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Cultural Competency for the Healthcare Professional

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Contact Hours: 3

This educational activity is credited for 3 contact hours at completion of the activity.

Course Purpose   

To provide an overview of cultural competency and a review of assessment tools and federal laws to help healthcare professionals provide culturally and linguistically competent healthcare services.

Overview 

Although there has been improvement in the overall health of people living in the United States, incidences of illness and death among minorities and the disabled continue. As such, healthcare organizations are recognizing the need to improve services for culturally and linguistically diverse populations. To do so, organizations and their healthcare professionals must understand cultural competence to provide culturally and linguistically appropriate healthcare services.

Objectives

Upon completion of the independent study, the learner will be able to:

  • Define cultural competence
  • Summarize various assessments and tools to help improve culture within an organization 
  • Attribute how biases and stereotypes in various subgroups can influence the care received by patients within those groups
  • Review federal laws that relate to healthcare provided to disadvantaged populations
  • Recognize how personal history, values, and beliefs can influence perceptions of communication abilities and patterns

Policy Statement   

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.  If you want to review our policy, click here.

Disclosures  

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.  

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Definitions
CompetenceHaving the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs of a given community.
CultureThe integrated patterns of thoughts, communications, actions, customs, beliefs, values, and institutions are associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as religious, spiritual, biological, geographical, or sociological characteristics.
Cultural BlindnessAn organization that provides services with the expressed philosophy of being unbiased, and functions with the belief that color or culture makes no difference and that all people are the same.
Cultural CompetencyAcceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to service models, where healthcare professionals can effectively use their cultural knowledge during interviewing, assessment, and treatment.
Cultural DestructivenessAttitudes, policies, and practices are destructive to cultures and consequently to the people within the culture.
Cultural IncapacityOccurs when organizations and healthcare professionals do not seek to be culturally destructive but lack the capacity to help people of various cultures.
Cultural Pre-CompetenceOccurs when there is an awareness and an attempt to improve services to a specific population, and where healthcare professionals are aware of perceptions, values, and other elements of their own culture and of cultures different from their own.
Cultural ProficiencyOrganizations hold culture in high esteem and attempt to add to the knowledge base of culturally competent practice by conducting research, developing new therapeutic approaches based on culture, and publishing and disseminating the results of demonstration projects. In this stage, healthcare professionals lead cultural competence in practice by training others in cultural competence, recruiting personnel from diverse cultures, and conducting research that adds to the knowledge base.
Introduction

Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes, which can be used in appropriate cultural settings to increase the quality of care provided.

Cultural competence requiresā“:

  • An organization and healthcare professional have a defined set of values and principles and demonstrate behaviors and attitudes that enable them to work effectively cross-culturally.
  • An organization and healthcare professional to have the capacity to value diversity, conduct self-assessment, manage the dynamics of difference, acquire, and institutionalize cultural knowledge and adapt to diversity within the communities they serve.
  • An organization and healthcare professional to incorporate the above in all aspects of policymaking, administration, practice, service delivery, and involve systematically consumers, key stakeholders, and communities.

Principles of cultural competence includeĀ¹: 

  • Define culture broadly
  • Facilitate learning between healthcare professionals and communities
  • Normalize cultural competence
  • Involve the community in defining and addressing service needs
  • Professionalize staff hiring and training
  • Recognize complexity in language interpretation
  • Value a patientā€™s cultural beliefs

Cultural assumptions and stereotypes may be based on the following: 

Age Color Disability 
Education level Ethnicity Family structure 
Gender Identity Health practices Language and dialect 
Moral values and convictions National origin Occupation 
Perspective on diet and nutrition Perspective on family and community Physical ability and limitations 
Political beliefs Race Religious beliefs and practices 
Sex Sexual Orientation Socioeconomic status

The goal of cultural competence in healthcare is to have improved quality of care. ā“ It is suggested that using cultural competency in a focused or strategic way can be a helpful adjunct implemented by a healthcare professional who can help the quality improvement process within an organization. For example, if an organization wants to analyze a pattern of missed appointments, it might examine variables such as age, gender, race/ethnicity, or disability. If the analysis reveals that the hearing-impaired patients have the highest rate of missed appointments, the organization can target specific strategies to this group to improve outcomes. 

Cultural Assessment

Culture assessment is used to diagnose an organizationā€™s current and desired culture. It includes analyzing an organizationā€™s experiences, expectations, and philosophy, as well as the values that guide the healthcare professionalā€™s behavior within an organization. In a workplace, culture is based on attitudes, beliefs, and rules that have historically been in place. Culture also includes an organizationā€™s vision for itself and for the healthcare professionals who are associated with it. 

Unfortunately, most of us are not even aware of our organizationā€™s culture, or how culture represents ā€œnormal behavior.ā€ Culture equates to collective assumptions, expectations, and values that reflect explicit and implicit rules in an organization. ā· Until challenged or violated, most healthcare professionals are not even aware that these assumptions and rules exist, for example, when speaking a language other than English around English-speaking staff members. As a result, it is exceedingly difficult to intelligently discuss culture, and even more, try to change it.

The Competing Values Framework (CVF)Ā¹ā° is a widely recognized framework for culture assessment. It originated from research that focused on how to make organizations more effective in analyzing and evaluating culture. The CVF is not merely a conveniently created instrument, but rather, an integrated array of assessment devices aimed to help enable and enhance consistent and comprehensive improvement.

