The aging population includes an increasing number of older adults whose age exceeds 85 years. By the year 2000 there were four million more Americans older than 65 years of age than there were in 1990. This demographic change introduces many interrelated social, economic, political, education, and health problems. The fact that people are living longer allows more opportunity for the development of chronic illness. Social isolation and depression that result from losses of friends and family will present a challenge for mental health care providers. Primary care providers will be faced with identifying risks to independence and health for the aging population (U.S. Department of Health and Human Services, Healthy People 2010, 2000).

Federally Defined Minority Groups. Federally defined minority groups are African-Americans, Hispanics, Native Americans, and Asians/Pacific Islanders. Although tremendous strides have been made in improving health and longevity in the United States, statistical trends show a disparity in key health indicators among certain subgroups of the population (Nies and McEwen, 2001). There is a racial gap between African-Americans and Caucasians of 5.6 years, with average life expectancy being 75.2 years for Caucasians and 69.6 years for African-Americans. The infant death rate for African Americans is twice that of Caucasians (Nies and McEwen, 2001). Although the ranking of health problems according to excess deaths differs for minority groups, the six causes of death that are a priority are:

1. Cancer

2. Cardiovascular disease and stroke

3. Chemical dependency as measured by deaths caused by cirrhosis of the liver

4. Diabetes

5. Homicides and accidents

6. Infant mortality (Nies and McEwen, 2001)

Marginalized Populations. Not only should the concern for culturally competent care focus on ethnic minorities and populations that have a different heritage than Euro-Americans, but the needs of marginalized populations (Hall, Stevens, and Meleis, 1994), which are those populations that live on the periphery or in between, should be considered. Examples of such populations include gays and lesbians, older adults, recently arrived immigrants (e.g., from Russia, Afghanistan, and Rwanda), and groups that have been in this country for some time (e.g., from South America and the Middle East) who are less visible than the federally defined minorities (Lenburg et al., 1995). Their lives and health care needs often are kept secret and are understood only by them.

Marginalized populations usually have extreme insights about their health care needs, although they often seem voiceless. This is in part a result of the different ways in which they both communicate and are silenced. It also may be because they feel even more peripheral or shut out from mainstream society when they are ill or experiencing a crisis.

ECONOMIC AND SOCIAL CHANGES

Changing world economics have had profound consequences such as increased joblessness, homelessness, poverty, and limited access to health insurance and health care. Anxiety, hopelessness, depression, and despair commonly affect the individuals in our society who find themselves suddenly without a job and sometimes even without a home as a result of downsizing. These conditions often are associated with increased stress-related symptoms, substance abuse, violence, and crime (Lenburg et al., 1995). Dramatic changes in technology and specialization in the health care field have made health care costs skyrocket. Therefore not everyone can afford health care services. More minorities lack health insurance than the general population (Nies and McEwen, 2001). Higher costs and lower wages for minority groups make it difficult to rise out of poverty (Stanhope and Lancaster, 2000).

Poverty. Most families with racially or ethnically diverse backgrounds have a lower socioeconomic status than does the population at large. African-Americans, Hispanics, and Native Americans have much higher rates of poverty thaon-Hispanic Caucasians and Asians. The median family income of Asians is slightly higher than that of non-Hispanic Caucasians and is consistent with Asians’ high levels of education and the higher percentage of families with two wage earners (Council of Economic Advisers, 1999). However, opportunities for education, occupation, income earning, and property ownership that are available to upper- and middleclass Americans often are not available to members of minority groups (Stanhope and Lancaster, 2000).

The poor also suffer more than the population as a whole for nearly every measure of health. Substantial disparities remain in health insurance coverage for certain populations.

Among the nonelderly population, approximately 33% of Hispanic persons lacked health insurance coverage in 1998, a rate that is more than double the national average. Mexican Americans had one of the highest uninsured rates at 40%. For adults under age 65 years, 34% of those below the poverty level were uninsured. Lack of health care coverage has major implications for health (U.S. Department of Health and Human Services, 2000).

Minority members of society often live in poverty. This social stratification leads to social inequality. For instance, it is widely known that school systems and recreational facilities vary significantly between the inner city and the suburbs (Nies and McEwen, 2001). Residential segregation, substandard housing, unemployment, poor physical and mental health, and poor self-image are part of the cycle of poverty. This inequality is especially disturbing as it relates to health care. The United States has a history of providing the highest quality health care to those with the highest socioeconomic status and the worst health care to those with low socioeconomic status. Social, economic, and health problems have led to heated debates about the philosophy, scope and costs, and sources of funding for health care and insurance programs.

Violence. Changing economic and social conditions have contributed to the increasing level of violence in our society. Statistics indicate that homicide is the second leading cause of death among Americans ages 10 to 24 years and the leading cause of death among African-American males ages 15 to 34 years (Nies and McEwen, 2001). Businesses, schools, restaurants, playgrounds, and churches have become common settings for random acts of violence (Lenburg et al., 1995). Unemployment is associated with violence because it is an expectation in our society that people should be productive and gainfully employed. The inability to secure or hold a job may lead to feelings of inadequacy, guilt, and frustration, which in turn can precipitate acts of violence. Although the increasing incidence of violence affects all segments of society, women, children, the elderly population, and culturally vulnerable groups are especially at risk. “Young minority males have the highest rates of unemployment in the United States, ranging close to 50%” (Stanhope and Lancaster, 2000). This group also has the highest rate of violence, with homicide being a major problem for young African-American males. The differing rates of violence among races are more likely a result of poverty than race (Stanhope and Lancaster, 2000).

Societal changes have increased the tension between the empowered culturally dominant groups and the less visible vulnerable groups. This tension and behavioral response to tension has major implications for health care delivery and the education of nurses and other health care professionals (Lenburg et al., 1995).

ATTITUDES TOWARD CULTURALLY DIVERSE GROUPS

The range of attitudes toward culturally diverse groups can be viewed along a continuum of intensity, as illustrated in Fig. 11-1 (Lenburg et al., 1995).

The extreme negative manifestation of prejudice is hate in its many violent and nonviolent forms. Contempt is somewhat less intense but is problematic because it is so widespread and undermines many aspects of society. Tolerance reflects a more neutral attitude that accepts differences without attempting to convert them; it is the minimum-level attitude essential in democratic societies. Respect for diversity is manifested in behaviors that integrate differences into positive interactions and relationships. Respect is a demonstration of the inherent worth of the individual, regardless of differences. The most positive attitude is portrayed as a celebration (or affirmation) of the positive merits of cultural differences (i.e., of the value added to life experiences by multiple perspectives, traditions, rituals, foods, and art forms). The combination of ignorance of other cultures and arrogance about one’s own culture fosters disrespect and hate. The deliberate attempt to discover and apply the positive benefits of cultural variation promotes respect and a celebration of the value of diversity, whereas perpetuating prejudice fosters narrow-mindedness and contempt. By integrating these perspectives as part of professional role behavior, educators can help students prepare for culturally competent practice in communities of diversity.

 

 

DIVERSITY IN THE HEALTH CARE WORKFORCE

Need for Diversity in the Health Care Workforce. Members of some cultural groups are demanding culturally relevant health care that incorporates their beliefs and practices (Nies and McEwen, 2001). Consumers are becoming much more aware of what constitutes culturally sensitive and competent care and are less willing to accept incompetent care (Meleis et al , 1995). There is a lack of diversity and ethnic representation of health care professionals; and there is limited knowledge about values, beliefs, experiences, and health care needs of certain populations such as immigrants, the elderly population, and gays and lesbians. Each of these groups has a unique set of responses to health and illness.

Nurses make up the largest segment of the workforce in health care delivery. Therefore they have an opportunity to be proactive in changing health care inequities and access to health care (Meleis et al., 1995). The changing health care system must reflect the community; and, as health care moves into the community, it is vital that partnerships be formed between health care providers and the community. For these partnerships to become a reality, minority representation in all health professions is vital. Factors inhibiting minority members from attaining a career iursing include inadequate academic preparation, especially in the sciences; financial costs; inadequate career counseling; and better recruitment efforts by other disciplines (Sullivan, 1998).

 

 

Current Status of Diversity in the Health Care Workforce. Although most nurses are Caucasian women, an increasing proportion of minority students is graduating from nursing programs. In a survey conducted by the American Association of Colleges of Nursing (AACN) in 2001 (Table 11-1), minority representation was highest among those identified as black or African-American (11.4 %) and lowest among Native Americans (0.7%). Graduates from Hispanic or Latino groups totaled 4.8%; and Asian, native Hawaiian, or other Pacific Islander were 4.7% of the undergraduate students who responded to the survey. These totals lag behind the 73.55% reported Caucasian enrollment.

The number of men who graduate from basic registered nurse (RN) programs is increasing. In the AACN survey conducted in 2000, 9% of the undergraduate respondents were men (Table 11-2). Men continue to represent a minority iursing, although geographic representation varies widely, with west Texas reporting 15% to 18% male representation iursing. Because recruitment efforts are focused more on ethnic minorities, it is expected that the small representation from men will continue (Castiglia, 1997).

Recruitment and Retention of Minorities in Nursing. It is clear that we have been slow in preparing nurses to be reflective of our population, just as we have been unaware of the need for culturally sensitive patient care and sometimes less than welcoming to students different from the predominant population (Sullivan, 1998).

Recruitment and retention of students from minority populations must not be separated. In other words, recruitment programs must have retention as their primary focus because there is no point in recruiting minorities into nursing programs and theot helping them succeed.

Before World War II the only known effort to recruit minority students into nursing on a national scale was made by the National Association of Colored Graduate Nurses (NACGN), which had had recruitment of African-Americans into nursing as one of its objectives since its inception in 1908. During World War II a mechanism was set into motion by the federal government to produce additional nursing personnel by financing basic nursing education. This was done through the Cadet Nurse Corps. The Corps had a number of recruiters, two of whom were African-American. These two African-American nurses confined their recruiting to 82 African-American colleges and universities. By the end of the war, 21 African-Americaursing schools had participated in the Corps, and well over 2000 African-Americaurses had acquired their basic nursing education through this mechanism.

After the war, recruitment efforts for African-Americans at the national level reverted to NACGN, an organization that voted itself out of existence in 1949 and was dissolved in 1951. However, individual African-American schools in the North and South continued to recruit. In the south law segregated the nursing schools, and in the North they were segregated by custom. In 1954 the unanimous Supreme Court decision—Brown v. the Board of educationasserted that “separate educational facilities were inherently unequal,” making racial segregation in public schools unconstitutional. This decision was interpreted to mean that all kinds of educational discrimination would be considered, including nursing.

It was around the time of the Brown decision that schools of nursing were being accredited by national standards, and many schools, both African-American and Caucasian, just did not measure up to the standards. As a result, many schools closed. With integration permitting African-American students to be admitted to formerly all-Caucasian schools, quality African-American schools had difficulty attracting enough students, and many of the schools closed. However, the Caucasian schools that began admitting African-American students did not admit the number that would have been admitted by the African-American schools. For example, many Caucasian schools admitted only one or two African-American students per class.

 

 

In the late 1960s many efforts were made to help the economically disadvantaged in this country. Although not all people of minority groups are economically disadvantaged, the vast majority of disadvantaged people are members of ethnic minority groups. Nursing, too, became concerned about the disadvantaged and began concerted efforts to recruit more members of minority groups into nursing schools. The Sealantic Fund, one of the Rockefeller Brothers’ funds, was one of the first foundations that helped minorities enter nursing school.

