diverse health care beliefs and practices assignment

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3.2 Diverse Patients Basic Concepts

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Let’s begin the journey of developing cultural competency by exploring basic concepts related to culture.

Culture and Subculture

Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. The word “culture” may at times be interchanged with terms such as ethnicity, nationality, or race. See Figure 3.1 [1] for an illustration depicting culture by various nationalities. Cultural beliefs and practices bind group or community members together and help form a cohesive identity. [2] , [3] Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals. [4] Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. For example, sushi is a traditional Asian dish that has become popular in America in recent years.

Nurses and other health care team members are impacted by their own personal cultural beliefs. For example, a commonly held belief in American health care is the importance of timeliness; medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial.

Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures. The first step in developing cultural competence is to become aware of your own cultural beliefs, attitudes, and practices.

Nurses should also be aware of subcultures. A subculture is a smaller group of people within a culture, often based on a person’s occupation, hobbies, interests, or place of origin. People belonging to a subculture may identify with some, but not all, aspects of their larger “parent” culture. Members of the subculture share beliefs and commonalities that set them apart and do not always conform with those of the larger culture. See Table 3.2a for examples of subcultures.

Table 3.2a Examples of Subcultures

Culture is much more than a person’s nationality or ethnicity. Culture can be expressed in a multitude of ways, including the following:

• Language(s) spoken
• Religion and spiritual beliefs
• Gender identity
• Socioeconomic status
• Sexual orientation
• Educational background
• Life experiences
• Living situation
• Employment status
• Immigration status
• Ability/Disability

People typically belong to more than one culture simultaneously. These cultures overlap, intersect, and are woven together to create a person’s cultural identity. In other words, the many ways in which a person expresses their cultural identity are not separated, but are closely intertwined, referred to as intersectionality .

Assimilation

Assimilation is the process of adopting or conforming to the practices, habits, and norms of a cultural group. As a result, the person gradually takes on a new cultural identity and may lose their original identity in the process. [5] An example of assimilation is a newly graduated nurse, who after several months of orientation on the hospital unit, offers assistance to a colleague who is busy. The new nurse has developed self-confidence in the role and has developed an understanding that helping others is a norm for the nurses on that unit.

Assimilation is not always voluntary, however, and may become a source of distress. There are historic examples of involuntary assimilation in many countries. For example, in the past, authorities in the United States and Canadian governments required indigenous children to attend boarding schools, separated them from their families, and punished them for speaking their native language. [6] , [7]

Cultural Values and Beliefs

Culture provides an important source of values and comfort for patients, families, and communities. Think of culture as a thread that is woven through a person’s world and impacts one’s choices, perspectives, and way of life. It plays a role in all of a person’s life events and threads its way through the development of one’s self-concept, sexuality, and spirituality. It affects lifelong nutritional habits, as well as coping strategies with death and dying.

Culture influences how a patient interprets “good” health, as well as their perspectives on illness and the causes of  illness. The manner in which pain is expressed is also shaped by a person’s culture. See Table 3.2b for additional examples of how a person’s culture impacts common values and beliefs regarding family patterns, communication patterns, space orientation, time orientation, and nutritional patterns. As you read Table 3.2b, take a moment to reflect on your own cultural background and your personally held beliefs for each of these concepts.

Table 3.2b Cultural Concepts

A person’s culture can also affect encounters with health care providers in other ways, such as the following:

• Level of family involvement in care
• Timing for seeking care
• Acceptance of treatment (as preventative measure or for an actual health problem)
• The accepted decision-maker (i.e., the patient or other family members)
• Use of home or folk remedies
• Seeking advice or treatment from nontraditional providers
• Acceptance of a caregiver of the opposite gender

Cultural Diversity and Cultural Humility

Cultural diversity is a term used to describe cultural differences among people. See Figure 3.2 [8] for artwork depicting diversity. While it is useful to be aware of specific traits of a culture or subculture, it is just as important to understand that each individual is unique and there are always variations in beliefs among individuals within a culture. Nurses should, therefore, refrain from making assumptions about the values and beliefs of members of specific cultural groups. [9] Instead, a better approach is recognizing that culture is not a static, uniform characteristic but instead realizing there is diversity within every culture and in every person. The American Nurses Association (ANA) defines cultural humility as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.” [10]

Current demographics in the United States reveal that the population is predominantly white. People who were born in another country, but now live in the United States, comprise approximately 14% of the nation’s total population. However, these demographics are rapidly changing. The United States Census Bureau projects that more than 50 percent of Americans will belong to a minority group by 2060. With an increasingly diverse population to care for, it is imperative for nurses to integrate culturally responsive care into their nursing practice. [11] , [12] Creative a culturally responsive environment is discussed in a later subsection of this chapter.