The CVF consists of four quadrants:

  • The Collaborate Quadrant 
    • The Collaborate quadrant represents the kinds of people, purposes, and processes that give rise to cooperation and collaboration. Healthcare professionals in the Collaborate quadrant tend to be committed to their community, focusing on shared values and communication. Their culture is oriented towards involvement and building commitment over time. 
  • The Create Quadrant 
    • The Create quadrant represents the kinds of healthcare professionals, purposes, and practices that are associated with creativity, innovation, and vision. Individuals with this perspective tend to be change-oriented. The culture that supports their work is characterized by experimentation, flexibility, and looking forward to the future. 
  • The Compete Quadrant 
    • The Compete quadrant represents the kinds of healthcare professionals, purposes, and practices that are associated with aggressive competition and achievement. A focus on achieving results leads to defining winners and losers. tend to be People in this quadrant are focused on performance and goals.
  • The Control Quadrant 
    • The Control quadrant represents the kinds of healthcare professionals, purposes, and practices that give rise to predictable, dependable performance. People in the Control profile tend to be systematic, careful, and practical. Their culture focuses on planning, efficient systems and processes, and enforcing compliance.

An advantage of the CVF is that it is based on a well-developed theoretical and empirical foundation. A great deal of research has been produced to validate the CVF and its applications. Healthcare professionals who take the assessment, as well their organizations who receive the data on their attributes can link their results to other well-developed approaches to improvement. Most importantly, the empirical research conducted by scholars in hundreds of organizations, coupled with the hundreds of interventions in real organizations that have utilized the Competing Values Framework, provide a rich array of guidelines and prescriptions for how to improve individual and organizational performance. 

In addition to the CVF that focuses on the culture of an organization, healthcare professionals should utilize a cultural assessment that focuses on patient care. There are a variety of assessment guides that can be used for patient interviews to facilitate understanding and communication. The Four Cs of Culture modelā“ is a commonly used patient centered cultural assessment tool. The Four Cs of Culture model asks questions about what the patient:

  • Considers to be a problem
  • Cause of the problem
  • Coping abilities with the problem
  • Concerns about the problem

 Sample questions to ask a patient during a cultural assessment may include:

  1. Where were you born? Where were your parents born?
  2. What pronoun do you use (he, she, they)?
  3. In what language are you most comfortable speaking and reading?
  4. Did you grow up in a city or a town or a rural setting?
  5. When you were growing up, who lived with you and your family?
  6. Are your friends from the same cultural background as you?
  7. What is your religious preference?
  8. Do you have any dietary preferences related to your religious or cultural beliefs?
  9. In your culture, how do you celebrate the birth of a baby? A wedding?
  10. When a woman is pregnant, are there any special customs she needs to follow? Any special foods?
  11. When someone in your family is ill, who cares for them? What foods are prepared? Is there anything the ill person should avoid or refrain from doing?
  12. What home remedies might be used if someone is ill?
  13. As a family member is approaching death, what actions do you find comforting?
  14. After a loved one dies, what rituals are performed?
  15. What do you think a nurse should know about your culture if a family member is hospitalized?
  16. Who makes the decisions in your family?
  17. How are elders viewed in your culture?
  18. Are there any special beliefs regarding organ donation or blood transfusions that are held in your culture?
  19. Is your culture known for any special customs (e.g., rites of passage, foods, holidays, etc.)?
Special Considerations

Age

Ageism is the specific use of negative language and derogatory images to discriminate against a certain population group. Ā¹ For instance, an image of an older man with a walking cane may symbolize an elderly man with a disability, when in fact, that is not the case. These images can shape our socially accepted beliefs and attitudes regarding aging, especially after repetitive use in movies, television, stories, and advertisements. These images of aging and the notion of being sick or frail depict unpleasant ideas of growing old. The images also emphasize thoughts of physical fitness among the young and becoming a dependent and monetary burden when older.

Thoughts and images of aging that have perpetuated across time tend to categorize older adults as either dependent or capable. These beliefs have the power to shape the policies of an organization and the responses of its healthcare professionals towards the aging. Imagery and negative stereotypes are impactful, and ageism has direct implications on the lives of older adults. The following influences of negative stereotypes may perpetuate in the following areas and result in inappropriate behaviorĀ¹:

  • Family Life – Attitudes that older adults are a financial burden to family members; feelings of being demoralized and marginalized or patronized.
  • Ongoing Employment – Difficulty in hiring and maintaining employment, experiencing job displacement and the lack of job promotion, including views that older adults are unwilling to change their behaviors or ideas.
  • Health Care – Limitations in available physician services caused by the lack of interest and difficulty in treating complex health conditions, avoidance by physicians due to complexities with Medicare, and overall devaluation of concerns. 
  • Public policy – Sentiment that older adults are a social burden. 

Exposure to negative images of aging and policies that support stereotypes of the aging population ignore the capacity and contribution of older adults. These organizational policies should instead focus on the aging personā€™s health and independence. To support the change in culture, the organization should be encouraged to do the following, which will influence the behaviors of the organizationā€™s healthcare professionals: 

  • Consider the evidence used to make policy decisions 
  • Consider their duty to safeguard the rights of all individuals, including the aging population
  • Pro-active behavior to ensure equitable policy outcomes 
  • Understand how images shape views and beliefs 

Children

Cultural competency is an important component in early childhood development. It is important that children learn how to respect and accept others with different backgrounds and cultures, which can prevent implicit bias, discrimination, and prejudices later in life. The best way for children to model cultural competency is through emulation of adults, including parents and educators who exhibit cultural competency and inclusion. Children as young as three years old are aware of differences such as disability, ethnicity, and gender and can begin to internalize biases that are reflective of their family, community, and school. At home, parents can promote cultural competency and inclusion by:

  • Doing activities such as skin color matchups with flesh-colored crayons
  • Purchasing dolls and toys that depict children from a variety cultural background
  • Reading books that celebrate cultural diversity
  • Including children in preparing and trying new foods
  • Talk about different celebrations and holidays around the world

When discussing cultures that are different, it is important to be mindful of how those differences are viewed. For instance, children who are taught by culturally competent teachers are more likely to feel accepted, as well as develop a positive view of themselves and their families. In addition, these same children are also more likely to be accepting and empathetic toward other children and exhibit good social behaviors. This is extremely important, because research suggests that a childā€™s early social-emotional skills are predictive of their social-emotional skills later in life.
In addition to being inclusive through acceptance and empathy of others, a child must also feel safe and included. This can be achieved by encouraging a childā€™s self-expression and general curiosity about their environment and the people in it, such as:

  • Ensuring reading materials and written words that are in the childā€™s first language
  • Talking, eating, and singing songs from various cultural traditions, including the childā€™s own culture
  • Acknowledging celebrations and traditions from various cultures
  • Show pictures and read books that responsibility reflect diversity

An adult should never make assumptions about a child or their family because stereotyping can be very harmful. Instead, an adult should encourage a childā€™s learning about another culture and create a safe space for them to be open-minded to differences as something to be celebrated not something to be overcome.

Disability (Language)

Linguistics refers to language. Linguistic competence is the capacity of an organization and its healthcare professionals to communicate effectively and in a manner that is easily understood by diverse groups including people with limited English proficiency, those who have low literacy skills or are not literate, those who are disabled, and people who are deaf or hard of hearing. Ā¹Ā² Effective use of language is important to understand a patientā€™s needs and ensure that the patient understands the healthcare professional. To improve linguistic competence, the organization should have policies, practices, procedures, and dedicated resources for support. These requirements may include, but are not limited toĀ¹Ā²:

  • Bilingual/bicultural or multilingual/multicultural healthcare professionals
  • Computer assisted real time translation or viable real time transcriptions 
  • Cross-cultural communication approaches
  • Foreign language interpretation services 
  • Materials developed and evaluated for specific cultural, ethnic, and linguistic groups
  • Materials in alternative formats, such as audiotape, braille, and enlarged print 
  • Multilingual telecommunication systems
  • Print materials in easy to read, low literacy, picture, and symbol formats
  • Sign language interpretation services
  • Translation services
  • TTY and other assistive technology devices
  • Varied approaches to share information with individuals who experience cognitive disabilities
  • Videoconferencing and telehealth technologies

Military

Military cultural competence pertains to a healthcare professionalā€™s attitudes, understanding, and behaviors when working with service members and veterans. This form of cultural competence originated from the medical care of wounded members in battlefields, field hospitals, and military hospitals. ā· Following the Vietnam War, military veterans experienced increased incidences of mental health disorders, substance use disorders, suicide, and homelessness, however, there was a shortage of civilian healthcare professionals who understood the military culture and could care for the military veterans. For instance, 99% of counties within the United States had residents that deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Of those service members, 70% sought care in civilian communities and 40% of National Guard members met the criteria for a mental health disorder, however, less than 30% of civilian healthcare professionals were knowledgeable on how to refer military veterans to the Veterans Administration (VA) hospital system. The military has a unique language and organizational structure and its impact on the overall health and well-being of military veterans makes it difficult for civilian healthcare professionals to provide effective treatment. The military culture identifies three factors that establish it as a separate form of culture: 

  • The first is a hierarchical chain-of-command organizational structure, where each memberā€™s place in the military has behaviors, status, authority, and responsibility. 
  • The second is the norms of the military as a cultural group such as the beliefs and values (honor, integrity, commitment, loyalty, respect, and devotion to duty), traditions, behaviors, and events that occur during military service.
  • The third is the military identity where service members must obey military laws, norms, and rules of conduct even when not in uniform, and must maintain both a physical and psychological status of combat readiness, as they may be called to duty at any time. 

Essentially, service members have little to no situations where they can be free of their military identity and norms. To meet the needs of active service members and veterans, the following is suggested:

  • Recognize that the military is a culture that can impact service members and their perceptions of illness and treatment.
  • Screen for military service by asking about each patient’s military status to begin to learn how a patientā€™s illness is impacted by it.
  • Remember military culture will impact veterans as they integrate back into society and that it is still a part of their identity that needs to be assessed.
  • Consider the military context of symptoms and related illnesses, both behavioral and physical, and provide appropriate referrals and other resources when necessary.
  • Understand that the stigma of not being tough enough or being weak can lead members of the military to downplay illness.
  • Be aware of the impact service-related injuries, such as traumatic brain injuries and post-traumatic stress disorder have on mental and physical health.
  • Military sexual trauma (MST) is a common problem reported by 7% of women and 2% of men, although the actual numbers are estimated to be much higher.
  • Combat exposure can increase the risk for social seclusion, criminal behavior, homelessness, self-harm, substance misuse, unexplained medical complaints, and mental illness. 

Race and Ethnicity

The concept of cross-cultural medicine emerged in the 1970s after insight surrounding cultural and linguistic barriers to healthcare. These healthcare disparities reached far beyond immigrant populations and were noted to include racial and ethnic minorities. Race is described as a population of people that is believed to have distinct differences from other people based on physical differences such as skin color or facial characteristics, while ethnicity refers to social traits that are shared by a population of people, including nationality, tribe, religious faith, shared language, and shared culture.Ā²Ė’Ā¹ā“ Common race and ethnicity categories are as follows:

Native Hawaiian or Other Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Black or African AmericanA person having origins in any of the Black racial groups of Africa.
WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Nonresident alienA person who is not a citizen or national of the United States and who is in this country on a visa or temporary basis and does not have the right to remain indefinitely. Note: Nonresident aliens are to be reported separately in the places provided, rather than in any of the racial/ethnic categories described ab
Hispanic or LatinoA person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
American Indian or Alaska NativeA person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.
AsianA person having origins in any of the original peoples of East Asia, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Race/ethnicity unknownThe category used to report students or employees whose race and ethnicity are not known.
Resident alien (and other eligible non-citizens)A person who is not a citizen or national of the United States but who has been admitted as a legal immigrant for the purpose of obtaining permanent resident alien status and who holds either an alien registration card, a Temporary Resident Card, or an Arrival-Departure Record with a notation that conveys legal immigrant status.