Sealantic funded projects in 10 universities in different parts of the country to recruit students from minority groups and help them achieve success. The best example of an ongoing project, funded by the Division of Nursing since 1971, is the National Student Nurses Association’s “Breakthrough to Nursing” to accelerate the recruitment of minorities, including men.

In 1997 the American Nurses Foundation published a report of a project it had funded entitled Strategies for Recruitment, Retention and Graduation of Minority Nurses in Colleges of Nursing. Through survey and interview analysis, Bessent and a cadre of knowledgeable leaders investigated the most effective approach to increase the nursing profession’s representation of nurses of color (Bessent, 1997). Members of Chi Eta Phi, a national African-Americaursing society with chapters throughout the country, serve as mentors to minority nursing students. As mentors, sorority members provide intellectual and inspirational stimulation along with counseling.

Just as contributions of diverse cultural groups are beginning to be valued, so must nursing programs value the need for diversity in their students and faculty and view this diversity as a strength. Diversity withiursing programs can increase the understanding and sensitivity of nurses and positively affect the way they provide care to their patients (Baldwin, 1997).

Strategies for Recruitment and Retention of Minorities in the Health Care Workforce Recommendations of the American Academy of Nursing’s expert panel on cultural competence (Meleis et al., 1995) include recruitment and retainment of diversity in the workforce, raising consciousness, mentoring, and consultation. There also is a need to increase the number of nurse educators and researchers who are from diverse, marginalized, and vulnerable populations. Raising consciousness involves increasing the level of awareness of nurses and other health care professionals about the issues surrounding diversity. This can be accomplished by encouraging participation in forums related to different aspects of various cultural phenomena such as environmental control, communication, and health beliefs. Such forums might be offered by state and local professional nurses’ organizations and health care facilities.

Another successful strategy for recruiting and retaining minorities in education and clinical practice is matched mentoring. Matched mentoring would involve matching sameculture mentors either in the same institution or different institutions. A different mentoring strategy would involve teaching and modeling by nurses who have been trained in crosscultural care. Cross-cultural nursing consultants in the care of specific groups are available to agencies, professional groups, licensing bodies, and individual nurses. Organizations should contact the Transcultural Nursing Society to obtain the names of consultants in the field of transcultural nursing.

Audiovisual media should be used to teach the importance of human health conditions cross-culturally. Video conferencing can provide international links for students and faculty who cannot travel. Students from various cultures can share their clinical experiences. One of the greatest benefits is the discovery that thinking, values, and decision making differ in various cultures. Collaborative arrangements should be encouraged between colleges and universities so that exchange programs can be offered to students. Such exchanges can provide firsthand, in-depth experience with a culture that is different from their own. Interactive media could be used to gain a clearer perspective than can be obtained through the print medium on particular cultures.

Strategies such as mentoring by the same culture professional are effective in recruiting and retaining minorities iursing. In addition, the value of workshops, continuing education programs, and the use of consultants to promote culturally competent care should not be overlooked.

CULTURAL COMPETENCE

Health professionals, educators, and health care systems must all respond to the consequences of increasing cultural diversity for the future well-being of all populations. There is a shared responsibility to work collaboratively to achieve competence iursing practice. It is evident that professional competence must incorporate cultural competence and the skillful use of knowledge and interpersonal and technical abilities (Lenburg et al., 1995). Evaluation of cultural competence in students, faculty, and staff is essential. The authors suggest that it is essential that nurses take responsibility to:

• Be sensitive to and show respect for the differences in beliefs and values of others.

• Take responsibility to inquire, learn about, and integrate beliefs and values of others in professional encounters.

• Take responsibility to try to change negative and prejudicial behaviors in themselves and others.

In light of societal changes, responsible persons at all levels in education and health care delivery systems acknowledge the need to reassess the influence of culture on achieving expected health outcomes. There is an imperative need for nurse educators, administrators, students, and others to promote sensitivity to, acceptance of , and respect for the rights and mores of all individuals within the context of their cultural orientation and society as a whole. Nurses must be culturally competent because:

• The nurse’s culture often is different from the client’s culture.

• Care that is not culturally competent may be more costly.

• Care that is not culturally competent may be ineffective.

• Specific objectives for persons in different cultures need to be met as outlined in Healthy People 2000 (Stanhope and Lancaster, 2000).

For this reason the expert panels of the American Academy of Nursing (AAN) were developed in 1992 and 1995 to draft proposals for promoting cultural competence iursing.

Principles for Culturally Competent Care. The goal of culturally competent nursing care is to provide care that is consistent with the client’s cultural needs. The AAN Expert Panel Report (1992) on culturally competent nursing care suggested the following four principles:

1. Care is designed for the specific client.

2. Care is based on the uniqueness of the person’s culture and includes cultural norms and values.

3. Care includes empowerment strategies to facilitate client decision making in health behavior.

4. Care is provided with sensitivity to the cultural uniqueness of the client.

Nurses have a responsibility to become knowledgeable about the values, beliefs, and health care practices of the culturally diverse groups that are dominant in the nurse’s particular practice area or region of the country. For example, nurses who work for the Indian Health Service must be culturally competent to care for Native Americans. Nurses who practice in California should strive to increase knowledge and understanding of Asian and Hispanic populations. In south Texas, where 70% of the population is Hispanic, cultural competence also might include the ability to speak Spanish.

Cultural Competence in Nursing Education. Since the 1960s there has been a united effort to include concepts sensitive to cultural diversity iursing education. The National League for Nursing (NLN) has made this requirement mandatory for accreditation. The NLN specifies that the nursing curriculum should provide “learning experiences in health promotion and maintenance, illness care and rehabilitation for clients from diverse and multicultural populations throughout the life span” (NLN, 1996). Transcultural nursing was first introduced in the 1960s (Nies and McEwen, 2001). Since then some progress has been made, but only recently have nursing programs been systematically incorporating culturally diverse nursing care concepts into the curricula. Content about the health beliefs and practices of individuals from various cultural groups is essential. Information about the prevalence of health problems and disease incidence mortality rates, cultural factors related to situations such as birth and death, and specific culture-bound syndromes such as anorexia and bulimia should be essential content iursing curricula and in continuing education programs for practicing nurses.

The cross-cultural similarities and differences of roles and responsibilities of family members should be addressed, particularly in terms of support and health care functions of family members.

The AAN Panel (1992) also recommended the following principles to be used in preparing nursing graduates who are sensitive to cultural diversity and global health care needs and able to provide culturally competent care.

• Nurses must learn to appreciate intergroup and intragroup cultural diversity and commonalities in racial/ethnic minority populations.

• Nurses must understand how social structural factors shape health behaviors and practices in racial/ethnic minorities (e.g., nurses must avoid a “blaming” and “victim” pattern).

• Nurses must understand the dynamics and challenges of biculturalism and bilingualism.

• Nurses must confront their own ethnocentrism and racism.

• Nurses must begin implementing and evaluating service provided to cross-cultural populations.

SOURCES OF LAW AND NURSING PRACTICE

The actions of all individuals are regulated through two systems of principles known as laws and ethics. Laws enforce a minimum level of conduct by imposing penalties for violations of acceptable behavior (Rhodes, 1994). Laws are expressed in terms of “must” and “shall” and are based on a society’s interest in prohibiting or controlling certain behaviors. Ethics are described in terms of “should” and “may” and address beliefs about appropriate behaviors within a societal context (Lagana, 2000). Chapter 9 presents an in-depth discussion about nursing ethics. Professional nursing conduct also is regulated by a variety of laws. There are two major sources of law:

• Statutory law

• Common law

The standards for professional nursing practice are in great part derived from both statutory and common law. The following section of the chapter deals with statutory law and describes how it governs and indirectly influences nursing practice.

 

STATUTORY LAW

 

Laws that are written by legislative bodies such as Congress or state legislatures are enacted as statutes. The terms law and statute will be used interchangeably in this chapter. The aforementioned EMTALA is an example of a federal statute. Violation of law is a criminal offense against the general public and is prosecuted by government authorities. Crimes are punishable by fines or imprisonmenjt. The list of federal and state statutes that goverursing practice has multiplied over the past 25 years. Nurses at all levels of practice must develop a greater depth and breadth of knowledge about laws related to professional practice, their specific practice setting (i.e., the Emergency Department in the case of EMTALA), and health care systems in general. Ignorance of the law is never a defense when the nurse violates a health care statute. A nurse who violates the law is subject to penalties, including monetary fines, suspension or revocation of jhis or her license, and even imprisonment in some instances (Nurse’s Legal Handbook, 2000).

 

Federal Statutes

 

As I travel across the United States speaking with nurses about the rapid and often daunting changes in health care, a common question raised is, “Isn’t there a law prohibiting this—reduction in RN staff? floating? the use of nurse aides in this patient care situation?” Nursing staffing is influenced to some degree by federal (and state) laws. For instance, in 1999 California became the first state to enact a law (California Assembly Bill 394) that mandates the establishment of minimum nurse-patient ratios in acute care facilities (Schreiber, 2000). The projected nursing shortage may prompt other states to follow suit. Federal laws also have a major impact oursing practice, mandating a minimum standard of care in all settings that receive federal funds (i.e., reimbursement for treatment of Medicare patients).

 

Unfortunately, most nurses are unfamiliar with health care law and rely on authorities in their employment setting to know what is legal and therefore permissible. Automatically deferring to administrators or nurse managers about the legality of a particular issue is no longer acceptable behavior for the professional nurse. Each RN must take accountability for knowing the law and understanding how it relates to patient care and nursing practice. When concerns about work-related issues arise (e.g., a change in scope of practice for unlicensed staff or a reduction in RN staffing), the first question the nurse should ask and answer must be: “Is this legal?” (Mahlmeister, 1996).

 

Three federal statutes that nurses must be familiar with and have a clear understanding of are discussed. This list is not comprehensive, but it includes examples of federal law that directly impact nursing practice. Many federal laws are relevant to specific health care settings (i.e., mental health, Emergency Departments, maternity settings). When nurses are knowledgeable about the federal laws applicable to their area of practice, they will be able to more effectively advocate for patients in that setting.

 

Emergency Medical Treatment and Active Labor Law (COBRA, 42 U.S.C. 1395dd). This federal statute, often referred to as the “anti-dumping” law, was enacted in 1986 to prohibit the refusal of care for indigent and uninsured patients seeking medical assistance in the Emergency Department (Moy, 1999). This law also prohibits the transfer of unstable patients, including women in labor, from one facility to another. The law states:

 

• All persons presenting for care must receive the same medical screening examination and be stabilized, regardless of their financial status or insurance coverage, before discharge or transfer.

 

The Emergency Medical Treatment and Active Labor Law (EMTALA) is applicable to people presenting to non-Emergency Department settings such as urgent care clinics. It even governs the transfer of patients from an inpatient setting to a lower level of care in some parts of the United States (Roberts v. Galen of Virginia, Inc., 1997). Significant penalties can be levied against a facility that violates the EMTALA, including a $50,000 fine (not covered by liability insurance). The federal government also can revoke the facility’s Medicare contract, and this could result in a major loss of revenue for the institution or even insolvency. Many legitimate concerns that nurses have about the discharge or transfer of patients could be promptly addressed if the nurse had a solid understanding of the EMTALA. This is not a daunting task. Nursing journals have published many articles about the EMTALA and the nurse’s role in upholding this statute (Snyder, 1999; Casaubon and Sparks, 2000).

 

Americans With Disabilities Act of 1990 (Public Law No. 101-336), 42 U.S.C. Section 12101. The intent of this law is to end discrimination against qualified persons with disabilities by removing barriers that prevent them from enjoying the same opportunities available to persons without disabilities. Recent court cases have established that, as a place of public accommodation, a health care facility must provide reasonable accommodation to patients (and family members) with sensory disabilities such as vision and hearing impairment (Negron v. Snoqualmie Valley Hospital, 1997, and Aikins v. St. Helena Hospital, 1994).