Concepts Related to Culture

There are additional concepts related to culture that can impact a nurse’s ability to provide culturally responsive care, including stereotyping, ethnocentrism, discrimination, prejudice, and bias. See Table 3.2c for definitions and examples of these concepts.

Table 3.2c Concepts Related to Culture

Race is a socially constructed idea because there are no true genetically- or biologically-distinct races. Humans are not biologically different from each other. Racism presumes that races are distinct from one another, and there is a hierarchy to race, implying that races are unequal. Ernest Grant, president of the American Nurses Association (ANA), recently declared that nurses are obligated “to speak up against racism, discrimination, and injustice. This is non-negotiable.” [13] As frontline health care providers, nurses have an obligation to recognize the impact of racism on their patients and the communities they serve. [14]

Sexual Orientation and Gender Identity

Culture can exert a powerful influence on a person’s sexual orientation and gender expression. Sexual orientation refers to a person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors. [15] The acronym LGBTQ stands for lesbian, gay, bisexual, transgender, queer, or questioning in reference to sexual orientation. (A “+” is sometimes added after LGBTQ to capture additional orientations). See Figure 3.3 [16] for an image of participants in a LGBTQ  rally in Dublin. Historically, individuals within the LGBTQ community have experienced discrimination and prejudice from health care providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this group of people in recent years, members of the LGBTQ community continue to experience significant health disparities. Persistent cultural bias and stigmatization of lesbian, gay, bisexual, or transgender (LGBTQ) people have also been shown to contribute to higher rates of substance abuse and suicide rates in this population. [17] , [18] , [19]

Gender identity refers to a person’s inner sensibility that they are a man, a woman, or perhaps neither. Cisgender is the term used to describe a person whose identity matches their sex assigned at birth. [20] To the extent that a person’s gender identity does not conform with the sex assigned to them at birth, they may identify as transgender or as gender nonbinary. Transgender people, like cisgender people, “may be sexually oriented toward men, women, both sexes, or neither sex.” [21] Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms. [22] Sharing pronouns as part of a basic introduction to a patient can assist a transgender patient to feel secure sharing their pronouns in a health care setting. Asking a patient for their pronoun (he, she, they, ze, etc.) is considered part of a nursing assessment.

Related Ethical Considerations

Justice , a principle and moral obligation to act on the basis of equality and equity, is a standard linked to fairness for all in society. [23] The ANA states this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety) but also fairness in all operations of societal structures. This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence. [24]

Social justice is related to respect, equity, and inclusion. The ANA defines social justice as equal rights, equal treatment, and equitable opportunities for all. [25]   The ANA further states, “Nurses need to model the profession’s commitment to social justice and health through actions and advocacy to address the social determinants of health and promote well-being in all settings within society.” [26] Social determinants of health are nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life. [27] Health outcomes impacted by social determinants of health are referred to as health disparities. Health disparities are further discussed in a subsection later in this chapter.