The healthcare professionalā€™s views of race, ethnicity, and cultural competence have continued to evolve through understanding of the social, structural, and economic impacts to health disparities among minorities. For instance, studies have revealed a positive correlation between perceived racism, illness, and poor healthcare among minorities, however little is known about the extent of racism amongst healthcare providers, or exactly how to measure it. 

Personally mediated racism includes underlying (often unacknowledged) prejudices of a healthcare provider that causes them to treat others differently based on race or ethnicity, which can have negative clinical consequences. Ā¹ā“ An example of this would be a healthcare professional who disregards an Asian maleā€™s complaint of chest pain because he doesnā€™t ā€œlook ā€œlike he is in pain, based on the stereotype that all Asians are strong, stoic, and have high pain thresholds. Not providing adequate assessment, pain relief, and care to a patient could have dire consequences.

Individual level racism can manifest as omissions of care or failure to convey a welcoming environment, such as not acknowledging a new patient upon arrival, or refusing to order a test because of the perceived economic status of a minority patient in need of care. 

There are various reasons why racial and ethnic disparities exist in healthcare. Most notably is low socioeconomic status, as minorities are more likely to be unemployed, be undereducated, and to have lower salaries and live in poorer conditions than the nonminority population. These conditions are positively correlated with poorer access to healthcare services and poorer health outcomes. Interestingly, even minorities who are not socioeconomically disadvantaged have different healthcare experiences than the nonminority population. 

To improve cultural competence when caring for the minority population, healthcare professionals should consider interventions to improve patient/healthcare professional relationships, improve communications skills, and allow for collaborative decision making as it relates to patient care.

Religion and spirituality are important factors in many patients seeking care. Although they are important, healthcare professionals may not consider religious and spiritual beliefs when confronted with difficult health-related decisions regarding patients. 

Healthcare professionals must understand that many patients rely on their religious and spiritual beliefs when making medical decisions. These beliefs can impact a patientā€™s decisions regarding diet, medicines, modesty, and the preferred gender of their health providers. In addition, some religions have strict prayer times that may interfere with medical treatment. It is important for healthcare professionals to recognize and make accommodations for a patientā€™s religious and spiritual needs by tailoring the patientā€™s treatments, as necessary. The following is a list of the religious and spiritual groups most encountered in a healthcare environment. Ā¹Ā¹

ReligionDescriptionBeliefsRitualsClinical Considerations
Bahaā€™i Teaches the essential worth of all religions and the equality and unity of all peopleAbandonment of all prejudice: race, religion, gender, or community

Education for all children

Abolition of extreme wealth and poverty

Individual responsibility to search for the truth 

The oneness of God, the unity of humanity, and the essential harmony of religion

Religion is a divine revelation that is continuous and progressive. 

Religion and science exist in harmony.

Sexual equality is a spiritual and moral standard.

Humanityā€™s oneness and the wholeness of human relationships

Unity among diverse groups is possible

God is in every force in the universe.

One God has a single plan within the teachings of the major world religions.

The promise of world peace
Daily private prayer and annual fast lasting throughout the day from sunrise to sunset during the month of Ala from March 2 through March 20. Avoid sterilization procedures unless needed for the preservation of the mother.

Believe prayer assists in healing; allow uninterrupted time for prayer.

Believe a balanced and nutritious diet helps prevent disease.

Blood transfusion acceptable.

Will most likely avoid birth control.
Buddhism Encompasses a variety of beliefs, spiritual practices, and traditions based on original teachings.Buddhists follow the path to enlightenment by developing wisdom, morals, and meditation.

Personal insight replaces belief in God with the study of the laws of cause and effect, karma. 

Spiritual enlightenment through conscious living and meditation. 

Rebirth is based upon the actions of a person, and insight and the extinguishing of desire bring freedom.

Three major Buddhist traditions: Mahayana, Theravada, and Tibetan.

5 Lay Vows: no intentional killing, no stealing, no lying, no sexual misconduct, and no intoxicants
Ceremony around baby blessings, marriage, and death. 

Monthly atonement ceremony on the full moon.
Acceptable to use blood products.

Avoid mind-altering drugs.
Christian ScienceTeaches that sickness can be healed by prayer alone.The Christian Science church was founded to commemorate the word and works of our master Jesus Christ which should reinstate primitive Christianity and its lost element of healing.

Christian Scientists rely on consecrated prayer to God, the eternal good, and rooted in a faith lifted to spiritual perception, as a practical and reliable method to care for all human needs, including their health.
Church services are simple and Bible-centered. 

Patients might appreciate church services, weekly topical Bible lessons, or church periodicals. 

Members typically pray and study the Bible and other religious teachings daily.

Simple communion service and a special Thanksgiving Day service.

Christmas and Easter have deep spiritual meaning. 
Christian Scientists and their children have often availed themselves of religious belief accommodations for vaccination, but the choice is individual, and members are encouraged to comply with applicable public health laws.

They are taught not to fear vaccines.