 

 This statute has relevance for all nurses. As patient advocates, nurses have a legal and ethical duty to provide appropriate patient and family education and to support the process of informed consent. The health care facility must have a policy that defines how it will meet the client’s needs for education and information when there are vision or hearing disabilities. The policy also must delineate how the nurse can obtain translators and special types of equipment needed to facilitate communication.

 

Patient Self-Determination Act of 1990; Omnibus Budget Reconciliation Act of 1990 (Public Law No. 101-508, Sections 4206 and 4751). This federal statute is aMedicare/Medicaid amendment intended to support individuals in expressing their preferences about medical treatment and making decisions about end-of-life care. The law requires that all federally funded hospitals:

 

• Inform adult patients, in writing, about their right under state law to make treatment choices. These choices include collaborating with the physician in formulating “do not resuscitate” (DNR) orders.

• Ask patients if they either have prepared a “living will” or have executed a “durable power of attorney” for health care.

 

The law provides guidance to nurses who often are in the best position to discuss these issues with the patient (e.g., while completing a comprehensive admission assessment). (Legal considerations related to living wills, durable power of attorney, and DNR orders are discussed in the last section of this chapter.)

 

Health Insurance Portability and Accountability Act of 1996 (Public Law No. 104- 191). The intent of this law is to ensure confidentiality of the patient’s medical records. The introduction of electronic medical records has provided additional impetus for introduction of this legislation. The statute sets guidelines for maintaining the privacy of health data. Legitimate concerns regarding the uses of and release of medical information, particularly to private entities such as insurance companies, led to the passage of this law. It provides explicit guidelines for nurses who are in a position to release health information. To maintain confidentiality of the medical record and privacy of patients’ health data, all nurses must have a basic understanding of the new rules and regulations that went into effect in 2001.

 

State Statutes

 

In addition to federal laws, nursing practice is governed by state laws that delineate the conduct of licensed nurses and define behaviors of all health care professionals in promoting public health and welfare.

 

State Nursing Practice Act and Board of Nursing Rules and Regulations. One of the most important state laws governing nursing practice is the Nursing Practice Act. This law was enacted to define the scope and limitations of professional nursing practice. The aim of regulating practice in this manner is to protect the public and make the individual nurse accountable for his or her actions (Booth and Carruth, 1998). State legislatures authorize the nurses’ licensing board to promulgate administrative rules and regulations necessary to implement the Nursing Practice Act. Once these administrative rules and regulations are formally adopted, they have the same force and effect as any other law (Nurse’s Legal Handbook, 2000).

Although nursing practice acts vary from state to state, they usually contain the following information:

    Definition of the term registered nurse

    Description of professional nursing functions

    Standards of competent performance

    Behaviors that represent misconduct or prohibited practices

    Grounds for disciplinary action

    Fines and penalties the licensing board may levy when the Nursing Practice Act is violated

 

Provides excerpts from three separate state nursing practice acts to illustrate how the Nursing Practice Act defines the scope of practice for nurses.

Surprisingly, many nurses are not even aware that the Nursing Practice Act is a law, and they unknowingly violate aspects of this statute. They are not familiar with the administrative rules and regulations enacted by the licensing board. This is an unfortunate lapse because these administrative rules and regulations answer crucial questions that nurses have about the day-to-day aspects of practice and unusual occurrences. For example, rules promulgated by the Ohio Board of Nursing include the following section:

 

At all times when a licensed nurse is providing direct nursing care to a client within the scope of the licensed nurse’s practice as set forth in [the law] Section 4723.02 of the Revised Code, the licensed nurse shall display and identify applicable licensure as a registered nurse or as a licensed practical nurse (Ohio Administrative Code, Section 4723-4-03, (H), 1996).

 

An RN in Ohio who does not wear an identification badge that clearly displays his or her status as an “RN” is in violation of the law. In this era of health care redesign, knowledge of this administrative rule would be essential because many health care systems are attempting to remove the licensure status of health care professionals from identification badges. In these latter settings all workers (eveurses and physicians) are identified by a generic title such as “patient care team member.” An increasing number of licensing boards are considering amending administrative rules to require that the nurse’s licensure status (RN, licensed practical nurse [LPN], or licensed vocational nurse [LVN]) be clearly displayed on the worker’s identification badge.

 

 Each nurse should own a current copy of the Nursing Practice Act and the licensing board’s administrative rules and regulations. The dramatic changes occurring in health care often lead to uncertainty among nurses about which functions constitute the exclusive practice of registered nursing and which patient care tasks may be lawfully delegated to LPNs, LVNs, or unlicensed assistive personnel.

 

The Nursing Practice Act and licensing board rules and regulations provide essential information that clarify these important questions. The Nursing Practice Act broadly defines the practice of registered nursing in accordance with nursing’s rapidly evolving functions. In recent years, with the expansion of basic nursing functions and the development of advanced nursing practice, many states have revised their nursing practice acts (Weiss, 1995). Licensing boards also have been authorized in some states to provide guidelines for the development of “standardized procedures.” Standardized procedures are a legal means by which RNs may expand their practice into areas traditionally considered to be within the realm of medicine. The standardized procedure actually is developed within the facility where the expanded nursing functions have been approved. It is developed in collaboration with nursing, medicine, and administration. An example of a standardized procedure would be a written protocol authorizing a nurse to implement a peripherally inserted venous catheter for patients in the neonatal intensive care unit.

 

Violations of the Nursing Practice Act. State legislatures have given licensing boards the authority to hear and decide administrative cases against nurses when there is an alleged violation of the Nursing Practice Act or the nursing board’s rules and regulations. Nurses who violate the Nursing Practice Act or board’s administrative rules and regulations are subject to disciplinary action by the board. Research indicates that there has been an increase in the number of consumer complaints to licensing boards related to nursing misconduct (Malugani, 2000) Table 8-1 provides a synopsis of the licensing board proceedings when a complaint is made about a nurse. Box 8-2 presents the more common grounds for disciplinary action by state boards of nursing. Penalties that licensing boards may impose for violation of the Nursing Practice Act include:

 

• Issuing a formal reprimand

 

• Establishing a period of probation

 

• Levying fines

 

• Limiting, suspending, or revoking the nurse’s license

 

An estimated 7% of the 1.9 million RNs in the United States are chemically dependent (Bernzweig, 1996). The majority of disciplinary actions by licensing boards are related to misconduct resulting from chemical impairment, including the misappropriation of drugs for personal use and the sale of drugs and drug paraphernalia to support the nurse’s addiction. When the nurse’s license is limited or suspended because of problems related to chemical impairment, the ability to practice in the future often is predicated on successful completion of a drug rehabilitation program and evidence of abstinence. An increasing number of state licensing boards have established programs to guide nurses through the process of rehabilitation to reestablish licensure. Booth and Carruth have identified other grounds for disciplinary action in their study of Louisiana State Board of Nursing disciplinary actions for violation of the Nursing Practice Act (1998).

 

Reporting Statutes

 

In 1973 the United States Congress enacted the Child Abuse Prevention and Treatment Act. The law mandated all states to meet specific uniform guidelines to qualify for federal funding of child abuse programs. All 50 states and the District of Columbia now have created laws that mandate reporting of specific health problems and the suspected or confirmed abuse of vulnerable individuals in society. Nurses often are explicitly named within the context of these statutes as one of the groups of designated health professionals who must report the specified problems under penalty of fine or imprisonment. The following are reportable in all states:

 

• Infant and child abuse

 

• Dependent elder abuse

 

• Specified communicable diseases (for example, bubonic plague)

 

An increasing number of states also require a report of suspected or confirmed domestic violence. For example, a California law (Assembly Bill 890) enacted in 1995 requires nurses and other health care workers to recognize and report symptoms of domestic violence to local law enforcement authorities or face a misdemeanor charge.

 

The nurse must be familiar with these state-specific reporting statutes as they apply to his or her practice setting. For example, pediatric nurses must have in-depth knowledge regarding child abuse reporting laws. Agency policies and procedures in the nurse’s work setting may provide guidance regarding reporting duties. If information is not available within the institution, the nurse may consult with the State Department of Health or the state nurses’ licensing board for guidance in obtaining these reporting statutes.

 

Nurses need not fear legal reprisal from individuals or families who are reported to authorities in suspected cases of abuse. Most legislatures have granted immunity from suit within the context of the mandatory reporting statute. A recent court decision upheld this doctrine of immunity. In the case Heinrich v. Conemaugh Valley Memorial Hospital (1994), the family of an injured child initiated a lawsuit against a hospital that reported suspected child abuse after a state investigation found them innocent of the charge. The court ruled that the hospital and the physician who made the report in “good faith” were immune from litigation under a Pennsylvania Child Protective Service Law that required reports of suspected child abuse.

 

Institutional Licensing Laws

 

All facilities (i.e., hospitals, nursing homes, rehabilitation centers) providing health care services must comply with licensing laws promulgated by state legislatures. These laws are created to protect the public and ensure the safe and effective provision of health care services. Specific language usually is contained within health facility licensing statutes regarding the following:

 

• Minimum standards for the maintenance of the physical plant

 

• Basic operational aspects of major departments (nursing, dietary, clinical laboratories, and pharmacy)

 

• Essential aspects of patient rights and the informed consent process

 

Many state licensing laws mandate minimum levels of education, experience, or credentialing for department administrators such as nurses, anesthesia personnel, pediatricians, and obstetricians. Several states also require minimum nurse-patient ratios in critical care units and other specialty departments such as the operating room, nursery, or Emergency Department.

 

Health care restructuring and redesign have led to many changes in the way health care services are provided and the settings in which care is rendered. Not all change has been positive, and some redesign schemes have resulted in adverse outcomes for patients. Investigations by state authorities on report of patient injuries or death have discovered that in some cases health facilities have operated in violation of existing licensing laws (Hytha, 1997). In the past, direct-care RNs generally could rely on their nurse managers to have a comprehensive knowledge of health facility licensing law and to create policies and procedures that implement and enforce applicable aspects of the law. The trend toward flattened management and reduction in staff development personnel has altered this picture. In an increasing number of settings, nurse managers have been replaced with nonnurse administrators who may have minimal knowledge of the health facilities licensing laws.

 

COMMON LAW

 

In addition to statutory law, nursing practice is guided by common law, also known as decisional or judge-made law. Common law is created through cases heard and decided in federal and state appellate courts. Throughout the years judge-made law regarding nursing practice has accumulated in the form of written opinions. These opinions eventually contribute to the expected standard of nursing conduct (Trandel-Korenchuk and Trandel-Korenchuk, 1997). The body of written opinions about nurses also is known as nursing case law. The importance of nursing case law in establishing the current standard of practice cannot be overstated.

 

One of the most important cases to establish the expected conduct of nurses was Utter v. United Hospital Center, Inc. (1977). This West Virginia case affirmed that nurses were required to exercise independent judgments to prevent harm when caring for patients. Before the 1970s the issue of whether nurses were licensed professionals who made independent judgments was not clearly established. In the Utter case a patient whose arm was casted had signs and symptoms of compartment syndrome. The affected limb became progressively more edematous and eventually turned black. The nurses failed to activate the chain of command when the primary providers did not respond to their reports and requests for medical reevaluation. The patient’s arm eventually had to be amputated. The court wrote:

 

Nurses are specialists in hospital care who, in the final analysis, hold the well-being, in fact in some instances, the very lives of patients in their hands. In the dim hours of the night, as well as in the light of day, nurses are frequently charged with the duty to observe the condition of the ill and infirm in their care. If the patient, helpless and wholly dependent, shows signs of worsening, the nurse is charged with the obligation of taking some positive action … there was evidence that certain nurses did not fulfill their obligation.