• “ Cultural diversity large.jpg ” by მარიამ იაკობაძე is licensed under CC BY-SA 4.0 ↵
• Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18 , 174. https://doi.org/10.1186/s12939-019-1082-3 ↵
• Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35 (2), 94-102. https://doi.org/10.1097/hcm.0000000000000100 ↵
• Campinha-Bacote, J. (2011). Coming to know cultural competence: An evolutionary process. International Journal for Human Caring, 15 (3), 42-48. ↵
• Cole, N. L. (2018). How different cultural groups become more alike: Definition, overview and theories of assimilation . ThoughtCo. https://www.thoughtco.com/assimilation-definition-4149483 ↵
• The Truth and Reconciliation Commission of Canada.(2015). Honoring the truth, reconciling for the future: A summary of the final report of the truth and reconciliation commission of Canada.   http://www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_the_Future_July_23_2015.pdf ↵
• Smith, A. (2007, March 26). Soul wound: The legacy of Native American schools. Amnesty International Magazine . https://web.archive.org/web/20121206131053/http://www.amnestyusa.org/node/87342 ↵
• “ Pure_Diversity,_Mirta_Toledo_1993.jpg ” by Mirta Toledo is licensed under CC BY-SA 4.0 ↵
• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵
• Kaihlanen, A. M., Hietapakka, L., & Heponiemi, T. (2019) Increasing cultural awareness: Qualitative study of nurses’ perceptions about cultural competence training. BMC Nursing, 18 (1), 1–9. https://doi.org/10.1186/s12912-019-0363-x ↵
• American Nurses Association. (2020, June 1). ANA president condemns racism, brutality and senseless violence against black communities. https://www.nursingworld.org/news/news-releases/2020/ana-president-condemns-racism-brutality-and-senseless-violence-against-black-communities/ ↵
• Fulbright-Sumpter, D. (2020). “But I’m not racist ...” The nurse’s role in dismantling institutionalized racism. Texas Nursing, 94 (3), 14–17. ↵
• Brydum, S. (2015, July 31). The true meaning of the word cisgender. The Advocate . https://www.advocate.com/transgender/2015/07/31/true-meaning-word-cisgender ↵
• “ Dublin_LGBTQ_Pride_Festival_2013_-_LGBT_Rights_Matter_(9183564890).jpg ” by infomatique is licensed under CC BY-SA 2.0 ↵
• U.S. Department of Health and Human Services. Healthy People 2020. Lesbian, gay, bisexual, and transgender health . https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health ↵
• Chance, T.  F. (2013). Going to pieces over LGBT health disparities: How an amended affordable care act could cure the discrimination that ails the LGBT community. Journal of Health Care Law and Policy, 16 (2), 375–402. https://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1309&context=jhclp ↵
• Brydum, S. (2015, July 31). The true meaning of the word cisgender. The Advocate . https://www.advocate.com/transgender/2015/07/31/true-meaning-word-cisgende r ↵
• Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender population size in the United States: A meta-regression of population-based probability samples. American Journal of Public Health, 107 (2), e1–e8. https://doi.org/10.2105/AJPH.2016.303578 ↵
• Keuroghlian, A. S., Ard, K. L., & Makadon, H. J. (2017). Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments. Sexual Health, 14( 1), 119–122. https://doi.org/10.1071/SH16145 ↵

A set of beliefs, attitudes, and practices shared by a group of people or community that are accepted, followed, and passed down to other members of the group.

A smaller group of people within a larger culture, often based on a person’s occupation, hobbies, interests, or place of origin.

The many ways in which a person expresses their cultural identity are closely intertwined and not separated.

The process whereby a member of a cultural group adopts or conforms with the practices, habits, and norms of another group, usually a dominant group. As a result, the person gradually takes on a new cultural identity, often losing their original identity in the process.

Cultural differences in people.

A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.

Assuming that a person has the attributes, traits, beliefs, and values of a group because they are a member of that group.

The belief that one’s culture (or race, ethnicity, or country) is better and preferable than another’s.

Unfair and different treatment of another person or group, denying them opportunities and rights to participate fully in society.

To “pre-judge;” a preconceived idea, often unfavorable, about a person or group of people.

To carry an attitude, opinion, or inclination (positive or negative) towards a group or members of a group. Bias can be a conscious attitude (explicit) or a person may not be aware of their bias (implicit).

A socially constructed idea; there are no truly genetically or biologically distinct races. Humans are biologically similar to each other, not different.

The presumption that races are distinct from one another and there is a hierarchy to race, implying that races are unequal. In racism, expression of one’s cultural beliefs are viewed as a heritable trait.

A person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors.

Lesbian, gay, bisexual, transgender, queer, or questioning in reference to sexual orientation.

A person’s inner sensibility that they are a man, a woman, or perhaps neither.

A person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms.

Equal rights, equal treatment, and equitable opportunities for all.

Nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life.

Nursing Fundamentals Copyright © by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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3.4: Cultural Competence

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• Ernstmeyer & Christman (Eds.)
• Chippewa Valley Technical College via OpenRN

The freedom to express one’s cultural beliefs is a fundamental right of all people. Nurses realize that people speak, behave, and act in many different ways due to the influential role that culture plays in their lives and their view of the world. Cultural compe­tence is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes. [1] , [2] , [3]

Culturally-competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their patients’ cultural beliefs. It takes motivation, time, and practice to develop cultural competence, and it will evolve throughout your nursing career. Culturally competent nurses have the power to improve the quality of care leading to better health outcomes for culturally diverse patients. Nurses who accept and uphold the cultural values and beliefs of their patients are more likely to develop supportive and trusting relationships with their patients. In turn, this opens the way for optimal disease and injury prevention and leads towards positive health outcomes for all patients .