Usually do not seek immediate medical care.

They may prefer no, or minimal, medical intervention and drugs during pregnancy, labor, and birth, and they may request a midwife. 

Christian Science members have a preference against graphic descriptions of the severity, dangerousness, illness including matters of mental health.
Church of Jesus Christ of Latter-day Saints (Mormon) Mormons are a religious group of the Latter-Day Saint movement of Restorationist Christianity. They dedicate time and resources to serving in the church.The building of temples where personal and sacred covenants can be entered into with the Lord. 

Daily Prayer and reading of Scriptures. 

Jesus Christ is the Firstborn of God. 

Members are spiritual daughters and sons of a living Father in Heaven. 

They are family-oriented and believe that families are connected after death.

Mormons require abstention from sexual relations outside marriage.

Mortality on earth is a probationary period to evaluate to see if members will obey the Lordā€™s commandments given through current and ancient prophets.
Blessing and naming of children. 

Family home evenings once a week. 

Two elders are required for the blessing of the sick.
May avoid drugs containing alcohol and caffeine.
Eastern OrthodoxThe Eastern Orthodox Church teaches the One, Holy, Catholic, and Apostolic Church was established by Jesus Christ.A personā€™s communion with God is expressed in love; where there is no love, God is absent, and no spiritual life exists.

All are saved through Christā€™s death and resurrection, are still being saved through participation in the church, and will be saved again in the future second coming of Christ.

Christ is the Son of God, both fully divine and fully human, and the Holy Spirit enables humanity to apprehend Godā€™s presence in the world.

God reveals Himself in the Bible as living and present.

The Nicene Creed is recited at every Divine Liturgy.

In the Orthodox view, the Trinity is three persons, one in essence and undivided. 

The veneration of Mary is referred to as the God-bearer as she carried the New Covenant in the person of Christ. 

Consecration invoked by a priest that bread and wine become the body and blood of Christ.
The focus of the liturgy is the blessing and receipt of Holy Communion.

Worship is liturgical and structured, with chanted hymnody, iconography, and incense. 
No significant clinical issues
HinduismHinduism is one of the worldā€™s oldest religions, with roots and customs dating back more than 4000 years.An attitude of mutual tolerance and belief that all approaches to God are valid. 

Duties to God, parents, society, and teachers. 

Future lives are influenced by how one faces disability, illness, or death. 

Goal to break free of an imperfect world and reunite with God. 

Pain and suffering are seen because of prior actions, namely karma. 
Must be barefoot during religious worship

Must sit at a lower elevation than where the deity image has been placed.

No formal hierarchical structure

Not a church-based religion

Praying, meditating, recitation, and scripture reading

Special respect for elders

A supportive environment and privacy for rites

Ten to eleven days after birth, the priest performs the naming ceremony.
No clinical issues that inhibit healthcare.
IslamThe followers of Islam are Muslims who believe in one God, Allah, and his prophet Abraham. Complete submission to GodJudgment day

Life after death

Muhammad Godā€™s messenger

Required to pray 5 times a day

Give 2.5% to a charitable cause once each year.

Oneness of God, his angels, scriptures, and messengers

Pilgrimage to Mecca is required at least once in their lifetime.

Ramadan is a month-long fast of drink, food, and no sexual intercourse during daylight.

Reward and punishment

The Quran is the final revelation of humanity.

One God, Allah
Fridays are the Holiest Day for Muslims, and they have a noon prayer.

Days of observance occur throughout the Muslim lunar calendar.

Celebration of the Sacrifice of Abraham is a three-day celebration beginning on the 10th day of the 12th month.

Celebration of the Fast-Breaking is held on the first day of the 9th of the lunar calendar.

Prayer 5 times a day facing Mecca (dawn, midday, mid-afternoon, sunset, night)

Ramadan is during the ninth month of the Islamic lunar calendar and lasts 29 or 30 days, depending on the year.

Wash face, hands, and feet before prayer.
Find the same-sex practitioner if not an acute emergency.
Jehovahā€™s WitnessThe destruction of the present world system is imminent, and the establishment of Godā€™s kingdom over the earth is the solution for all problems faced by humanity.The world will be restored to a state of paradise; beneficiaries of Christ will be resurrected with healthy physical bodies and inhabit the earth.

Do not give gifts on holidays and do not recognize birthdays or national holidays.

God is the Father, and Jesus Christ is his son.

The Holy Spirit is Godā€™s motivating force.

Reject the doctrine of the Holy Trinity.

Do not salute the national flag or sing the national anthem and refuse military service. 
Adult baptism

Shunning of those who fail to live by the groupā€™s standards and doctrines
Refuse all blood products
Judaism Judaism is the expression of the covenant that God established with the Children of Israel.One all-powerful God who created the universe

God communicated the commandments to Moses on Mount Sinai, and they are written in the Torah.

Commandments, commitments, duties, and obligations have priority over individual pleasures and rights.

Sanctity of life overrides religious obligations.

Orthodox Jews: Strict interpretation of the Torah.

The Torah is divine and unalterable. Following the code of Jewish Law

Conservative Jews: Modern and traditional religious observances accepted.

Reform Jews: Choose religious observances and freedom to interpret the Torah
Lighting candles before Holidays and SabbathSynagogue attendance.Kosher food

Require saving of amputated limbs
Native American SpiritualityTheology may be animistic, monotheistic, henotheistic, polytheistic, or some combination thereof. Traditional beliefs are passed down in the form of oral histories.A basic sense of community

Fundamental inter-connectedness of all-natural things ā€“ life, land, and Mother Earth

Passed down by storytelling

Use ā€œGodā€ and ā€œCreatorā€ interchangeably.