 

The duty to prevent harm, known as the nurse’s “affirmative duty,” has been reaffirmed iumerous court decisions.

 

Every nurse should understand the impact that nursing case law has on his or her current practice. Case law made in appellate court decisions has addressed a range of vital issues related to professional nursing including:

 

Nursing malpractice cases

 

Lawsuits claiming violation of the nurse’s civil rights, including free-speech issues and reasonable accommodation for nurses with disabilities

 

v    Questions concerning labor law and collective bargaining

 

v    Lawsuits alleging wrongful termination

 

v    Legal challenges to state board of nursing disciplinary action against a nurse’s license

 

v    Legal actions against the nurse instituted by medical licensing boards

 

v    “Practicing medicine without a license” claims

 

Efforts should be made by professional nurses to review case law as it is published and discussed iursing journals. There has been a trend to incorporate “legal advice” columns into many practice journals, and journals often include discussions about nursing case law. There also has been a proliferation of nursing journals dedicated solely to legal issues iursing practice. Table 8-2 lists examples of these publications.

 

CIVIL LAW

 

Two major types of categories of law have been created to deal with conduct that is considered unacceptable—criminal law and civil law. Nurses generally are more familiar with civil law and, in particular, the branch of civil law that deals with torts. Tort law is discussed first, and a discussion of criminal law follows.

 

A tort is a civil wrong or injury committed by one person against another person or a property. The wrong results from a breach in one’s legal duty regarding interpersonal relationships between private persons. This duty is established through societal expectations regarding interpersonal conduct (Nurse’s Legal Handbook:, 2000). Civil suits almost always are brought by one person against another and generally are based on the concept of “fault.” The person who initiates the civil lawsuit, the plaintiff, seeks damages for the wrongful behavior from the offending person, known as the defendant. The determination of whether wrongful behavior has occurred usually is determined by a jury, although in certain cases the right to a trial by jury can be waived by the private parties in the suit. In that case the judge considers the facts and determines the outcome. If the plaintiff succeeds in the civil lawsuit (plaintiff verdict), damages generally are awarded in the form of monetary compensation. Damages may include “hard” damages—financial reimbursement for treatment of injuries, loss of wages, rehabilitation services, or special equipment—and “soft” damages—monetary compensation for pain and suffering, loss of companionship, or mental anguish, among other things (Aiken, 1994).

 

Negligence and Malpractice

 

There are two types of torts: an unintentional tort or wrong and an intentional tort. An unintentional tort is an unintended wrong against another person. The two most common unintentional torts are negligence and malpractice.

 

Negligence is defined as the failure to act in a reasonable and prudent manner. The claim of negligence is based on the accepted principle that everyone is expected to conduct themselves in a reasonable and prudent fashion. This is true of lay persons, student nurses, and licensed professionals. A more formal definition of negligence is the “failure to exercise the degree of care that a person of ordinary prudence would exercise under the same circumstances” (Nurse’s Legal Handbook, 2000).

 

Malpractice is a special type of negligence—that is, the failure of a professional, a person with specialized education and training, to act in a reasonable and prudent manner. As state nurse practice acts have evolved to reflect the increasing professionalism of RNs, courts have begun to recognize the negligent acts of nurses as malpractice. Evidence of this change in perceptions is apparent in the increasing use of RNs as expert witnesses in “malpractice” cases.

 

In general, expert testimony is not needed in cases of “simple” negligence, when the actions of the defendant are so obviously careless that even a lay person would recognize the conduct as negligent. In contrast, if the jury does not possess the special knowledge and information that professionals ordinarily have, an expert witness is required to establish whether the person breached the expected standard of care. In that case the breach in duty is not simple negligence, but malpractice.

 

Elements Essential to Prove Negligence or Malpractice. Although any patient or surviving family member in the case of a patient death may sue the nurse and his or her employer, the following elements must be proved for the plaintiff to succeed in the case.

 

A. The nurse owed the patient or client a special duty of care based on the establishment of a nurse-patient relationship.

 

1. When the nurse accepts a patient assignment, it establishes the relationship and requires the nurse to meet his or her duty to the patient.

 

a. The duty of the nurse is to possess the knowledge and skill that a reasonable and prudent nurse would possess and exercise in the same or similar patient care situation.

 

b. The duty of the nurse as described is the standard of care.

 

2. A nurse-patient relationship also may be established through telephone communication in the case of a nurse who performs telephone triage and advice or via computer or audio-video systems that are now being introduced in some health care settings (Mahlmeister, 2000b).

 

B. The nurse has breached his or her duty to the patient or client.

 

1. Evidence is presented that proves the nurse breached the standard of care.

 

2. The standard of care is essentially what the nurse expert witness states that it is.

 

3. The standard of care is derived from a multiplicity of sources, and they are described in Box 8-4.

 

C. Actual harm or damage is suffered by the patient.

 

D. There is proximate cause or a causal connection between the breach in the standard of care by the nurse and the patient’s injury.

 

1. No intervening event is responsible for the injury.

 

2. A direct cause and effect can be demonstrated.

 

3. In some jurisdictions the nurse’s breach in duty must only be proven to be a “substantial cause” of the patient’s injury.

 

This last element merits further discussion. The relationship between the nurse’s breach in the standard of care and the patient’s injury must be established by the plaintiff. To prove “proximate cause,” there must be a direct causal link. For example, a patient reports that he has an allergy to penicillin and wears a MedicAlert bracelet to that effect. A physician orders penicillin to treat the patient’s infection. The nurse fails to check for or ask the patient about allergies. The nurse administers the penicillin, and the patient suffers an anaphylactic reaction and dies. There is a direct connection between the nurse’s actions and the patient’s death. Proximate cause has been established.

 

In some jurisdictions it only is necessary to prove that the nurse’s actions were a substantial cause of the injury or harm to prove negligence. For example, in a large teaching hospital a nurse notes a significant change in a patient’s vital signs, suggesting a deterioration in his condition. A first-year resident is called to the bedside and made aware of the patient’s status. The resident orders the nurse to simply continue observing the patient. The physician remains immediately available in the unit and receives repeated reports of a continued decline in the patient’s condition. There is a clear chain of command policy established in the hospi tal to deal with unresolved disagreements between health care professionals. Despite the policy’s existence, the nurse does not activate the chain of command.

CULTURAL BELIEF SYSTEMS

A value is a standard that people use to assess themselves and others. It is a belief about what is worthwhile or important for well-being. There is a tendency for people to be “culture bound” (i.e., to assume that their values are superior, sensible, or right). Cross-cultural health promotion requires the nurse to work with clients without making judgments as to the superiority of one set of values over another. Box 11-1 provides a comparison of Anglo-American values and those of more tradition-bound countries.

Each culture has a value system that dictates behavior directly or indirectly by setting norms and teaching that those norms are right. Health beliefs and practices tend to reflect a culture’s value system. Nurses must understand the patient’s value system to foster health promotion.

 

 

CULTURAL PHENOMENA

Giger and Davidhizar (1999) have identified six cultural phenomena that vary among cultural groups and affect health care. These phenomena are environmental control, biologic variations, social organization, communication, space, and time orientation.

Environmental Control. Environmental control is the ability of members of a particular culture to control nature or environmental factors. Some groups perceive humans as having mastery over nature; others perceive humans to be dominated by nature, and still other groups see humans as having a harmonious relationship with nature (Spector, 2000a). People who perceive that they have mastery over nature believe that they can overcome the natural forces of nature. Such individuals would expect positive results from medications, surgery, and other treatment modalities. Persons who believe that they are subject to the forces of nature or that they have little control over what happens to them may not be compliant with treatments because they believe that whatever happens to them is part of their destiny. African-Americans and Mexican Americans are most likely to subscribe to this view. Persons who hold the harmony with nature view, such as Asians and Native Americans, believe that illness represents a disharmony with nature. These clients may see medication as relieving only the symptoms and not curing the disease. Therefore they are more likely to rely oaturalistic remedies such as herbs or hot and cold treatments to effect a cure (Stanhope and Lancaster, 2000). Included in this concept are the traditional health and illness beliefs, the practice of folk medicine, and the use of traditional and nontraditional healers. Environmental control plays an important role in the way clients respond to health-related experiences and use health resources (Spector, 2000a).

Biologic Variations. Biologic variations such as body build and structure, genetic variations, skin characteristics, susceptibility to disease, and nutritional variations exist among different cultures. For example, babies who are born in Western culture weigh more thaon-Western babies. Other common variations include skin color, eye shape, hair texture, adipose tissue deposits, shape of ear lobes, and body configuration (Stanhope and Lancaster, 2000). For example, AfricanAmericans have denser bones than Caucasians, which may account for the low incidence of osteoporosis in the African-American population. The size of teeth varies among cultures, with Caucasians having the smallest, followed by African-Americans, Asians, and Native Americans. Larger teeth can cause protruding jaws, a condition common in African-Americans, which does not represent an orthodontic problem (Nies and McEwen, 2001).

Laboratory values for some tests also vary among cultural groups. For example, serum cholesterol levels essentially are the same for African-Americans and Caucasians at birth. During childhood the levels are higher in African-Americans, but they are lower than in Caucasians in adulthood. This finding is interesting because of the high morbidity and mortality from cardiovascular disease in African-Americans (Nies and Mcewen, 2001). The maternal mortality rate of African-Americans is three times that of Caucasians; occurrence of stomach cancer is twice as high among African-American men as Caucasian men; and occurrence of esophageal cancer is three times more common among African-Americans than the general population. Japanese-Americans have a lower incidence of cardiovascular and renal disease than the general population but a higher incidence of stress-related diseases such as ulcers, colitis, psoriasis, and depression. Native Americans have a higher incidence of streptococcal sore throat and gastroenteritis than the general population (Medcom, 1997). Native American women have the highest incidence of diabetes (Nies and McEwen, 2001).

Mexican-Americans have higher rates of obesity and diabetes than the general population, although they have lower rates of cardiovascular disease. The Mexican-American population has a pattern of less use of preventive services, including prenatal care; immunizations for children, and vision, hearing, and dental care (Nies and McEwen, 2001).

Social Organization. Social organization refers to the family unit (nuclear, single-parent, or extended family) and the religious or ethnic groups with which families identify. Family is defined differently across cultures. For instance, in the African-American culture, family often includes people who are unrelated or distantly related. Families depend on the extended family for emotional and financial support in times of crisis. Mothers and grandmothers play important roles in African American families and are involved in decision making, especially as it relates to health (Stanhope and Lancaster, 2000).

Communication. Communication differences include language differences, verbal and nonverbal behaviors, and silence. Language can be the greatest obstacle to providing multicultural care. If the client does not speak the same language as the nurse, a skilled interpreter is mandatory (Giger and Davidhizar, 1999). Comfort with direct eye contact during communication is an area that varies among cultures. Although some cultures such as the Euro-American value direct eye contact as a sign of attention, other cultures such as African-American or Native American may view direct eye contact as rude behavior.

In the Asian culture it is considered important behavior to agree with those in authority. This aspect of the Asian culture has important implications for the nurse who is involved in patient education. The patient may seem compliant and nod his or her head as in agreement with the nurse’s instruction even when the instruction is not clear or when the patient has no intention of carrying out the instruction (Stanhope and Lancaster, 2000).