The roots of providing culturally-competent care are based on the original transcultural nursing theory developed by Dr. Madeleine Leininger. Transcultural nursing incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way. [4] See Figure 3.4 [5] for an image of Dr. Leininger. Read more about transcultural nursing theory in the following box.

Madeleine Leininger and the Transcultural Nursing Theory [6]

Dr. Madeleine Leininger (1925-2012) founded the transcultural nursing theory. She was the first professional nurse to obtain a PhD in anthropology. She combined the “culture” concept from anthropology with the “care” concept from nursing and reformulated these concepts into “culture care.”

In the mid-1950s, no cultural knowledge base existed to guide nursing decisions or understand cultural behaviors as a way of providing therapeutic care. Leininger wrote the first books in the field and coined the term “culturally congruent care.” She developed and taught the first transcultural nursing course in 1966, and master’s and doctoral programs in transcultural nursing were launched shortly after. Dr. Leininger was honored as a Living Legend of the American Academy of Nursing in 1998.

Nurses have an ethical and moral obligation to provide culturally competent care to the patients they serve. [7] The “Respectful and Equitable Practice” Standard of Professional Performance set by the American Nurses Association (ANA) states that nurses must practice with cultural humility and inclusiveness. The ANA Code of Ethics also states that the nurse should collaborate with other health professionals, as well as the public, to protect human rights, fight discriminatory practices, and reduce disparities. [8] Additionally, the ANA Code of Ethics also states that nurses “are expected to be aware of their own cultural identifications in order to control their personal biases that may interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the patient’s culture…nurses should possess knowledge and understanding how oppression, racism, discrimination, and stereotyping affect them personally and in their work.” [9]

Developing cultural competence begins in nursing school. [10] , [11] Culture is an integral part of life, but its impact is often implicit. It is easy to assume that others share the same cultural values that you do, but each individual has their own beliefs, values, and preferences. Begin the examination of your own cultural beliefs and feelings by answering the questions below. [12]

Reflect on the following questions carefully and contemplate your responses as you begin your journey of providing culturally responsive care as a nurse. (Questions are adapted from the Anti Defamation League’s “Imagine a World Without Hate” Personal Self-Assessment Anti-Bias Behavior). [13]

• Who are you? With what cultural group or subgroups do you identify?
• When you meet someone from another culture/country/place, do you try to learn more about them?
• Do you notice instances of bias, prejudice, discrimination, and stereotyping against people of other groups or cultures in your environment (home, school, work, TV programs or movies, restaurants, places where you shop)?
• Have you reflected on your own upbringing and childhood to better understand your own implicit biases and the ways you have internalized messages you received?
• Do you ever consider your use of language to avoid terms or phrases that may be degrading or hurtful to other groups?
• When other people use biased language and behavior, do you feel comfortable speaking up and asking them to refrain?
• How ready are you to give equal attention, care, and support to people regardless of their culture, socioeconomic class, religion, gender expression, sexual orientation, or other “difference”?

The Process of Developing Cultural Competence

Dr. Josephine Campinha-Bacote is an influential nursing theorist and researcher who developed a model of cultural competence. The model asserts there are specific characteristics that a nurse becoming culturally competent possesses, including cultural awareness, cultural knowledge, cultural skill, and cultural encounters. [14]

Cultural awareness is a deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, attitudes, practices, and problem-solving strategies of a patient’s culture. To become culturally aware, the nurse must undergo reflective exploration of personal cultural values while also becoming conscious of the cultural practices of others. In addition to reflecting on one’s own cultural values, the culturally competent nurse seeks to reverse harmful prejudices, ethnocentric views, and attitudes they have. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures. Although cultural diversity training is typically a requirement for health care professionals, cultural desire refers to the intrinsic motivation and commitment on the part of a nurse to develop cultural awareness and cultural competency. [15]

Acquiring cultural knowledge is another important step towards becoming a culturally competent nurse. Cultural knowledge refers to seeking information about cultural health beliefs and values to understand patients’ world views. To acquire cultural knowledge, the nurse actively seeks information about other cultures, including common practices, beliefs, values, and customs, particularly for those cultures that are prevalent within the communities they serve. [16] Cultural knowledge also includes understanding the historical backgrounds of culturally diverse groups in society, as well as physiological variations and the incidence of certain health conditions in culturally diverse groups. Cultural knowledge is best obtained through cultural encounters with patients from diverse backgrounds to learn about individual variations that occur within cultural groups and to prevent stereotyping.