Daily Practices 

Prayers often include sacred objects.
Prayer accompanied by the burning of cedar, sage, sweetgrass, or tobacco. 

Seeing and understanding a vision of clarity for oneself. 
No clinical issues that inhibit healthcare. 
Protestant Protestants emphasize justification by faith alone rather than by good works and the highest authority of the Bible alone in faith and morals.Community worship is important.

Emphasis on the Holy Bible and Scriptures Jesus of Nazareth is the son of God.

Two Sacraments: Baptism and Communion.
Anointing, prayer, Eucharist, and other rituals

Prayers for healing, individual prayer, and the Sacraments
No clinical issues that inhibit healthcare
Rastafarian Movement A monotheistic belief in a single God, Jah, who partially resides within each person.African civilization and culture are superior.

Being as close to nature as possible.

Dream of returning to Africa.

Follows the Old Testament.

Jah is the Messiah promised in the Bible.

Love and respect for all living things.

One God, Jah, the former emperor of Ethiopia, incarnated.

Spiritual use of marijuana

Believe in everlasting life; may not talk about terminal illness or impending death.
Dancing, singing, and marijuana use

Old Testament readings
Maybe mistrusting of medications or drugs that contain alcohol.
Roman CatholicismThe Catholic religion teaches that it is the One, Holy, Catholic, and Apostolic Church founded by Jesus Christ, its bishops are successors of Christā€™s apostles, and the Pope is the successor to Saint Peter to whom Jesus Christ conferred primacy.Belief in Apostolic leaders that are male successors of the original apostles of Jesus

Dedication to creeds

Emphasis on sacraments including baptism, confession, confirmation, Eucharist, holy orders, penance, prayers for the ill, and marriage

A strong tradition of liturgy
Attending Mass on Sunday and Holy Days, optional daily

Lighting candles

Observing sacraments

Praying the rosary beads to aid in prayers 
May request saving of amputated limbs 
ScientologyScientologyā€™s beliefs and practices are based on rigorous research, and its doctrines are accorded an equivalent to scientific laws.Adherents are encouraged to validate the practices through their own experience.

It aims to create a society without insanity, criminals, and war, where the world prospers, and honest beings can have rights, and where a man is free to rise to greater heights. 
Congregations celebrate weddings, naming and marking the passing of their fellows with funeral rites.

Each Sunday, public worship service is open to both members and non-members of the Church.

Services comprise a recitation of the Creed of Scientology, sermons, congregational auditing, and prayer. 
A Scientologist with a physical condition will usually seek and obtain examination and treatment by a qualified medical professional.
Seventh-day AdventistThe Seventh-day Adventist Church is a Protestant Christian that observes Saturday, the seventh day of the week in Christian and Jewish calendars, as the Sabbath. The religion also emphasizes the imminent Second Coming of Jesus Christ. Bible is interpreted literally. 

The body is the temple of God and must be kept healthy. 

Duty to warn others to prepare for the second coming of Christ. 
An ill person is anointed with oil; elders and Pastors and elders may pray. May require a special restricted diet.
Sikhism The fundamental belief is faith and meditation in the name of one creator, unity of all humankind, engaging in selfless service, striving for social justice, and honest conduct.All people are equal. 

God is eternal, formless, and unobserved.

God is the supreme Guru, guide, and teacher.

The ideal life is charity, work, and worship.

Reincarnation is a cycle of rebirth. 

Salvation is achieved through disciplined meditation and union with God. 

Salvation is liberation from the cycle of rebirth. 

There is a tension between Godā€™s sovereignty and human free will. 
Meet as a congregation for prayer service on six holidays.

Morning and night private worship following the 10 Sikh gurus and the Holy Scriptures
Hair removal may be an issue for surgery.
Voodoo The Voodoo religion is elaborate, steeped in secret languages, spirit-possessed dancing, and special diets that are usually eaten by the voodoo priests and priestesses. All creation is considered divine and contains the power of the divine.

Ewe asks for help and change. 

Ewe rule the world and decide the fate of everything. 

One God, Bondye, and other spiritual beings, called Ewe
Animals are sacrificed to thank the spirits. 

Ceremonies include animal sacrifice, drums, and dancing. 

Ceremonies may be held in secret. 
Maybe mistrusting of modern medicine.
WiccaWicca is a neo-pagan, earth-centered belief.Concern for ecological issues.

Consecrated items should not be removed or handled by anyone but the wearer. 

Multiple gods and goddesses

No action occurs without significant repercussions throughout the world, eventually affecting the original actor (Law of Nature).

Pre-Christian civilization worship practices.

The principal deity is Mother Nature.
The full moon is a time of great magical energy.


Rituals are a large part of the faith.
Maybe mistrusting of modern medicine.

Understanding the values and reasons for special requests for healthcare will improve cultural competence and provide culturally sensitive health care that is good for the patient.

The religion of a patient will likely guide their opinions on the healthcare system and healthcare professionals, and as such, healthcare professionals must understand a patientā€™s beliefs to provide culturally sensitive healthcare. The following are recommendations to help the healthcare professional to provide culturally competent careāµ:

  • Apologize for cultural mistakes
  • Avoid being judgmental
  • Avoid making assumptions 
  • Be aware of the uniqueness of religion and special needs
  • Be respectful
  • Observe body and facial language
  • Recognize how values, behaviors, and beliefs may affect others
  • Train staff about cultural competence
  • Use medically competent and fluent interpreters with training in cultural competence

The diversity of religions around the world creates challenges for healthcare professionals and organizations to provide culturally competent medical care. Culturally competent care can improve patient quality and care outcomes. Strategies to move health professionals and systems towards these goals include providing cultural competence training and developing policies and procedures that decrease barriers to providing culturally competent patient care.

