Cultural Competence
Cultural competence "is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups" (Management Sciences for Health, n.d., p. 2). The OMH (n.d.) says that culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Culture defines:
- how rights and protections are exercised
- what is considered a health problem
- how symptoms and concerns about health problems are expressed
- who should provide treatment for the problem
- what type of treatment should be provided
Competence implies having the capacity to function effectively as an individual and as an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.
The demand for cultural competence arose because health care delivery systems did not adequately respond to all population groups. Initially, the emphasis was on cultural sensitivity. During the 1980s, however, this emphasis shifted to a demand for skill-based competencies.
Cultural and linguistic competence means that health care providers and organizations understand and respond effectively to the unique cultural and linguistic needs exhibited by patients during the health care encounter. Consider the following example (OMH, 2001, p. 6):
An elderly Bosnian woman is being admitted with terminal cancer and may present the following challenges for health care staff and organizations: She and her family do not read, speak, or understand English. Her Muslim faith requires modesty during physical examinations and her family may have cultural reasons for not discussing end-of-life concerns or her impending death. A culturally and linguistically appropriate response would include interpreter staff; translated written materials; sensitive discussions about treatment consent and advance directive forms; clinical and support staff who know to ask about and negotiate cultural issues; appropriate food choices; and other measures.
The development of culturally competent care is a process that involves five components (Breier-Mackie, 2007; Dossey et al., 2000; Ndiwane et al., 2004):
- open-mindedness about other worldviews and a desire to learn and appreciate the norms and uniqueness of clients from diverse cultures
- awareness of one's own cultural values and an examination of one's own biases so one can sensitively appreciate others' cultures
- an understanding of the dynamic differences among cultures
- a basic knowledge about a client's culture and a willingess to seek and obtain diverse cultural information and education in order to better understand the client's perspective
- adaptation skills that include being receptive to different cultures, actively seeking advice and consultation from individuals of that culture, and incorporating those ideas into one's health care practices
Cultural competence may encompass four major challenges for health care providers (Breier-Mackie, 2007):
- distinguishing clinical differences among people of different ethnic and racial groups (such as the risk of hypertension among African Americans or diabetes among Native Americans)
- communication variations (nuances and expressions or the use or non-use of technology) and the need for translators or interpreters (since some cultures have "taboo" subjects such as sexual activity or death)
- ethics and ethical practice (including the respect for belief systems and the effects of those beliefs on the well-being of individuals within a particular culture
- trust and the perception within some cultures that authority figures (including caregivers) are immediately mistrusted (sometimes for good reasons since they have been the victims of atrocities at the hands of authority figures in their homelands)
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"Cultural and linguistic competence means that health care providers and organizations understand and respond effectively to the unique cultural and linguistic needs exhibited by patients during the health care encounter."
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Why is Culturally Competent Care Important?
Imagine that you are vacationing in a foreign country where the national language is not your own. You suddenly become ill and are admitted to the local hospital. While you may be confident that the hospital has high standards of health care, you may also wonder about the following:
- What is everyone saying?
- What is my diagnosis?
- What is my prognosis?
- How does the health care system work here?
- What if they don't understand what I am saying?
- How will I be able to get what I need?
- Can I trust them with my life?
Health care practitioners bring their own familial and cultural values, as well as education and life experiences, to the healing profession. It is important for health care providers to be aware of their own values, beliefs, expectations, and cultural practices and consider how these impact a client from a different culture. When health care practitioners do not consider cultural health care practices, they may order more or fewer diagnostic tests because they may not understand or believe the patient's description of the symptoms. Patients may not adhere to medical regimens if they do not clearly understand the health care practitioner.
Knowledge of cultural diversity is important at all levels of health care and for all practitioners, regardless of where they practice. The delivery of culturally and linguistically appropriate care leads to improved health outcomes, increased efficiency in the delivery of services, and increased client satisfaction (OMH, 2001). A lack of respect for persons of differing cultural values can lead to potential and real harm, either culturally, psychologically, physically, or spiritually.
Consider the following examples of care that were not delivered in a culturally sensitive manner (Habel, 2001):
A Navajo woman gives birth in a large area hospital. After the birth, the nurses dispose of the placenta and umbilical cord as part of their routine care. When the mother is ready to go home, she requests both the placenta and umbilical cord and is devastated when she discovers that the staff has destroyed them. She assumed that the staff understood the significance of the placenta and umbilical cord to her native traditional practices. She and her family leave the hospital in great distress.
An elderly Chinese woman who had just had surgery was told by the nursing staff to "force fluids." The patient refused to drink any water from the water pitcher left at her bedside and was threatened by the staff that if she did not drink fluids orally, an intravenous line would need to be started. The staff labeled the woman "uncooperative." When the patient's daughter came to visit, she told the nursing staff that about the Chinese belief in the use of hot and cold foods and beverages in healing. She stated that her mother could drink hot herbal tea but not cold water.
Unfortunately, many health care providers do not feel they have clear guidelines on how to prepare for, or behave in, such situations.