While obtaining cultural knowledge, it is important to demonstrate cultural sensitivity. Cultural sensitivity means being tolerant and accepting of cultural practices and beliefs of people. Cultural sensitivity is demonstrated when the nurse conveys nonjudgmental interest and respect through words and action and an understanding that some health care treatments may conflict with a person’s cultural beliefs. [17] Cultural sensitivity also implies a consciousness of the damaging effects of stereotyping, prejudice, or biases on patients and their well-being. Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the patient and their family members. When a patient experiences nursing care that contradicts with their cultural beliefs, they may experience moral or ethical conflict, nonadherence, or emotional distress.

Cultural desire, awareness, sensitivity, and knowledge are the building blocks for developing cultural skill. Cultural skill is reflected by the nurse’s ability to gather and synthesize relevant cultural information about their patients while planning care and using culturally sensitive communication skills. Nurses with cultural skill provide care consistent with their patients’ cultural needs and deliberately take steps to secure a safe health care environment that is free of discrimination or intolerance. For example, a culturally skilled nurse will make space and seating available within a patient’s hospital room for accompanying family members when this support is valued by the patient. [18]

Cultural encounters is a process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

By developing the characteristics of cultural awareness, cultural knowledge, cultural skill, and cultural encounters, a nurse develops cultural competence.

• Centers for Disease Control and Prevention. (2020, October 21). Cultural competence in health and human services . https://npin.cdc.gov/pages/cultural-competence ↵
• Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3 ↵
• Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35 (2), 94-102. https://doi.org/10.1097/hcm.0000000000000100 ↵
• Murphy, S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association: JMLA, 94(2 Suppl), e143–e151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/ ↵
• “ Leininger.jpg ” by Juda712 is licensed under CC BY-SA 3.0 ↵
• Murphy, S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association: JMLA , 94(2 Suppl), e143–e151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/ ↵
• American Nurses Association. (2015). Code of ethics for nurses with interpretive statements . American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only / ↵
• American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/ ↵
• Gillson, S., & Cherian, N. (2019). The importance of teaching cultural diversity in baccalaureate nursing education. Journal of Cultural Diversity, 26 (3), 85–88. ↵
• Gavin-Knecht, J., Fontana, J. S., Fischer, B., Spitz, K. R., & Tetreault, J. N. (2018). An investigation of the development of cultural competence in baccalaureate nursing students: A mixed methods study. Journal of Cultural Diversity, 26 (3), 89-95. ↵
• Zeran, V. (2016). Cultural competency and safety in nursing education: A case study. Northern Review, 43 , 105–115. https://thenorthernreview.ca/index.php/nr/article/view/591 ↵
• Anti-Defamation League. (2013). Imagine a world without hate: Anti-Defamation League 2012 Annual Report . https://www.adl.org/media/4528/download . ↵
• Transcultural C.A.R.E. Associates. (2020). The Process of Cultural Competemility. http://transculturalcare.net/the-process-of-cultural-competence-in-the-delivery-of-healthcare-services/ ↵
• Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18 , 174. https://doi.org/10.1186/s12939-019-1082-3 ↵
• Brooks, L., Manias, E., & Bloomer, M. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26 (3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007 ↵

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Understanding and Coping with Diversity in Healthcare

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• Volume 21 , pages 259–270, ( 2013 )