Sexual Orientation

Caring for members of the lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) community involves understanding the community and avoiding unconscious and perceived biases. Historically, members of the LGBTQ community have experienced a lot of challenges, and health professionals must become aware of these challenges, and provide compassionate, comprehensive, and high-quality care. Ā³ 

Members of the LGBTQ community include all races, ethnic and religious backgrounds, and socioeconomic status, and consist of two distinct features: gender identity and sexual orientation.

Gender identity describes identifying with a sex other than the one assigned at birth, whereas cisgender describes identifying with the sex given at birth.ā¶ The term transgender includes gender identity and can include non-binary; a gender identity that is not exclusive to males or females.

Sexual orientation for gay and lesbian people involves being attracted to people of the same sex, opposite of heterosexuals, who are attracted to people of the opposite sex. Sexual orientation is an identity label and sometimes does not correspond to a personā€™s sexual behavior.

The healthcare needs of the LGBTQ community should be considered to provide the best care and avoid inequalities of care. When obtaining a history, healthcare professionals should ask about gender identity and sexual orientation to better understand a patientā€™s health risks.

When evaluating a patient, the healthcare professional should use non-gendered words and evaluate how the patient describes themselves, and their relationships. They should not assume gender or sexuality.ā¶ For example, a transgender couple may prefer to be described as a same-gender couple and not a straight couple. People in a relationship who have non-binary genders may prefer the term partner. The following is a list of terms in the LGBTQ community:

Androgyny (gender fluid, gender neutral)In between genders, having both male and female characteristics.
Asexual Individuals that do not experience sexual attraction.
Bisexual (pansexual queer) Individuals that are attracted to both males and females.
Cisgender Denoting or relating to a person whose sense of personal identity and gender corresponds with their birth sex.
Cissexism Prejudice or discrimination against transgender people.
Coming out Sharing gender identity publicly.
F2M/FTM (female to male) Female at birth but identifies as a male.
Gay Identify gender as male but are attracted emotionally, erotically, and sexually to other males.
Gender Emotional, psychological, and social traits describe an individual as androgynous, masculine, or feminine.
Gender attribution Process in which an observer assigns the gender they believe an individual to be.
Gender binary Belief that individuals must be one of two genders, male or female.
Gender expression Individual appearance, behaviors, dress, mannerisms, speech patterns, and social behavior associated with femininity or masculinity.
Gender identity Personal sense of gender that correlates with individually assigned sex at birth or can differ from it.
Gender nonconformingGender behaviors that are in between feminine or masculine binaries.
Gender role Traditional behaviors, characteristics, dress, mannerisms, roles, and traits associated with being male or female.
Genderqueer Individuals that identify themselves as both feminine and masculine.
Hermaphrodite A no longer acceptable way of describing intersex individuals.
Heterosexism Discrimination against gay individuals based on the belief that heterosexuality is the normal sexual orientation.
Heterosexual Individuals attracted to members of the opposite sex.
Homophobia Prejudice against the gay community.
Homosexual Individuals attracted emotionally, erotically, or sexually to members of their own sex. This term has been replaced with lesbian, gay, bisexual, transgender, or queer
In the closet Hiding individual gender identity.
Intersex Individuals born with sexual characteristics that are not typical of male or female binary notions.
Lesbian Females that are emotionally, erotically, or sexually attracted to females.
LGBTQ Individuals that are lesbian, gay, bisexual, transgender, or queer.
M2M/MTF (male to female) Male at birth but identifies as a female.
Men who have sex with men (MSM) Males who participate in sexual relations with other men regardless of sexual orientation.
Queer A general term refers to lesbian, gay, bisexual, transgender, and queer individuals, sometimes considered derogatory.
Questioning Individuals uncertain of their gender identity and sexual orientation.
Same gender lovingBisexual, gay, and lesbian African American individuals.
Sex assigned at birth Sex assigned based on an infant’s external genitalia.
Sexual behavior How an individual displays their sexuality.
Sexual identity Individuals’ description of their sexuality.
Sexual orientation Individuals’ sexual identity concerning their gender attraction.
Transgender Individuals whose gender expression is different from their birth sexual assignment.
Transition Individual’s psychological, medical, and social process of transition from one gender to another.
Transphobia Discrimination, harassment, and violence against individuals that do not follow stereotypical gender identities.
Transsexual A term formally used to describe individuals whose gender identity is different from their assigned birth.
Cultural Competence Versus Stereotyping

Cultural competence requires the healthcare professional to consider how values and norms are uniquely shaped. Even when people share similar cultural backgrounds, their values may be differently shaped by their own individual experiences and interpretations of those experiences. Stereotyping uses preconceived ideas (and often prejudices) of a particular group of people and may result in inappropriate clinical decisions for a patient from that group. Ā¹Ā³

For example, cultural competence in a patient who is a Jehovahā€™s Witness includes recognizing the patientā€™s preferences for not receiving blood products, even in life threatening situations. Stereotyping a patient who is a Jehovahā€™s Witness as one who rejects modern science could cause the healthcare professional to omit acceptable alternatives to blood products, thereby providing substandard care.

Consequences of Cultural Competence Deficiencies

If healthcare professionals and organizations do not work together to provide culturally competent care, patients may receive poor quality care, have negative health consequences, and be dissatisfied with the care they receive. 

Why should healthcare professionals and organizations be culturally sensitive? The Joint Commission requires hospitals to be accountable for maintaining patient rights, including accommodations for cultural, religious, and spiritual values. ā“ Healthcare professionals and organizations must care for patients as whole persons, and this includes the body, mind, and spirit.

