Cultural Competence Guidelines
Prior to 2001, no comprehensive national standards on cultural or linguistic competence existed. Instead, many variations had been developed by organizations and individuals about what constitutes culturally competent care and how it should be delivered (OMH, 2001). In 2001, however, the OMH and the United States Department of Health and Human Services stated that cultural competence can be achieved if specific guidelines are implemented for providers, policymakers, accreditation and credentialing agencies, purchasers, patients, advocates, educators, and the general health care community.
These guidelines, developed in 2001, are based on an analysis of key laws, contracts, and standards currently used by federal and state agencies and other national organizations (OMH, 2001, pp. 33–46):
1. Health care organizations should ensure that patients/consumers receive from all staff members effectively understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.
3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.
4. Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
5. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
6. Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).
7. Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered group and/or groups represented in the service area.
8. Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
9. Health care organizations should conduct initial and ongoing organizational self-assessments of culturally and linguistically appropriate service (CLAS) related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.
10. Health care organizations should ensure that data on the individual patient's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information system, and periodically updated.
11. Health care organizations should maintain a current demographic cultural and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
12. Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.
13. Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.
14. Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing CLAS standards and to provide public notice in their communities about the availability of this information.
______________________________ "Practitioners must have the tools to assess their own competence and address diverse patient populations."
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What Else Can Be Done?
Theoretical knowledge about cultural competence is not enough. Practitioners must have the tools to assess their own competence and address diverse patient populations. But how do health care professionals acquire the knowledge, skill, and respect for differences that lead to cultural competence?
As a health care professional, you can improve your care by implementing the following suggestions (Breier-Mackie, 2007; Dossey et al., 2000; Leonard, 2001; Management Sciences for Health, n.d.):
- Orient the client to the process and purpose of the translator.
- Orient the translator to the topics to be discussed, the client's situation, and the need for accuracy.
- Sit down so the client can make eye contact and observe the body language of the health care professional and the translator.
- Observe the client for nonverbal communication that does not match the intended message and clarify as necessary.
- Slow the communication process down.
- Limit the use of jargon, slang, and metaphors.
- Consider the differences in gender, socioeconomic status, and educational level between the translator and the client.
- Ask the translator to translate in the client's own words and ask clients to repeat the information communicated to ensure accuracy.
- the individual's birthplace
- time since immigration (if appropriate)
- ethnic affiliation and its strength
- primary and secondary languages
- speaking and reading ability
- family organization, structure, role differentiation, and child care practices
- social support networks and relationships
- the importance of religion in the individual's daily life
- food preferences and prohibitions
- exercise and physical activities
- health and illness beliefs and practices
- customs and traditions pertaining to birth, illness, and death
- coping and communication styles
- spiritual beliefs, rituals, and practices
1. Examine, honestly, your personal cultural beliefs and attitudes, biases, and behaviors to discover how these factors have (consciously or unconsciously) influenced the care you provide to clients as well as your interactions with colleagues and staff from diverse racial, ethnic, and sociocultural backgrounds.
2. Maintain a sense of humility and self-understanding. Each encounter with a client is a cross-cultural encounter. Maintaining "cultural humility" helps you understand your clients' historical, familial, community, occupational, and environmental framework.
3. Understand that there is no one way to treat any specific racial or ethnic group. Within each group is a tremendous amount of diversity. "Cookbook" strategies for working with patients from diverse backgrounds or stereotypes and generalizations about groups can be dangerous. Researching a cultural group and finding out as much as possible about the group's culture is a start. Understanding builds trust. Begin by being formal with patients and, with the exception of treating children or very young adults, using the patient's last name when addressing him or her.
4. Develop proper transcultural communication skills. This develops trust and allows you to obtain accurate information from the client. Even if an individual speaks English fluently, information may be subject to misinterpretation. Poor English speaking skills does not indicate a hearing disorder or lack of intelligence, so raising your voice does not mean you will be better understood.
5. Identify yourself clearly with a readable name tag, and communicate with a smile and a friendly attitude. Tone of voice; body language; taking your time; and calm, patient, gentle actions can convey reassurance to a frightened individual.
6. Don't make any assumptions about the individual's level of understanding. Speak clearly and slowly and ask the client if he or she would like more clarification (e.g., writing down words that are not clear). Repeat important information, make things simple and clear, avoid the use of jargon, do not use double negatives, and do not sound condescending.
7. Listen to the client and observe his or her body language. The same body language in different cultures can mean entirely different things. In some cultures, for example, smiling is a sign of apprehension. Be sensitive to your own body language. Be aware of the cultural variations in personal space and comfort with proximity to others. For example, in western culture, there are three zones: intimate (less than 18 inches); personal (18 inches to 3 feet); and social (3 feet to 6 feet). Do not be offended if the patient fails to use eye contact or ask questions about the treatment. In many cultures, it is considered disrespectful to look directly at another person or to make someone "lose face" by asking questions.
8. Exercise sensitivity when using interpreters. Some patients may not want intimate information revealed in front of a third party, especially when it includes common taboo subjects such as sexual behavior, contraceptive use, abortion, or menstruation. The use of professional interpreters varies widely among organizations. A professional "qualified" interpreter should be someone who "can demonstrate a high level of expressive and receptive skills and a thorough knowledge of the Code of Ethics on interpreting, or a person who speaks English and other language fluently enough to accurately and effectively enhance communication . . . fluency includes an understanding of nonverbal and cultural patterns to effectively communicate in a language" (OMH, 2001, p. 29). Professional interpretation requires a minimum level of proficiency in two languages and the demonstrated ability to convey complex messages by using the appropriate words and grammar for both provider and patient. Family, friends, and "informal" interpreters are more likely to modify what the patient actually says in order to be helpful (Management Sciences for Health, n.d.).
When using a translator, keep the following guidelines in mind:
The error rate of untrained interpreters (including family, children, and friends) is sufficiently high that their use is actually more dangerous in some circumstances than having no interpreter at all. Using an untrained interpreter provides a false sense of security to the client and the health care provider. Extra care should be taken when telephone interpretation is used.
9. Obtain a comprehensive cultural assessment. This assessment should include information about the following factors:
10. Develop an awareness of the barriers to care (such as ethnocentrism, lack of exposure to other cultures, and inaccurate information about cultural values, beliefs, and health care practices). This is the first step in eliminating them.
11. Do not make assumptions about the patient's ideas concerning ways to maintain health, the cause of illness, or the means to prevent or cure it. Develop a style of questioning that will help determine some of the patient's central beliefs about health, illness, and illness prevention. Allow the patient to be open and honest. There may be times when patients are afraid to say they have utilized both Western treatment and alternative remedies or folk medicine because they have been ridiculed in the past.
12. Determine the value of involving the entire family in the treatment since in many cultures the immediate or extended family is involved in decisions about medical care. Appropriately involving the family in the patient's care may increase compliance.
13. Refrain from delivering bad news or providing details about complications that can arise from treatment since many cultures do not have the "need to know" aspect of care. Watch for signs that the patient has heard as much as he or she can manage.
14. When developing a plan of care, be sure to incorporate (as appropriate) the patient's folk medicine or beliefs. This can enhance trust between the patient and the caregiver and help ensure compliance.
