Chapter 2

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Cultural Competence:Cultural Competence:
Cultural CareCultural Care
Chapter 2Chapter 2

Chapter 2: Cultural Competence: Cultural CareChapter 2: Cultural Competence: Cultural Care
Cultural CompetencyCultural Competency
 Who are you meeting for the first time?Who are you meeting for the first time?
 Where does the patient come from?Where does the patient come from?
 What is his or her heritage?What is his or her heritage?
 What is his or her cultural background:What is his or her cultural background:
ethnicity and religion?ethnicity and religion?
Slide 2-2

Cultural Competency (cont.)Cultural Competency (cont.)
 Does the patient understand, speak, and readDoes the patient understand, speak, and read
English?English?
 What language does her or she understand,What language does her or she understand,
speak, and read?speak, and read?
 What is his or her health and illness beliefsWhat is his or her health and illness beliefs
and practices?and practices?
Slide 2-3

ObjectivesObjectives
 Demographic profile of United StatesDemographic profile of United States
 National Standards for Culturally and LinguisticallyNational Standards for Culturally and Linguistically
Appropriate ServicesAppropriate Services
 Background of Heritage AssessmentBackground of Heritage Assessment
 Methods for conducting Heritage AssessmentMethods for conducting Heritage Assessment
 Traditional health and illness beliefs and practicesTraditional health and illness beliefs and practices
 Steps to cultural competenceSteps to cultural competence
Slide 2-4

Health and IllnessHealth and Illness
 Health:Health:
 Balance of a person is a complex, interrelatedBalance of a person is a complex, interrelated
phenomenon:phenomenon:
• Within one’s being: physical, mental, spiritualWithin one’s being: physical, mental, spiritual
• In outside world: natural, communal, metaphysicalIn outside world: natural, communal, metaphysical
 Illness:Illness:
 Loss of a person’s balance:Loss of a person’s balance:
• Within one’s being: physical, mental, spiritualWithin one’s being: physical, mental, spiritual
• In outside world: natural, communal, metaphysicalIn outside world: natural, communal, metaphysical
Slide 2-5

Demographic Profile ofDemographic Profile of
United StatesUnited States
 Total population passed 300 million in 2006Total population passed 300 million in 2006
 1 out of 3 residents are in a group other than1 out of 3 residents are in a group other than
single-race, non-Hispanic whitesingle-race, non-Hispanic white
 Minority, or emerging majority populations total 98Minority, or emerging majority populations total 98
million peoplemillion people
 Hispanics: largest and fastest growing groupHispanics: largest and fastest growing group
 Blacks: second largest populationBlacks: second largest population
 Asians, American Indians, Alaska natives, NativeAsians, American Indians, Alaska natives, Native
Hawaiians, and other Pacific Islanders make upHawaiians, and other Pacific Islanders make up
the third largest part of the populationthe third largest part of the population
Slide 2-6

United States (cont.)United States (cont.)
 Emerging majority groups tend to be:Emerging majority groups tend to be:
 YoungerYounger
 Lower median agesLower median ages
 Higher proportions under 18 years oldHigher proportions under 18 years old
 Dominant, non-Hispanic, single-race, whiteDominant, non-Hispanic, single-race, white
population is:population is:
 Older median ageOlder median age
 Smaller proportion under 18 years oldSmaller proportion under 18 years old
Slide 2-7

United States (cont.)United States (cont.)
 One birth every 8 secondsOne birth every 8 seconds
 One death every 13 secondsOne death every 13 seconds
 One international migrant (net) every 30One international migrant (net) every 30
secondsseconds
 Net gain of one person every 11 secondsNet gain of one person every 11 seconds
Slide 2-8

ImmigrationImmigration
 Categories of Interest to Health CareCategories of Interest to Health Care
ProvidersProviders
 Legal permanent residentsLegal permanent residents
 Naturalized citizensNaturalized citizens
 Undocumented aliensUndocumented aliens
 Refugees, asylees, and paroleesRefugees, asylees, and parolees
 Legal nonimmigrant residentsLegal nonimmigrant residents
Slide 2-9