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• J. Jhutti-Johal 1  

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In the healthcare sector, race, ethnicity and religion have become an increasingly important factor in terms of patient care due to an increasingly diverse population. Health agencies at a national and local level produce a number of guides to raise awareness of cultural issues among healthcare professionals and hospitals may implement additional non-medical services, such as the provision of specific types of food and dress to patients or the hiring of chaplains, to accommodate the needs of patients with religious requirements. However, in an attempt to address the spiritual, cultural and religious needs of patients healthcare providers often assume that ethnic minority groups are homogenous blocks of people with similar needs and fail to recognize that a diverse range of views and practices exist within specific groups themselves. This paper describes the example of the Sikh community and the provision of palliative care in hospitals and hospices. Although, the majority of patients classifying themselves as Sikhs have a shared language and history, they can also be divided on a number of lines such as caste affiliation, degree of assimilation in the west, educational level and whether baptized or not, all of which influence their beliefs and practices and hence impact on their needs from a health provider. Given that it is unfeasible for health providers to have knowledge of the multitude of views within specific religious and ethnic communities and accounting for the tight fiscal constraints of healthcare budgets, this paper concludes by raising the question whether healthcare providers should step away from catering for religious and cultural needs that do not directly affect treatment outcomes, and instead put the onus on individual communities to provide resources to meet spiritual, cultural and religious needs of patients.

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End-of-Life Healthcare Experiences of Indigenous People and Ethnic Minorities: The Example of Canada

Race relations laws, such as the Race Relations (Amendment) Act 2000 place a legal duty on healthcare providers to tackle racism in service delivery and respect the needs of citizens from all cultures [ 27 ].

There are approximately 400,000 Sikhs in the United Kingdom. Gurharpal Singh and Darshan Tatla had the figure at 336,000 in 2006 [ 32 , p. 2].

Keshdhari Sikhs follow very similar practices to the Amritdhari Sikhs; however there is diversity in their adherence to ‘orthodox’ Sikh principles. They keep their hair uncut and possess either all or some of the 5 K’s and will follow the Sikh way of life, as outlined in the Rehat Maryada [ 29 ]. The only issue is that they have not been baptized and therefore they are not members of the Khalsa brotherhood. What is important to note is that non-baptized Sikhs are distinguished by their commitment to the 5 K’s, especially unshorn hair; which somehow implies that Keshdharis observe all of the 5 K’s [ 36 ]. Tatla, reassesses this statement in Singh and Tatla [ 32 ], changing the statement to ‘most’ of the 5 K’s. A Keshdhari may uphold all of the 5 K’s but still use their family/caste name. Alternatively, they may go purely by the Khalsa name of Singh or Kaur but only uphold one or two of the K’s, mainly Kesh and Kara . The only unifying factor in ‘ Keshdhari’ identity is that they all observe unshorn hair, hence the name ‘ Kesh - dhari’ [ 32 , p. 18].

Mona Sikhs, like Keshdhari Sikhs, are diverse; some use the Khalsa names of Singh and Kaur only, some use only their family/caste names, however, the majority will use both, taking on the Khalsa name as a ‘middle name’. They will wear the Kara, so they can be identified as Sikh, and observe the teachings of the Gurus. Some Keshdhari Sikhs can also be referred to as Mona Sikhs because there is an increasing trend to trim beards, this is particularly so among caste groups such as: Tarkhan, Ramgarhia and Jat. The element of practicality that surrounds Sikhism means that Sehajdhari and Mona Sikhs view themselves as Sikhs because they practice the religion according to the practical actions that the Guru Nanak introduced: nam japna( meditation on God’s name), kirat karna ( honest labour) and vand chakhna (giving to those in need) [ 16 , p. 91].

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Jhutti-Johal, J. Understanding and Coping with Diversity in Healthcare. Health Care Anal 21 , 259–270 (2013). https://doi.org/10.1007/s10728-013-0249-0

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DOI : https://doi.org/10.1007/s10728-013-0249-0

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Quality and Safety Education for Nurses

Strategy submission, using a capstone cultural diversity paper for program outcomes evaluation.

Lisa Sue Flood

Associate Professor

Institution:

Northern Michigan University

[email protected]

Competency Categories:

Patient-Centered Care

Learner Level(s):

Pre-Licensure BSN, RN to BSN

Learner Setting(s):

Clinical Setting

Strategy Type:

Paper Assignments

Learning Objectives:

• Identify dimensions of the client’s diversity identified through the nursing interview.
• Discuss common problems/concerns for the cultural/diverse group.
• Plan potential patient-centered interventions which promote wellness and demonstrate respect for the client’s diversity.
• Identify how knowledge gained from this assignment will influence your future nursing care with diverse clients.
• During the interview, identify the client’s cultural affiliation, values, beliefs, practices, preferences, and expressed needs related to health care, illness, and religion.
• Determine the client’s communication needs and identify family structure, needs, and preferences.
• Evaluate the communication skills you used during the interview.
• Demonstrate written scholarly communication skills using correct APA format.
• Evaluate and use a variety of scholarly/professional references cited correctly per the APA manual.
• Value continuous improvement of your communication skills.
• After reflection, recognize and analyze how your culturally-based attitudes, values, and beliefs impact nursing care.