Anglo-Americans tend to be informal in their style of communication, whereas other cultures may prefer a more formal style. Health professionals should not assume that a first name basis is appropriate for client relationships. With any client, terms of endearment such as “honey” or “dear” are unacceptable and can be interpreted as disrespectful, derogatory, or condescending. The best solution to the challenge of different communication styles and preferences is always to ask the client how he or she prefers to be addressed.

If the nurse and the client do not speak the same language, an interpreter should be consulted. An interpreter can help the nurse establish rapport with the client and explain concepts to the patient that are foreign to the nurse. When interpreters are needed, they should be selected carefully. Adult family members or friends are possible choices, as are bilingual staff and community volunteers. Nurses should be aware that some ethnic groups consider it a breach of confidentiality to have a stranger interpret, whereas certain individuals may not want other family members or friends to know the specifics of their medical condition.

The nurse also should be careful to consider the different dialects spoken in the same country and the culture’s view of women and children. Children should not be used as interpreters because of the subject matter and because of certain cultural views of authority. Many cultures view adults as having more authority than children. In many cultures women would not be acceptable interpreters because of the cultural view of women.

Nurses should be aware that AT&T has an interpreter service. A two-way calling system is arranged in which the nurse, the interpreter, and the client are on the telephone at the same time. This service is available in many hospitals, although many nurses and other health care professionals are unaware of this resource.

Space. Space refers to people’s attitudes and comfort level regarding the personal space around them. There are vast cultural differences in the comfort level associated with the distance between persons. Anglo-Americaurses tend to feel comfortable with an intimate zone of 0 to 18 inches. This usually is the distance between the nurse and the patient when the nurse performs certain parts of a physical assessment such as an eye or ear examination. Entering this zone could be uncomfortable for clients and nurses who have not had time to establish a trusting relationship. This discomfort would be increased for persons whose culture is not comfortable at all with such a limited space. For instance, Asians frequently believe that touching strangers is inappropriate; therefore they have a tendency to prefer more distance between themselves and others, particularly health professionals whom they have not previously known. On the other hand, Mexican-Americans tend to be comfortable with less space because they like to touch persons with whom they are talking (Stanhope and Lancaster, 2000).

Time. Time orientation is the view of time in the present, past, or future. Present-oriented persons enjoy what they are experiencing at the moment and only move on to the next event or activity “when the time is right.” Punctuality and “watching the clock” are definitely part of Western culture, but many cultural groups, such as Native Americans, do not view time in the same way. This difference in time orientation can have implications for the present-oriented professional in the work setting, who may always be late for work without thinking it is an important issue. In addition, there are implications for health teaching. For example, when teaching medication schedules to a patient, it would be important to consider how that individual views time.

Clients who view the past as more important than the present or the future may focus on memories of the past. For instance, the Vietnamese may take actions that they believe are consistent with the views of their ancestors and look to their ancestors for guidance (Giger and Davidhizar, 1999). In the Asian culture time is viewed as being more flexible than in the Western culture and being on time or late for appointments is not a priority (Stanhope and Lancaster, 2000).

People who are future-oriented are concerned with long-range goals and health care measures that can be taken in the present to prevent illness in the future. These persons plan ahead in scheduling appointments and organizing activities. They may be seen as having “distant” or “cold” personalities because they are not always engaged in communication at the moment because they may be thinking about their plans for the future. Persons who are oriented more to the present may be late for appointments because they are less concerned with planning ahead (Table 11-3).

 

PRACTICE ISSUES RELATED TO CULTURAL COMPETENCE

Health Information and Education. According to the Task Force on Black and Minority Health, minority populations are less knowledgeable about specific health problems than are Caucasians. African-Americans and Hispanics receive less information about cancer and heart disease than do nonminority groups. African-Americans tend to underestimate the prevalence of cancer, give less credence to the warning signs, obtain fewer screening tests, and are diagnosed at later stages of cancer than are Caucasians. Hispanic women receive less information about breast cancer than do Caucasian women. Hispanic women are less aware that family history is a risk for breast cancer, and only 29% have heard of breast self-examination. Successful programs to increase public awareness about health problems are being offered to minority groups, but efforts must be continued to reach more of the population. Families, churches, employers, and community organizations need to be involved in facilitating behavior changes that will result in healthier lifestyles. Education programs have the greatest impact on diseases that are affected by lifestyle such as hypertension, obesity, and diabetes. For example, if patients with diabetes could improve their self-management skills, 70% of complications could be prevented, saving human suffering and health care dollars (Nies and McEwen, 2001).

 

 

International Marketplace. Nurses trained in the United States work, teach, and consult in hundreds of foreign countries on every continent. They often are recognized as international pacesetters and are viewed as “commodities for import” by both the more developed countries and the less developed third or fourth-world nations. Nurses can make a difference in the health outcomes of people all over the world. Technology has enhanced global communication and facilitated travel. As nurses help solve emerging health problems in countries throughout the world, they are the most valuable assets of the health care system. They will be called on to design, implement, and evaluate international projects, educational endeavors, and research with an intercultural focus. Therefore it is important that nurses understand the intercultural issues related to our global society (Nies and McEwen, 2001).

Nursing Literature. The number of journal articles about culturally diverse clients, transcultural nursing research, international nursing, and the inclusion of transcultural concepts iursing curricula has increased considerably since the 1950s. The Journal of Transcultural Nursing is a refereed journal that was first published in 1989. This journal was created to advance transcultural nursing knowledge and practices. The Journal of Transcultural Nursing focuses on theory, research, and practice dimensions of transcultural nursing and provides a forum for researchers. Other journals that address cultural issues include the Western Journal of Medicine: Cross Cultural Issues, the: Journal of Cultural Diversity, the Journal of Multicultural Nursing the International Journal of Nursing Studies, the International Nursing Review, and the Journal of Holistic Nursing. Nurse authors also need to be encouraged to publish articles related to clients’ cultural views and health care needs iursing specialty and practice journals that are more widely read by nurses who actually are providing care on a daily basis to clients from diverse cultures.

Although research articles on transcultural issues are becoming a common feature in health care journals, there is a need for additional research that examines individual behavioral responses to normal life processes such as pregnancy, birth, death, and human growth and development. There also is a need for well-designed studies that explore the biologic, psychologic, sociologic, and spiritual differences within, between, and among cultural groups (Purnell and Paulanka, 1998). Even though there have beeumerous research studies conducted on cultural diversity issues, a significant time gap often exists between the identification of findings and publication of results. The limited dissemination of research findings inhibits widespread acceptance of new interventions that could potentially improve health care practices of culturally diverse populations. Computer information technology and online networks help to narrow this gap and distribute research findings in a timely manner (Purnell and Paulanka, 1998).

Responsibility of Health Care Facilities for Cultural Care. Nursing policies should reflect an openness to including extended family members and folk healers in the nursing care plan, provided their presence is not harmful to the client’s well-being. For example, Hispanic clients may want the support of a curandero, espiritualista (spiritualist), yerbo (herbalist), or sabador (equal to a chiropractor). African-Americans may turn to a hougan (voodoo priest or priestess) or “old lady.” Native Americans may seek assistance from a shaman or medicine man. Clients of Asian descent may want the services of an acupuncturist or bonesetter. In some religions spiritual healers may be found among the ranks of the ordained and may be called priest, bishop, elder, deacon, rabbi, brother, or sister (Nies and McEwen, 2001). Most hospital chaplaincy programs have access to religious representatives available for patients of various religions.

Clients may need to consult with their support persons and folk healers before making medical decisions. Nurses must respect the client’s right to privacy and allow time for the client to interact with his or her spiritual or cultural healers. Nurses must respect unconventional beliefs and health practices and work with clients to develop a plan of care that builds on their beliefs and incorporates nontraditional health practices that are not harmful. These nontraditional healers should be received with respect and provided privacy to enable the healers to interact with their patients (Nies and McEwen, 2001).

Health care facilities should provide resources for nurses and other health care professionals to assist with culture-specific needs of clients. Health care facilities should have a list of interpreters fluent in the major languages spoken by persons typically using the organization. Translators who have knowledge of health-related terminology would be more effective than those who do not. Gender, birth origin, and socioeconomic class need to be considered when selecting a translator. Gender is an important consideration because many cultures prohibit discussion of intimate matters between women and men. Birth origin of the client and translator should be determined because often there are many dialects spoken within the same country, depending on the particular region (Stanhope and Lancaster, 2000).

Differences in socioeconomic class between client and interpreter can lead to problems of interpretation. Clinical nurse specialists (CNSs) in transcultural nursing should be added to the staff of institutions serving large numbers of culturally diverse persons. The transcultural CNS could be a role model to the staff in delivery of culturally sensitive and competent care, provide in-service education to staff related to cultural differences, and conduct research related to cultural and social issues. In addition, consultants should be used to deal with specific cultural issues.

Continuing education programs for nurses should be offered by health care institutions. Programs should focus on promoting awareness of the nurses’ own culturally based values, beliefs and attitudes, cultural assessment, biological variations of cultural groups, cross-cultural communication, and culture-specific beliefs and practices related to childbearing and childrearing, death and dying, issues of mental health, and cultural aspects of aging.

 

CULTURAL ASSESSMENT

Cultural Self-Assessment. The first step to becoming a culturally sensitive and competent health provider is to conduct a cultural self-assessment. The nurse should engage in a cultural self-assessment to identify individual culturally based attitudes about clients who are from a different culture. Cultural self-assessment requires self-honesty and sincerity and reflection on attitudes of parents, grandparents, and close friends in terms of their attitudes toward different cultures. Through identification of health-related attitudes, values, beliefs, and practices the nurse can better understand the cultural aspects of health care from the client’s perspective. Everyone has ethnocentric tendencies that must be brought to a level of consciousness so that efforts can be made to temper the feeling that one’s own culture is “best.” Box 11-2 shows a cultural self-assessment guide adapted from Swanson and Nies (1997) for the nurse who is not African-American but is caring for an African-American client.

Cultural Client Assessment. After the nurse performs a cultural self-assessment, he or she should obtain a cultural assessment for the client. Nursing assessments in institutional and community settings should include the gathering of data pertinent to cultural beliefs and practices. Cultural assessments lead to culturally relevant nursing diagnoses and give direction to effective nursing intervention. Basic cultural data include ethnic affiliation, religious preference, family patterns, food patterns, and ethnic health care practices. Cultural assessments should be used as an adjunct to other patient assessments. These data will give the nurse sufficient information to determine if a more in-depth assessment of cultural factors is needed. A major reason that cultural assessments are performed is to identify patterns that may assist or interfere with a nursing intervention or treatment regimen (Giger and Davidhizer, 1999).

The nurse needs to find out if the client’s beliefs, customs, values, and self-care practices are adaptive (beneficial), neutral, or maladaptive (harmful) in relation to nursing interventions. For example, if a Mexican-American client who is diagnosed with hypertension insists on taking garlic instead of an antihypertensive, this could be harmful. If the client agrees to take the garlic in addition to the antihypertensive, this would be a neutral practice.

 

MANAGEMENT FUNCTIONS

 

Classic theories of management suggest that the primary functions of managers are planning, organizing, and controlling (Stogdill, 1974). Leaders iursing management have added two additional functions to this list and now recognize five major management functions as necessary for the management of nursing organizations: (1) planning, (2) organizing, (3) staffing, (4) directing, and (5) controlling (Marquis and Huston, 2000) (Fig. 16-1).

 

• Planning includes defining goals and objectives, developing policies and procedures; determining resource allocation; and developing evaluation methods.

 

• Organizing includes identifying the management structure to accomplish work, determining communication processes, and coordinating people, time and work.

 

• Staffing includes those activities required to have qualified people accomplish work such as recruiting, hiring, training, scheduling and ongoing staff development.