Immigration (cont.)Immigration (cont.)
 Many new immigrants have only minimalMany new immigrants have only minimal
understanding of:understanding of:
 Modern health care delivery systemModern health care delivery system
 Modern medical and nursing practices andModern medical and nursing practices and
interventionsinterventions
 English languageEnglish language
 It is imperative that the nurse’s care beIt is imperative that the nurse’s care be
tailored to meet the person’s perceived needstailored to meet the person’s perceived needs
Slide 2-10

National StandardsNational Standards
 National Standards for Culturally andNational Standards for Culturally and
Linguistically Appropriate ServicesLinguistically Appropriate Services
in Health Carein Health Care
 First and Landmark StandardFirst and Landmark Standard
• Health care organizations should ensure that patientsHealth care organizations should ensure that patients
receive from all staff members effective, understandablereceive from all staff members effective, understandable
and respectful care that is provided in a mannerand respectful care that is provided in a manner
compatible with their cultural health beliefs and practicescompatible with their cultural health beliefs and practices
and preferred language*and preferred language*
*Source: National Standards for Culturally and Linguistically Appropriate Services in Health Care,*Source: National Standards for Culturally and Linguistically Appropriate Services in Health Care,
Final Report, March 2001, Washington, DC: Office of Minority Health, DHHSFinal Report, March 2001, Washington, DC: Office of Minority Health, DHHS
Slide 2-11

National Standards (cont.)National Standards (cont.)
 Effective care: positive outcomes andEffective care: positive outcomes and
satisfaction for patientsatisfaction for patient
 Respectful care: considers values,Respectful care: considers values,
preferences, and expressed needs of patientpreferences, and expressed needs of patient
 Cultural and linguistic competence: congruentCultural and linguistic competence: congruent
behaviors, attitudes, and policies that comebehaviors, attitudes, and policies that come
together in a system among professionalstogether in a system among professionals
that enables work in cross-cultural situationsthat enables work in cross-cultural situations
Slide 2-12

Linguistic CompetenceLinguistic Competence
 Title VI of Civil Rights Act of 1964:Title VI of Civil Rights Act of 1964:
 Services cannot be denied to people of limitedServices cannot be denied to people of limited
English proficiencyEnglish proficiency
 47 million Americans over 5 years of age47 million Americans over 5 years of age
speak a language other than English in theirspeak a language other than English in their
homeshomes
 An increase of 15 million people over 1990 censusAn increase of 15 million people over 1990 census
 Some states require providers to offerSome states require providers to offer
language assistance in health care settings:language assistance in health care settings:
 California, Massachusetts, and New YorkCalifornia, Massachusetts, and New York
Slide 2-13

Linguistic Competence (cont.)Linguistic Competence (cont.)
 People with limited ability to speak, read,People with limited ability to speak, read,
write, and understand English encounterwrite, and understand English encounter
countless barriers that limit access to criticalcountless barriers that limit access to critical
public health, hospital, and other medical andpublic health, hospital, and other medical and
social services to which they are legallysocial services to which they are legally
entitledentitled
Slide 2-14

Cultural CompetenceCultural Competence
 Culturally sensitive:Culturally sensitive:
 Possessing basic knowledge of and constructivePossessing basic knowledge of and constructive
attitudes toward diverse cultural populationsattitudes toward diverse cultural populations
 Culturally appropriate:Culturally appropriate:
 Applying underlying background knowledgeApplying underlying background knowledge
necessary to provide the best possible health carenecessary to provide the best possible health care
Slide 2-15

Cultural Competence (cont.)Cultural Competence (cont.)
 Culturally competent:Culturally competent:
 Understanding and attending to total context ofUnderstanding and attending to total context of
patient’s situation including:patient’s situation including:
• Immigration statusImmigration status
• Stress factorsStress factors
• Social factorsSocial factors
• Cultural similarities and differencesCultural similarities and differences
Slide 2-16