Strategy Overview:

For nursing students in isolated rural areas, opportunities to meet a diverse population can be limited. The capstone course at Northern Michigan University requires senior nursing students to write a scholarly paper based on interviews with a client from another culture, religion, or sexual orientation. In addition to student evaluations, this three-part paper is also used to evaluate the baccalaureate program outcomes of critical thinking, written communication, and therapeutic interventions. First, students interview a diverse client. Second, students analyze the interview data and compare their findings with the literature. Third, students reflect on their own cultural beliefs and values and discuss their influence on future nursing practice.

NOTE: The following excerpts have been reprinted with the publisher’s permission.

Flood, L. S. (2007). online pharmacy Using a capstone cultural diversity paper for program outcomes evaluation. Nursing Education Perspectives, 28(3), 130 – 135.

Guidelines for Cultural Diversity Paper (Excerpts from Course Syllabus)

Students will need to interview a person of a different race, ethnicity, religion, or sexual orientation to complete part of this assignment. The paper consists of three parts. In Part I the student interviews a client using a standard cultural assessment tool (minimum 3–5 pages). In Part II, the student must submit a typed analysis of the client’s diversity supported with in-text references citations (minimum 3 – 4 pages). In Part III, the student must submit…a personal reflection of how this knowledge might influence their nursing care with persons from different cultures (minimum 2 pages).

For Part I: Client Interview Data

Using the attached questionnaire, the student will explore the client’s health beliefs as they relate to his/her cultural diversity by completing the Cultural Assessment Guide…Previous students have found it helpful to review the literature before the actual interview to be better prepared for asking specific questions.

For Part II: Cultural Analysis and Health Care Needs Identification

The student needs to analyze their client’s diversity using interview data and reference sources. At a minimum you should include the following:

• Using the client interview data and current literature, describe the traditional cultural health care beliefs and practices, which includes illness beliefs and customs, interpersonal relationships, spiritual/religious beliefs and practices, worldview beliefs, and social structures.
• Discuss any differences between what you’ve read in the literature regarding the culture’s traditional health and what your client told you. Include possible explanations for these differences.
• Identify actual or potential health care problems/concerns (for example cultural, physical, psychological, social, financial, or developmental) for the client and their cultural /diversity group.
• Discuss potential therapeutic interventions for the client and/or their cultural group that promote wellness, which demonstrate respect for the client’s culture/diversity, rights, beliefs, values, and life experiences and that incorporate professional values and practice standards.
• Record your observations from the interview regarding nonverbal and verbal communication (such as eye contact, rate of speech, personal space, and touch) demonstrated by yourself and the client.

For Part III: Personal Reflections

The student needs to reflect upon how their own culture and beliefs influences their nursing care and how knowledge gained from this assignment will influence future nursing care with clients from diverse cultures. At a minimum you should include the following: analyze how your culture (beliefs, values, religion, orientation, etc.) influences your nursing care.

• To what extent do your beliefs, prejudices, or bias influence your thinking and nursing care? Give several examples.
• Discuss specifically how the knowledge from this assignment will influence your future nursing care of clients from different cultures/orientations. Discuss several examples.

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

Oriana handtke.

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

Benjamin Schilgen

Mike mösko, associated data.

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

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

Methods and findings

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

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

Introduction

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

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

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

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

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

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

Search strategy

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

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

Eligible criteria and assessment

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

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

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

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

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

Data extraction and summary

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

Study selection

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

General study characteristics

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

a 33 studies included more than one ethnic group

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

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

Categorizations of identified culturally competent components and strategies

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

Effects of identified components and strategies

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

Components of culturally competent healthcare–Individual level

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

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

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

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

Components of culturally competent healthcare–Organizational level

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

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

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

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

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

Strategies for providing access to culturally competent healthcare

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

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

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

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

Strategies for implementing culturally competent healthcare

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

Model of culturally competent healthcare provision

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

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

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

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

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

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

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

Supporting information

Funding statement.

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

Data Availability