 

• Directing encourages employees to accomplish goals and objectives and involves communicating, delegating, motivating, and managing conflict.

 

• Controlling analyzes results to evaluate accomplishments and includes evaluating employee performance, analyzing financial activities, and monitoring quality of care.

 

These management functions are interrelated; different phases of the process occur simultaneously, and the processes should be circular, with the manager always working toward improving the quality of health care, patient safety, and staff and customer satisfaction. Because understanding these five management functions is essential for success as a nurse manager, they will now be discussed in further detail.

 

Planning

 

Planning Questions

 

What is the right thing to do for the organization, its customers, and its employees?

 

What programs or services do customers need or want?

 

What financial and manpower resources are available?

 

What goals and objectives can be established to meet customer needs?

 

How can goals and objectives be communicated throughout the organization?

 

Planning is the first management function and has been defined as “deciding in advance what to do; who is to do it; and how, when, and where it is to be done” (Marquis and Huston, 1998, p. 49). All management functions are based on planning. Without effective planning, the management process will fail. Effective planning requires the nurse manager to understand the:

 

• Mission statement and philosophy of the organization.

 

• Organizational strategic plan.

 

• Goals and objectives for the entire organization.

 

• Operational plan for the individual unit or facility.

 

Mission and Philosophy. The mission statement, the foundation of planning for any organization, describes the purpose of the organization and the reason it exists. Most health care organizations exist to provide high-quality patient care, but emphasis may be on different concepts such as research, teaching, preventive care, spiritual care, or community service. The philosophy is the set of values and beliefs that guides the actions of the organization and thus serves as the basis of all planning. The philosophy statement should speak for the primary mission of the organization and reflect the values of the organization, any special approaches to care, and/or any particular beliefs regarding patients and/or employees (Marquis and Huston, 1998). New nurses should be aware of the mission and philosophy of the employing organization and understand the relationship between their own personal value system and that of the organization.

 

 Strategic Planning. Strategic planning is long-range planning (extending 3 to 5 years into the future) and results from an in-depth analysis of (1) the business, community, and regulatory and political environment outside the organization (external assessment); (2) customer needs; (3) technologic changes; and (4) strengths, problems, and weaknesses internal to the organization. The purposes of strategic planning are to:

 

• Provide direction for the organization.

 

• Identify strategies to respond to changes in customer needs, technology, health care legislation, the business environment, or the community.

 

• Dedicate resources to important services.

 

• Eliminate duplication, waste, and underused services.

 

The strategic plan is a written document that details organizational goals, allocates resources, assigns responsibilities, and determines time frames. Responsibility for development of the strategic plan rests with upper-level management, although there is increasing emphasis on including employees at all levels in strategic planning processes. Consider the following example.

 

Melanie Clements, an RN employed by the Quality Care Home Health Agency, noticed that the office had been receiving several calls per week for home nursing care for pediatric oncology patients. The agency did not provide services for pediatric patients. Melanie reported the situation to the administrator. Melanie soon was involved in gathering information about the number of home health agencies that offered pediatric oncology care, the standards of nursing care recommended for pediatric oncology patients, how many pediatric patients in the area might need such services, and what reimbursement was available for these services. Within the next few months, the administrator for Quality Care Home Health decided that, as part of the agency’s strategic plan, a program for pediatric oncology services would be developed.

 

Goals and Objectives. Goals and objectives state the actions necessary to achieve the strategic plan and are central to the entire management process. Goals should be measurable, observable, and realistic. Objectives are more specific and detail how a goal will be accomplished with an established target date.

 

Goals and objectives serve as the manager’s road map; without them it is difficult to know where one is going. Organization-wide goals will be established in the strategic planning process, and then unit goals that support the organization-wide goals should be developed. Every nurse manager should be able to clearly articulate the organization-wide goals, as well as the goals of the nursing unit for which he or she is responsible. In addition, goals and objectives must be communicated to everyone who is responsible for their attainment. Consider the following case example.

An adaptive or beneficial practice would include daily exercise in addition to the garlic and antihypertensive.

In the case of Southeast Asians, dermal practices such as cupping, pinching, rubbing, and burning are a common part of self-care. The dermal methods are perceived as ways to relieve headaches, muscle pains, sinusitis, colds, sore throats, diarrhea, or fever. Cupping involves placing a heated cup on the skin; as it cools it contracts, drawing what is believed to be toxicity into the cup. A circular ecchymosis is left on the skin. Pinching may be at the base of the nose or between the eyes. Bruises or welts are left at the site of treatment. Rubbing or “coining” involves rubbing lubricated skin with a spoon or a coin to bring toxic “wind” to the body surface. A similar practice is burning, which involves touching a burning cigarette or piece of cotton to the skin, usually the abdomen, to compensate for “heat” lost through diarrhea (Nies and McEwen, 2001). These practices nurture the client’s sense of well-being and security in being able to do something to correct disturbing symptoms. In most cases the practice would be considered adaptive (beneficial) or neutral. However, if the client had a clotting disorder, the practices would pose a threat to physical integrity and therefore be considered maladaptive (harmful) (Nies and McEwen, 2001).

Cultural Client Nutrition Assessment. A cultural nutrition assessment should be obtained for clients who are minorities. It is necessary to assess the client’s cultural definition of food. For example, certain Latin American groups do not consider greens to be food. Therefore when asked to keep a food diary, these individuals would not list greens, which are an important source of vitamins and iron. Frequency and number of meals, amount and types of food eaten, and regularity of food consumption are other important factors that should be considered.

Among Asian-Americans dietary intake of calcium may appear inadequate because this group usually has a low rate of consumption of dairy products. However, they commonly consume pork bone and shells, thus taking in adequate quantities of calcium to meet minimum daily requirements. In cultures in which obesity is a problem, it is helpful for the nurse to have an idea of food preferences to help the client select low-calorie, low-fat foods. Asians tend to prefer spicy foods that may lead to the high incidence of stomach cancer, ulcers, and gastrointestinal bleeding (Purnell and Paulanka, 1998).

Nurses should avoid cultural stereotyping as it relates to food because all Italians do not necessarily like spaghetti, nor do all Chinese like rice. However, knowing the clients’ food preferences makes it possible to develop therapeutic interventions that do not conflict with their cultural food practices (Stanhope and Lancaster, 2000). Food preferences of aggregate groups are described in Table 11-4.

Cultural Beliefs About Sickness and Cures. It also is important for the nurse to consider the nontraditional beliefs of sickness and cure of various cultures. For example, there are diseases that are not classified as Western culture diseases. For different cultural groups they are real diseases for which the group has medicines and treatments. Examples of such diseases include mal ojo, susto, bilis, and empacho.

Mai ojo, also called “evil eye,” is thought to be caused by persons giving admiration. “According to this belief, some people are born with ‘vista fuerte’ (strong vision) with which they unwittingly harm others with a mere glance” (Nies and McEwen, 2001). For example, a stranger who lovingly admires a Mexican-American baby by looking into the baby’s face actually can cause mal ojo. An infant who has mal ojo sleeps restlessly, has fever and diarrhea, and may ultimately die. Treatment consists of rubbing the body with an egg for three consecutive nights. The egg is broken and left under the bed overnight. In the morning if the egg appears to be cooked, then mal ojo was definitely the cause of the illness. For protections mothers often adorn their children with red yarn around their wrists or amulets that usually are a deer’s eyes (Nies and McEwen, 2001).

Susto, or fright sickness, is an emotion-based illness that is common among Mexicans. An unexpected fall, a barking dog, or a car accident could cause susto. Symptoms include colic, diarrhea, high temperature, and vomiting. Treatment involves brushing the body with “ruda” for nine consecutive nights. The brushing is performed to allow the spirit that has been removed by the disease to return to the body. The treatment often is accompanied by burning candles and prayers in home or church (Nies and McEwen, 2001).

Bilis is a disease brought on by anger. It primarily affects adults and commonly occurs a day or two after a fit of rage. If untreated, bilis can cause acute nervous tension and chronic fatigue, although herbal remedies usually are effective (Giger and Davidhizer, 1999).

Empacho is a disease that can affect children or adults and is caused by food particles becoming lodged in the intestinal tract, causing sharp pains. To manage this illness, the afflicted person lies face down on the bed with his or her back bared. The curer pinches a piece of skin at the waist, listening for a snap from the abdominal region. This is repeated several times in hope of dislodging the material. Empacho usually is not a serious disease (Nies and McEwen, 2001).

It is important to determine how culturally diverse clients define health and illness and whether their health beliefs and practices differ from the norm in the Western health care delivery system (Spector, 2000a). For example, the Chinese often find many aspects of Western medicine distasteful. They cannot understand why so many diagnostic tests are necessary and tend to believe that a “good” physician has the ability to diagnose by thoroughly examining the client’s body. Chinese clients dislike painful procedures such as the practice of drawing blood. In their culture blood is seen as the source of life for the entire body, and the Chinese believe that it is not regenerated. They have a deep respect for their bodies and prefer to die with their bodies intact. Therefore it is not uncommon for the Chinese to refuse surgery that would be mutilating to the body (Spector, 2000a). Health represents a balance within the body, mind, and spirit. It is strongly affected by the family and community. Spector (2000b) suggests a model for assessing health traditions (Box 11-3).

Spector (2000b) also has developed a guide that can be used to assess clients’ personal methods for maintaining health, protecting (preventing) illness, and restoring health (Table 11-5).

SUMMARY

In a society as diverse as the United States, health care cannot come in one form to fit the needs of everyone. Culture has a powerful influence on one’s interpretation of health and illness and response to health care. Al l clients have the right to be understood and respected, despite their differences. They have the right to expect health care providers to acknowledge that their perspectives on and interpretations of health are legitimate. Health care professionals must make a commitment to increase their knowledge, sensitivity, and competence in cultural concepts and care. Perhaps no other group in the health profession has recognized the impact of cultural diversity on outcomes of health care more thaursing. Nurses always have supported the concept of holistic care. By understanding the client’s perspective, the nurse can be a better advocate for the client. With increased knowledge, sensitivity, respect, and understanding, therapeutic interventions can be maximized to promote the highest quality of health for clients in our multicultural society. Additional information can be found in the websites listed in Box 11-4.

 

The Need for Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals

While attention to cultural issues as they arise in the health care of diverse populations has been a part of the training of some professionals in some schools for some of the time, this field has not been regularly offered or institutionalized in many courses of study for health care professionals. However, the United States has experienced, over the last two decades, the largest wave of immigration in its history. As a result, many cultural groups with diverse concepts of illness and health care are coming into our clinics and hospitals, making it increasingly important that health care professionals acquire new knowledge and competencies to meet their needs.

Additionally, there is clear evidence of large disparities in health access and status across race/ethnic groups within the U.S. population—a serious situation that calls for focused attention to the health care needs of these groups and the factors that are affecting their levels of care. The result of these circumstances is a call for educating health care professionals in the attitudes, knowledge and skills necessary for providing quality care to a diverse population—a nexus of practice patterns and attributes that has come to be known as cultural competence. The need for this type of education is seen to be important in the basic, formal education of health care professionals and in continuing education for professionals already in practice.

Numerous professional associations, including the American Medical Association, the Association of American Medical Colleges, the American Association of Medical Students, the American Academy of Nursing and the National Association of Social Workers have endorsed cultural competence education as important in the training of professionals in their disciplines.

Specific practice specialties, such as the American Academies of Family Practice and Pediatrics and the American Colleges of Emergency Medicine and Obstetrics and Gynecology, have policy statements recommending study in culture and health care.