HeritageHeritage
 CultureCulture
 EthnicityEthnicity
 Religion and SpiritualityReligion and Spirituality
 SocializationSocialization
 AcculturationAcculturation
 AssimilationAssimilation
 BiculturalismBiculturalism
 Time OrientationTime Orientation
Slide 2-17

Heritage (cont.)Heritage (cont.)
 Heritage consistency:Heritage consistency:
 Degree to which a person’s lifestyle reflects his orDegree to which a person’s lifestyle reflects his or
her traditional heritageher traditional heritage
 Heritage consistency continuum:Heritage consistency continuum:
 Traditional: living within norms of traditional cultureTraditional: living within norms of traditional culture
 Modern: acculturated to norms of dominantModern: acculturated to norms of dominant
societysociety
Slide 2-18

 Culture:Culture:
 Thoughts, communications, actions, beliefs,Thoughts, communications, actions, beliefs,
values, and institutions of racial, ethnic, religious,values, and institutions of racial, ethnic, religious,
or social groupsor social groups
 Characteristics of cultureCharacteristics of culture
• LearnedLearned
• SharedShared
• AdaptedAdapted
• DynamicDynamic
Slide 2-19

 EthnicityEthnicity
 Describes a group united by:Describes a group united by:
• Common geographic originCommon geographic origin
• Migratory statusMigratory status
• ReligionReligion
• RaceRace
• LanguageLanguage
• Shared values, traditions, or symbolsShared values, traditions, or symbols
• Food preferencesFood preferences
Slide 2-20

 Religion:Religion:
 Belief in divine or superhuman power, or powersBelief in divine or superhuman power, or powers
to be obeyed and worshipped as creator/ruler ofto be obeyed and worshipped as creator/ruler of
universeuniverse
 System of beliefs, practices, and ethical valuesSystem of beliefs, practices, and ethical values
 Shared experience of spiritualityShared experience of spirituality
Slide 2-21

 SocializationSocialization
 Process of being raised within a culture andProcess of being raised within a culture and
acquiring characteristics of that groupacquiring characteristics of that group
 Related terms:Related terms:
• Acculturation: process of adapting to and acquiringAcculturation: process of adapting to and acquiring
another cultureanother culture
• Assimilation: process of developing a new culturalAssimilation: process of developing a new cultural
identity and becoming like members of dominant cultureidentity and becoming like members of dominant culture
• Biculturalism: dual pattern of identification and often ofBiculturalism: dual pattern of identification and often of
divided loyaltydivided loyalty
Slide 2-22

 Time OrientationTime Orientation
 Focus on pastFocus on past
• Traditions and ancestors play important role in person’sTraditions and ancestors play important role in person’s
lifelife
 Focus on presentFocus on present
• Little attention paid to past or future; concerned with now,Little attention paid to past or future; concerned with now,
and future perceived as vague or unpredictableand future perceived as vague or unpredictable
 Focus on futureFocus on future
• Progress and change highly valued; person may expressProgress and change highly valued; person may express
discontent with both past and presentdiscontent with both past and present
Slide 2-23

Heritage AssessmentHeritage Assessment
 Indicators of heritage consistencyIndicators of heritage consistency
 Childhood occurred in country of origin orChildhood occurred in country of origin or
immigrant neighborhood of like ethnic groupimmigrant neighborhood of like ethnic group
 Extended family support of traditional activitiesExtended family support of traditional activities
 Frequent visits to old country or old neighborhoodFrequent visits to old country or old neighborhood
 Family home within ethnic community to whichFamily home within ethnic community to which
they belongthey belong
 Participation in ethnic cultural eventsParticipation in ethnic cultural events
 Raised in extended family settingRaised in extended family setting
Slide 2-24

Heritage Assessment (cont.)Heritage Assessment (cont.)
 Indicators of heritage consistency (cont.)Indicators of heritage consistency (cont.)
 Regular contact with extended familyRegular contact with extended family
 Name not anglicizedName not anglicized
 Educated in parochial schoolEducated in parochial school
 Social activities primarily with members of ethnicSocial activities primarily with members of ethnic
communitycommunity
 Knowledge of language and culture of originKnowledge of language and culture of origin
 Expresses pride in heritageExpresses pride in heritage
Slide 2-25

Health-Related BeliefsHealth-Related Beliefs
and Practicesand Practices
 Health-Related Behaviors Affected byHealth-Related Behaviors Affected by
ReligionReligion
 MeditatingMeditating
 Exercising/physical fitnessExercising/physical fitness
 Sleep habitsSleep habits
 VaccinationsVaccinations
 Willingness to undergo physical examinationWillingness to undergo physical examination
 PilgrimagePilgrimage
 Truthfulness about how patient feelsTruthfulness about how patient feels
Slide 2-26

and Practices (cont.)and Practices (cont.)
 Health-Related Behaviors Affected byHealth-Related Behaviors Affected by
Religion (cont.)Religion (cont.)
 Maintenance of family viabilityMaintenance of family viability
 Hoping for recoveryHoping for recovery
 Coping with stressCoping with stress
 Genetic screening and counselingGenetic screening and counseling
 Living with a disabilityLiving with a disability
 Caring for childrenCaring for children
Slide 2-27

and Practices (cont.)and Practices (cont.)
 Differing views of epilepsy:Differing views of epilepsy:
 Uganda: contagious, untreatableUganda: contagious, untreatable
 Greece: source of family shameGreece: source of family shame
 Mexican-American community: evidence ofMexican-American community: evidence of
physical imbalancephysical imbalance
 Hutterites: evidence of having endured trial byHutterites: evidence of having endured trial by
GodGod
Slide 2-28

Developmental CareDevelopmental Care
 Culture affects choices parents make forCulture affects choices parents make for
children regarding:children regarding:
 Presumed cause of illnessPresumed cause of illness
 First treatment triedFirst treatment tried
 Acceptability of treatments offered by cliniciansAcceptability of treatments offered by clinicians
 For older patients, culture is likely toFor older patients, culture is likely to
 Define their family responsibilitiesDefine their family responsibilities
 Affect their view and knowledge of health careAffect their view and knowledge of health care
systems used by dominant culturesystems used by dominant culture
Slide 2-29

Traditional Causes of IllnessTraditional Causes of Illness
 BiomedicalBiomedical
 Assumes cause and effectAssumes cause and effect
 Views the body as a machineViews the body as a machine
 Life can be divided into partsLife can be divided into parts
 Endorses germ theoryEndorses germ theory
 NaturalisticNaturalistic
 Forces of nature must be kept in balanceForces of nature must be kept in balance
 Embraces idea of opposing categories or forcesEmbraces idea of opposing categories or forces
• Yin and yang, hot and coldYin and yang, hot and cold
Slide 2-30

Traditional CausesTraditional Causes
of Illness (cont.)of Illness (cont.)
 MagicoreligiousMagicoreligious
 Supernatural powers predominate in area ofSupernatural powers predominate in area of
health and illnesshealth and illness
• Examples include voodoo, witchcraft, and faith healingExamples include voodoo, witchcraft, and faith healing
 Healing and cultureHealing and culture
 In addition to seeking help from health careIn addition to seeking help from health care
providers, patients may also seek help from folk orproviders, patients may also seek help from folk or
religious healersreligious healers
 Hispanics or American Indians may believe thatHispanics or American Indians may believe that
cure is incomplete unless healing of body, mind,cure is incomplete unless healing of body, mind,
and spirit are all carried outand spirit are all carried out
Slide 2-31

Traditional CausesTraditional Causes
of Illness (cont.)of Illness (cont.)
 Folk HealersFolk Healers
 Hispanic: curandero, espiritualista, yerbo, orHispanic: curandero, espiritualista, yerbo, or
sabedorsabedor
 Black: hougan, spiritualist, old ladyBlack: hougan, spiritualist, old lady
 American Indian: shaman, medicine woman,American Indian: shaman, medicine woman,
medicine manmedicine man
 Asian: herbalists, acupuncturists, bone settersAsian: herbalists, acupuncturists, bone setters
 Amish: braucherAmish: braucher
Slide 2-32