While excellent courses of study in cultural competence education have been developed in some medical schools, residency programs, nursing schools and in the programs of study for health educators, social workers and dentists, this kind of training is by no means universal nor is it standardized as to content, duration or integration into overall curricular programs. Offerings range from a one-time brown-bag lecture to a full-scale integration of cultural competence knowledge and skills infused into several years of training. For the continuing education of practicing professionals, cultural competence education is even more haphazard and varying in quality. Up until now, there have beeo criteria by which to plan or assess courses of study in cultural competence. This set of Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals, created by a diverse group of health care professionals and educators, is designed to fill that need. The project, conceived and funded by

The California Endowment, was conducted by the consulting firm Cultures in the Clinic and directed by M. Jean Gilbert, Ph.D.

The Process Used to Develop the Principles and Recommended Standards

There were several stages in the development of this publication. The first was an environmental scan of all the published and unpublished curricula and training materials used over the last three decades in medical and nursing training, social work, health education and public health (see appendices for a selected listing of these materials and The California Endowment’s publication, Resources in Cultural Competence for Health Care Professionals for a more extensive bibliography). Policy statements and standards from numerous professional associations were obtained and reviewed. A contact list of several hundred educators and trainers working in the field was developed. Letters were sent to these persons inviting them to forward curricula, tools and methods they had developed.

They were also asked if they would be interested in participating in an on-going dialogue that would result in the creation of standards for cultural competence education. Many responded with materials and expressions of interest.

An initial Expert Panel met in the Fall of 2001 to set the framework and direction for the work.

Following this, materials were drafted and more resources gathered. In the Spring of 2002, a Working Symposium of 40 physicians, nurses, medical anthropologists, health educators, behavioral health professionals and association representatives from all parts of the United States met for two days. This multicultural group of individuals were persons who had in-depth experience and well-developed expertise in the field of cultural competence education in health care. The symposium provided opportunities to discuss critical issues, review resources and demonstrate best practices in the field of cultural competence education. Five multidisciplinary working groups were formed to meet all of one day to create criteria around the areas of content, skills, training methods, evaluation and qualifications of cultural competence education. Each workgroup summarized and discussed their work product with the full group.

Following the symposium, these summaries were posted on a Listserv for review and more discussion. Based on the materials produced by the workgroups and subsequent commentary, a first draft of Principles and Recommended Standards was drawn up and posted on the Listserv for review and input. Then a newly revised draft of the document was posted, and the Listserv was opened to an expanded group of persons drawn from the original contact list that had expressed interest in participating in the process. The Listserv method for circulating the document and posting responses made it possible for the many who participated to see what others had to say about the Principles and Recommended Standards and to comment on their observations and points of discussion. Thus, this final document is the result of research and input from numerous trainers and educators working in the field, many constituencies within the health care professions and various stakeholder groups.

Who Are the Principles and Recommended Standards For?

The Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals are designed to provide guidance to:

Health Care Professionals, to assist them in becoming aware of the depth and relevancy of cultural competence issues in the provision of quality, patient-centered care and to help them in evaluating their own needs for education and training in these aspects of health care delivery.

Educators in academic settings where health care professionals receive their basic training, to help them design curricula and activities that will provide comprehensive background in the skills and knowledge of cultural competence.

These would include medical schools, residency programs, nursing schools, schools of social work, public health and any other basic education of professionals that provide direct services to patients.

Trainers and Consultants who design in-service training, continuing education workshops, symposia and conferences for the purpose of educating practicing health care professionals in culturally competent care. The Principles and Recommended Standards will aid them in assessing the levels and kinds of training that are required for quality training in the field.

Administrators and Managers who are charged with allocating resources for curricula or training students or practicing professionals, to help them understand the rationale for and components of quality education in the field of cultural competence in health care.

Licensing and Accreditation Organizations who oversee the credentialing of health care professionals or accrediting of the organizations in which they practice, to ensure that cultural competence education is appropriately and fully included as part of basic professional education and continuing education requirements.

Policymakers, to guide them in drafting requirements which include cultural competence education for health care professionals in contracts for publicly supported health care services and in creating regulations covering the quality of care provided under those services.

Advocates, to promote cultural competency as a specific standard of care expected of the health care professionals and organizations that serve their communities.

The Principles and Recommended Standards are written at a level of generality that makes them applicable to the education of all types of health care professionals, that is, persons who are charged with direct patient care and the delivery of health care services. However, the Standards, in particular, are specific enough to provide guidance in the design of cultural competency education with respect to content, pedagogical methods and the qualifications of teachers and trainers. Furthermore, while the Standards provide guidance as to the general content and organization of educational programs, they do not suggest specific disciplinary content (e.g., what types of epidemiological data, gender role issues and case studies, that might be used to appropriately flesh out a treatment of cultural competence in obstetrics and gynecology). Experts in specific health care disciplines, using the guidance supplied by Principles and Recommended Standards, are best able to integrate relevant subject matter into the framework suggested.

Appendices were constructed to provide resources supportive of Principles and Recommended Standards so that interested persons could acquaint themselves with the scope of the field and the tools and models available. A glossary of cultural competence terms is also appended.

It is critical for all audiences and users of these Principles and Recommended Standards to understand that it takes time to implement them in educational curricula and practice. They should be viewed as guidance for long-term, carefully planned and constructed programs to integrate cultural competence education into basic and on-going education for health care professionals.

The Principles and Recommended Standards are not intended for use by consumers/patients.

Working with advocates and consumers, The California Endowment hopes to develop and disseminate tailored, multilingual guides about culturally competent care to patients and health care consumers.

Guiding Principles and Recommended Standards for Cultural Competence Education and Training of Health Care Professionals

Considerations:

Guiding Principles

(This list is not ranked in any particular order.)

1. The goals of cultural competence training should be: 1) increased selfawareness and receptivity to diverse patient populations on the part of health care professionals; 2) clinical excellence and strong therapeutic alliances with patients; and 3) reduction of health care disparities through improved quality and cost-effective care for all populations.

2. In all trainings, there should be a broad and inclusive definition of cultural and population diversity including consideration of race, ethnicity, class, age, gender, sexual orientation, disability, language, religion and other indices of difference.

3. Training efforts should be developmental, in terms of the institution and the individual. Institutions may start out simply in their inclusion of cultural competency training as a specific area of study but are expected to build in more complex, integrated and in-depth attention to cultural issues in later stages of professional education. Trainees should be expected to become progressively more sophisticated in understanding the complexities of diversity and culture as they relate to patient populations and health care.

Both instructional programs and student learning should be regularly evaluated in order to provide feedback to the on-going development of educational programs.

4. Cultural competence training is best organized around enhancing providers’ attitudes, knowledge and skills, and attention to the interaction of these three factors is important at every level of the training. It is important to recognize the extensive preexisting knowledge and skill base of health care professionals, and to seek to promote cultural competence within this context.

5. While factual information is important, educators should focus on process-oriented tools and concepts that will serve the practitioner well in communicating and developing therapeutic alliances with all types of patients.

6. Cultural competence training is best integrated into numerous courses, symposia and experiential, clinical, evaluation and practicum activities as they occur throughout an educational curriculum. Attention may need to be directed to faculty, staff and administrative development in cultural competence in order to effect this integration.

7. Following on the above, cultural competence education should be institutionalized within a school or health care organization so that when curriculum or training is planned or changed, appropriate cultural competence issues can be included.

8. Cultural competence education is best achieved within an interdisciplinary framework and context, drawing upon the numerous fields that contribute to skill and knowledge in the field.

9. Education and training should be respectful of the needs, the practice contexts and the levels of receptivity of the learners.

10. Education in cultural competence should be congruent with, and, where possible, framed in the context of existing policy and educational guidelines of professional accreditation and practice organizations, such as the Accreditation Council on Graduate Medical Education, the Liaison Committee on Medical Education, the American Academy of Nursing, the National Association of Social Workers, the Society for Public Health Education and the Academies and Colleges of Family Practice, Pediatrics, Emergency Medicine and Obstetrics and Gynecology.

11. Wherever possible, diverse patients, community representatives, consumers and advocates should participate as resources in the design, implementation and evaluation of cultural competence curricula.

12. Finally, cultural competence education should take place in a safe, non-judgmental, supportive environment. While the Principles and Recommended Standards are focused on the education and training of health care professionals, the schools and organizations in which they study and work must be settings that are conducive to functioning in a culturally competent way and visibly support the goals of culturally competent care.

 

Recommended Standards for the Content of Cultural Competence Education

Considerations:

Attitudes:

• Similar to all aspects of health care professionals’ continuing education, cultural competence education should be a continuous learning process as well. Cultural competence education for health care professionals should foster a lifelong commitment to learning and self-evaluation through an ability to recognize and question their own assumptions, biases, stereotypes and responses.

 • Health care professionals should be encouraged to adopt attitudes of open-mindedness and respect for all patients including those who differ from them socially or culturally.

 • Health care practitioners should be taught techniques that promote patientand family-centered care, along with the understanding that effective therapeutic alliances may be construed differently across patients and cultures.

 • As they learn about health care disparities and inequities and the factors that lead to unequal treatment, health care professionals should be encouraged to undertake a commitment to equal quality care for all and fairness in the health care setting.

 • To actively serve this commitment, educators can teach students ways to identify systemic or organizational barriers to access and use of services by their patients and encourage them to be proactive within their practice environments to eliminate these barriers.

Knowledge:

 • Self-awareness and self-knowledge are the first types of knowledge crosscultural training would seek to establish. This involves bringing to the learner’s awareness internalized beliefs, values, norms, stereotypes and biases. They should be made aware of how ethnocentrism, that is, the belief that one’s own culture is superior to others, operates in all cultures and encouraged to be attentive to the possibility of ethnocentrism in their own thinking. They should be made aware of how ethnocentrism may influence their own interaction with patients.

 • Essential to their understanding of both themselves and their patients is an understanding of the concept of culture. The theory of culture makes clear the connections between worldview, beliefs, norms and behaviors related to health, illness and care-seeking in different populations. In this regard, practitioners can be taught to explore how their own cultures, including the cultures of biomedicine, inform their perceptions and behaviors. All people operate within multiple cultures.

 • Information about local and national demographics would be part of a health professional’s cultural competence education. This should include attention to specific populations, immigration and changing demographics, such as alterations in age or occupational distributions. Students/trainees should be encouraged to draw implications from this information for their current and future professional practices. Organizations should have a process in place to reassess relevant demographics on a consistent basis.

 • Practitioners need to know the legal, regulatory and accreditation issues which address cultural and linguistic issues in health care. These would include such things as the position of the federal Department of Health and Human Services (DHHS) on civil rights and language access, federal and state cultural competence contract requirements for publicly funded health care and state legislation around the provision of language services and culturally sensitive health care. The DHHS Recommended Standards for Culturally and Linguistically Appropriate Health Care Services should be reviewed.

 • Health care professionals need to be made aware of any cultural and linguistic policy statements or standards espoused by their own or other professional associations, such as the Society for Teachers of Family Medicine, the American Academies of Family Physicians, Pediatrics or the American Academy of Nursing. They should be given an understanding of how cultural competence fits into the goals of their professional education.

 • Health care professionals should know the kinds and degrees of disparities in health status, health care access and use of preventive strategies across racial, ethnic, gender and other discrete population groups in the United States. This information should be placed in a context that allows the learner to understand how class, racial and ethnic discrimination, social variables and structural variables, including the structure of health care, contribute to these disparities.

 • Health care professionals should be given a framework for exploring the family structure and dynamics, health beliefs, behaviors and health practices demonstrated in different cultures and population groups, especially those in the local areas of service.