Transcultural Expressions ofTranscultural Expressions of
IllnessIllness
 Transcultural expression of painTranscultural expression of pain
 Expectations, manifestations, and management ofExpectations, manifestations, and management of
pain are all embedded in a cultural contextpain are all embedded in a cultural context
 Pain has been found to be a highly personalPain has been found to be a highly personal
experience, depending on cultural learning, theexperience, depending on cultural learning, the
meaning of the situation, and other factors uniquemeaning of the situation, and other factors unique
to the personto the person
 Silent suffering has been identified as the mostSilent suffering has been identified as the most
valued response to pain by health carevalued response to pain by health care
professionalsprofessionals
Slide 2-33

Illness (cont.)Illness (cont.)
 Culture-bound syndromesCulture-bound syndromes
 Condition that is culturally definedCondition that is culturally defined
• Some have no equivalent in a biomedical, scientificSome have no equivalent in a biomedical, scientific
perspectiveperspective
• Anorexia nervosa and bulimia are examples of culturalAnorexia nervosa and bulimia are examples of cultural
aspects of illness in dominant cultural population in Northaspects of illness in dominant cultural population in North
AmericaAmerica
Slide 2-34

 Culture and treatmentCulture and treatment
 First effort at treatment is often self-careFirst effort at treatment is often self-care
 Home treatment attractive for accessibility,Home treatment attractive for accessibility,
particularly for people from rural or sparselyparticularly for people from rural or sparsely
populated areaspopulated areas
 Home treatment may mobilize person’s socialHome treatment may mobilize person’s social
support network and provide a caring environmentsupport network and provide a caring environment
in which to convalescein which to convalesce
 Alternative or complementary interventions areAlternative or complementary interventions are
gaining recognition from health care professionalsgaining recognition from health care professionals
in health care systemin health care system
Slide 2-35

 Culture and disease prevalenceCulture and disease prevalence
 Disparity continues in deaths and illnessesDisparity continues in deaths and illnesses
experienced by racial and ethnic populationsexperienced by racial and ethnic populations
• Diseases are not distributed equally among all segmentsDiseases are not distributed equally among all segments
of populationof population
 Abnormal biocultural variations may be genetic orAbnormal biocultural variations may be genetic or
acquiredacquired
• Information about disease prevalence for racial andInformation about disease prevalence for racial and
ethnic groups provides focus for assessment regardingethnic groups provides focus for assessment regarding
increased probability that particular conditions may occurincreased probability that particular conditions may occur
• Nurses must be certain that they have gathered dataNurses must be certain that they have gathered data
needed to support or refute suspicionsneeded to support or refute suspicions
Slide 2-36

Steps to Cultural CompetenceSteps to Cultural Competence
 Understand one’s own heritage-based values,Understand one’s own heritage-based values,
beliefs, attitudes, and practicesbeliefs, attitudes, and practices
 Identify meaning of “health” to patientIdentify meaning of “health” to patient
 Understand how health care system worksUnderstand how health care system works
 Acquire knowledge about social backgroundsAcquire knowledge about social backgrounds
of patientsof patients
 Become familiar with languages, interpretiveBecome familiar with languages, interpretive
services, and community resources availableservices, and community resources available
to nurses and patientsto nurses and patients
Slide 2-37

Cultural Care NursingCultural Care Nursing
 Cultural care nursing is goal to strive forCultural care nursing is goal to strive for
 It is a long trajectoryIt is a long trajectory
Slide 2-38

RESPECTRESPECT
 RRealize you must know heritage of yourself andealize you must know heritage of yourself and
patientpatient
 EExamine patient within cultural contextxamine patient within cultural context
 SSelect simple questions and speak slowlyelect simple questions and speak slowly
 PPace questioning throughout examace questioning throughout exam
 EEncourage patient to discuss meaning of healthncourage patient to discuss meaning of health
and illness with youand illness with you
 CCheck patient’s understanding and acceptance ofheck patient’s understanding and acceptance of
recommendationsrecommendations
 TTouch patient within boundaries of his or herouch patient within boundaries of his or her
heritageheritage
Slide 2-39

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