 • Practitioners should understand the concept of medical pluralism — the concurrent use of both traditional and biomedical systems of care. Familiarity with the kinds of healers and healing traditions within their communities of practice or those frequently associated with their specialty field should be discussed. Interaction with traditional healers, if possible, is recommended. Improved understanding of traditional practices does not mean endorsing them, but it can lead to improved provider-patient or provider-family interaction.

 • In developing understandings about epidemiology and group health practices, the tendency to make inferences from probabilistic, group-level generalizations to individual cases, which, carelessly done, can lead to stereotyping, should be addressed. Its clinical risks and benefits should be carefully explored. Sources of within-group variation, including class and acculturatioeed to be clarified. A “recipe” approach to cultural and clinical descriptions of groups should be rigorously avoided.

 • Emergent data, such as those being developed in genome research and ethnopharmacology, which apply to specific racial and ethnic groups, should be carefully evaluated as to their potential use in enhancing the quality of care for these groups. The positive and negative implications of these types of data for the care of diverse populations should be discussed and well understood.

 • Practitioners should learn about the epidemiology of disease among specific populations, both nationally and within their local areas, and be able to use this knowledge in patient assessment, health promotion and other aspects of care. This includes an awareness of the limitations of epidemiological information for diverse populations. For example, there is not much data on epidemiological differences for ethnic sub-populations. Existing broad ethnic group data may not be able to be applied generally across sub-populations.

 • Knowledge of the dangers of attempting to care for a patient whose language they do not understand well and of the problems associated with the use of family members, friends or unskilled interpreters should be part of a health professional’s cultural competence training.

 • Without using a recipe approach, health care practitioners should become knowledgeable about cross-cultural variations in verbal and non-verbal communication and etiquette and be taught techniques for recovering, if they discover that they have inadvertently breached a cultural norm.

 • Trainers and teachers should inform trainees of available resources, such as bibliographies, web sites, case studies and community contacts and resources, so that practitioners can continue to expand their knowledge and education around cultural issues while engaging in professional practice.

Skills:

 • Skills that enable health care professionals to assess their own responses, biases and cultural preconceptions on an ongoing basis are critical baseline skills to be learned.

 • Providers need to be given communication tools and strategies for eliciting patients’ social, family and medical histories, as well as patients’ health beliefs, practices and explanatory models. Communication skills for fostering positive therapeutic alliances with diverse patients should be taught. These would include ways for assessing patients’ expectations around levels of interactive formality with providers, valuing and incorporating the patients’ beliefs and understanding into diagnosis, treatment options and preventive health care where possible and negotiating conflicting patient/provider perspectives when necessary.

 • Health care practitioners should be taught ways of accessing and interacting with diverse local communities for the purpose of understanding their traditional or group specific health care practices and needs. Collaboration with local communities, for example, is useful in tailoring effective outreach, prevention and educational programs and materials.

 • Health care professionals should be able to assess patients’ language skills as they relate to their ability to communicate fully with the practitioner and staff and to their understanding of written instructions, prescriptions and educational materials. While language and literacy issues may be particularly important in working with limited English speakers, they should be considered in relating to all patients.

 • Practitioners should be taught methods of realistically assessing their own proficiency in languages other than English and should acquire the skills for effective use of interpreters, including working with an untrained interpreter, a trained interpreter and telephone interpreting.

 • Skills in accessing translated written materials through their organizations and commercial resources; as well as computer programs and web-based resources should be taught.

 • Cultural competence education should foster skills for retrieving data concerning cultural issues in health care, population data and epidemiological information on the web.

 

Recommended Standards for Training Methods and Modalities

Considerations:

 Recognizing that health care professionals are a large and diverse set of audiences and that achieving cultural competence is an incremental process, cultural competence education and training methods should be suited to the level, needs and learning styles of the students and trainees.

 • Cultural competence training should be developmental iature—a step-bystep process, increasing in complexity as the students/trainees acquire the ability to apply the understandings and skills in a variety of situations and settings. No brief or one-time training can meet these criteria appropriately.

 • Cultural competence education is best achieved through a diverse set of training strategies; e.g., lectures, in-depth, interactive exercises and discussions, case study analysis, genograms, journal keeping, selected readings and web-based learning and data gathering, videos, CDROMs, DVDs and simulations.

 • While many training methods as suggested may be used, the most important learning opportunities should come through experiential learning, ranging from role plays with feedback to working with diverse patients and getting hands-on experience in community settings where care is delivered to diverse patient populations.

 • Ideally, cultural competence education should not be confined to one course or workshop but should be integrated into many curricular offerings and educational activities such as case discussions, grand rounds, symposia, clinical rotations, preceptor ships and continuing education courses and conferences.

 • Cultural competence training may best be accomplished by an interdisciplinary, multicultural team and should bring together information from different backgrounds and perspectives as it relates to patient care and health care settings. The use of community members and indigenous healers as informants, lecturers and training team members has been extremely effective in many instances and should be considered as an appropriate part of education and training.

 • Faculty and trainers should articulate the attitudes engendered by cultural competency and model cultural competency skills, knowledge and attitudes so that students/trainees can learn by example.

 

Standards for Evaluating Cultural Competence Learning

Considerations:

Evaluation of students’ mastery of cultural competence attitudes, knowledge and skills should rely on a variety of techniques both qualitative and quantitative, including written examination, self-assessment and, where possible, evaluation of the application of attitudes, knowledge and skills in actual practice. Similar and consistent high-level expectations should be obtained, whether in a didactic course or in a practice setting.

 • Students and trainees may demonstrate application of knowledge, processes and skills through role play, case study analysis or observed interactions with diverse patients followed by self-, peer, patient, staff, professor or trainer feedback and evaluation. Work with standardized patients and Objective Structured Clinical Examinations (OSCEs) offer similar opportunities.

 • Students should be given the opportunity to self-assess their application of cultural competence knowledge and skills at various points along their educational trajectory. A developmental assessment inventory or tool may be useful in this regard. For example, The California Endowment funded a project for Stanford University’s Geriatrics Department wherein providers were given tools for self-assessment.

 • The effectiveness and usefulness of the cultural competence curriculum or training itself should be evaluated by students/trainees, teachers and trainers, faculty, administrators and patients, in order to refine and improve its effectiveness in developing the desired attitudes, knowledge and skills in health care professionals.

 • Clearly, the ultimate test of knowledge and application of cultural competence attitudes, content and skills is in increased patient satisfaction with clinical encounters and improved health status. Efforts to test competencies in these ways are certainly desirable but may not be possible within an education and training context. Should tests of these kinds of outcome be desired, they should be designed with the same scientific rigor that any intervention is subject to, including well-designed methods to recruit, track and monitor the attitudinal, behavioral and health outcomes of patients while controlling for intervening variables.

 

Standards Relating to the Qualifications of Cultural Competence Teachers and Trainers

Considerations:

A cultural competence educator/trainer should clearly demonstrate a commitment to the attitudes and values underlying cultural competence education in health care and an ability to model their application in life-long learning and practice.

 • The educator should have a thorough understanding of the concept of culture and be able to demonstrate how it is reflected in the interconnected beliefs, values and behaviors of various groups, including those involved in the culture of biomedicine. He or she should be able to analyze complex cultural situations in health care and be able to move beyond simple stereotypical assessments.

 • The educator must have knowledge and skills in pertinent medical/health care content areas and be familiar with health care settings and service delivery.

 • The educator should be well versed in educational methods and demonstrate strong teaching skills, be able to use a wide variety of teaching methods and evaluative techniques and be able to flexibly adapt them to the training situation and level of the trainees.

 • Because the subject areas of cultural competence education sometimes involve controversial and/or emotional issues, the educator should be skilled in facilitation and management of diverse opinions.

 • The educator/trainer should recognize the limits of his/her knowledge and be ready to enrich the training with contributions from community members, traditional healers and educators from various disciplines. Some of the best cultural competence information can come from bicultural individuals with a thorough knowledge of their cultures and their experiences with the health care system.

• The educator should be able to work respectfully and well with an interdisciplinary team.

 • If teaching cultural competence in an academic setting, the educator ideally should have a professional degree, clinical knowledge and experience commensurate with the rest of the academic faculty. He/she should have a thorough knowledge of the overall curriculum design and other course offerings.

 • The educator/trainer should be well versed in the resources available for education and training in cultural competence and for enhanced learning by students.

 • There is significant and growing literature on cultural competence in health care, including a body of theory, standards, policy, legislative and accreditation requirements. The educator/trainer should be familiar with this literature.

 

Appendix 1: Glossary of Terms

Words related to culture and cultural competence

Acculturation: The process of taking on some of the traits, values, norms and behaviors of another culture.

Concept of culture: The understanding that culture plays a controlling role in shaping how people perceive reality, acquire a sense of self, think, feel, behave and understand the behaviors of others. Includes an understanding that that there is variation in the degree and extent of a shared culture across individuals within a cultural group.

Cross-cultural: Action or understanding that involves a comparison of or interaction across more than one culture.

Cultural competence: A set of integrated attitudes, knowledge and skills that enable a health care professional or organization to care effectively for patients from diverse cultures, groups and communities.

Cultural effectiveness: The ability to achieve desired results for patients through mutually satisfactory relationships between providers and patients.

Cultural humility: A concept proposed by M. Tervalon and J. Murray-Garcia, two physicians, which they defined as “a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.”

Cultural relevance: The congruence of a concept, value or behavior with a particular cultural orientation.

Cultural responsiveness: Ability to knowledgeably and congruently meet the needs of people belonging to a specific culture or cultures.

Cultural sensitivity: An awareness of the nuances of one’s own and other cultures.

Culture: An integrated pattern of learned core values, beliefs, norms, behaviors and customs that are shared and transmitted by a specific group of people. Some aspects of culture, such as food, clothing, modes of production and behaviors, are visible. Major aspects of culture, such as values, gender role definitions, health beliefs and worldview, are not visible.

Ethnocentrism: The assumption that the beliefs, values, norms and behaviors of one’s own culture are the correct ones, and that those of other cultures are inferior or misguided.

Multicultural: Characterized by two or more cultures.

Other words and phrases

Developmental: A step-by-step process—each step building upon the one before, progressing through stages or levels on a continuum over time.

Ethnicity: Identity defined by membership in a specific group with a shared cultural and social heritage.

Evidence-based: A concept, theory, understanding or practice that is based upon scientifically established fact.

Generalization: A statement or description of a type, rule or quality based on deductive evidence from many cases; e.g., a prevalence or incidence rate of a disease in a specific population.

Appropriate generalizations are based on scientific evidence.

Health care professionals: Individuals educated to provide specialized care.

Identity: Individuals have multiple aspects to their persons, and these aspects may be referred to as identities. The salience of identity changes in different contexts. For example, in one setting, a person’s identity as a woman is more salient than her identity as an American.

Medical pluralism: The resort to treatment and healing from more than one medical system; e.g., the use of traditional and biomedical systems simultaneously or alternatively.

Race: A socially defined population that is based on distinguishable physical characteristics.

Recipe approach: A method of teaching about cultures that simply lists the core beliefs, values, norms, practices and behaviors of groups without consideration of factors effecting within group variation or cultural context.

Stereotyping: The idea that all people from a given group are the same, that there is no within group variation.

Universal: Traits, needs and behaviors that are shared across all cultural and racial groups, such as families, need for healing and health-seeking behaviors. The expression of universals is shaped by culture, such as concepts of illness etiology or perception of appropriate healing methods.

Within group differences: Cultural or biological differences across individuals within a specific ethnic or racial group. Differs from across group differences, which identify cultural or biological differences across cultural or racial groups.