To provide culturally competent care, healthcare professionals should be empowered with the knowledge and skills to appropriately respond to the needs of patients. Healthcare organizations and healthcare professionals should develop strategies and techniques to respond to the cultural, religious, and spiritual needs of patients for several reasons. One reason is that, in addition to Joint Commission, state and federal guidelines encourage organizational responsiveness to population diversity. These strategies are necessary to meet the federal government’s Healthy People goal of eliminating ethnic and racial health disparities.

Developing Cultural Competence

Developing cultural competence is an ongoing process. It involves the healthcare professionalā€™s self-awareness and cultural humility, and it may require them to recognize their own inadequacies as it relates to languages and cultures of patients. The healthcare professional will need to seek out culture-specific knowledge and experiences to better provide culturally competent care. The healthcare professional can develop cultural competence byĀ¹ā°: 

  • Gaining an understanding of how personal perceptions might influence interactions and service delivery to a variety of patients.
  • Self-assessment, including a review of the healthcare professionalā€™s personal history, values, beliefs, and biases.
  • Understanding how their own personal history, values, and beliefs may influence perceptions of communication abilities and patterns .

The healthcare professional should also consider the following while developing cultural competency:

  • Engage in cultural self-scrutiny to assess cultural biases and improve self-awareness.
  • Understand the communication needs of patients.
  • Utilize evidence-based practice to include patient characteristics, the healthcare professionalā€™s expertise, and empirical evidence in clinical decisions. 

Specific steps in the development of cultural competence are identified based on a healthcare professionalā€™s stage within the cultural competence continuum, the essential characteristics of the culturally competent healthcare professional, and a reflection on individual needs. These steps are as follows:

  • Learning about a patientā€™s language, experience, history, and alternative sources of care.
  • Developing a dynamic definition of what constitutes culture that allows for possible change. 
  • Demonstrating respect for the cultural background of patients by integrating the patientā€™s personal preferences and cultural practices into assessment and treatment, including recognizing the influence of culture on linguistic variations, which may result in variations in communication patterns due to the context, communication intent, and communication partner. 
  • Recognizing that power in the clinical situation is reciprocal and that patients have the power to make choices and changes in their lives and to participate in treatment and care as appropriate for their culture and personal preferences. 
  • Identifying both explicit cultural variables, such as food and language, and implicit variables, including religious practices and beliefs, spiritual beliefs, educational values, age and gender roles, child-rearing practices, and fears and perceptions. 
  • Developing an ethnogenetic viewpoint that recognizes that groups, cultures, and the people within them are complex in their identities and relationships. 
  • Moving away from ethnocentrism, the belief that one’s way of life and view of the world are inherently superior to others’ and are more desirable. 
  • Moving away from essentialism, which defines groups as essentially different, with characteristics natural to a group.
Federal Legislation

Organizations and their healthcare professionals must follow federal legislation as it relates to healthcare, for example, when offering care to patients, an organization must provide access to services, make accommodations to facilitate participation by individuals with disabilities, have interpreters readily available, reduce health care disparities, and provide privacy. The following provides an overview of federal laws related to healthcare. āø

Individuals with Disabilities Education Act (IDEA)

2006 IDEA made significant steps toward addressing problems with inappropriate identification and disproportionate representations by race and ethnicity of children with disabilities. A provision was added requiring states to review ethnicity data in addition to race data to determine the presence of disproportionality. The term disproportionality refers to the overrepresentation or underrepresentation of a particular demographic group in a special education program relative to the number in the overall student population. If significant disproportionality is determined, not only will the state be required to review and revise policies, procedures, and practices, but the local education agency will be required to reserve the maximum amount of funds under of the statute to provide early intervening services to children. These regulations clearly define steps that states must take to address the problem of disproportionality in special education. 

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Title II of HIPPA, known as the Administrative Simplification provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. This act gives individuals the right to privacy. The provider must have a signed disclosure from the affected patient before giving out any information on provided healthcare to anyone else, including the patient’s parents. The provisions also address the security and privacy of health data. So that patients can understand their rights, materials are to be provided in a manner that is culturally and linguistically accessible.

Title VI of the 1964 Civil Rights Act

Title VI of the 1964 Civil Rights Act prohibits discrimination in any federally funded program based on race, color, or national origin. According to the Office of Civil Rights, all healthcare professionals who work for any agency funded by the U.S. Department of Health and Human Services are required to provide language access services to patients who do not speak English.

Executive Order 13166

Executive order 13166 requires federal agencies to examine the services they provide and identify any need for services to patients with limited English proficiency and develop and implement a system to provide those services so these patients can have meaningful access to them. 

Americans with Disabilities Act (ADA)

The Americans with Disabilities Act (ADA) is intended to protect people with disabilities and guarantee access to and participation in society. The statute is specifically directed at employment, public accommodations, public services, transportation, and telecommunication. To be protected by the ADA, one must have a disabilitywhich is defined by the ADA as a physical or mental impairment that limits one or more major life activities; has a history or record of such an impairment; or be perceived by others as having such an impairment.

Patient Protection and Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (ACA) addresses the expansion of health care coverage to populations that may not have been served in the past, explicitly linking health literacy to patient protection, and then offering funds and grants for programs to increase cultural competence. 

Conclusion

Healthcare professionals have an obligation to provide culturally competent care to patients, as it reduces biases, and improves patient outcomes and satisfaction with healthcare services. To help the healthcare professional meet this obligation, organizations must identify deficiencies in competency through cultural assessments and provide steps to change that culture. This can be achieved by providing the healthcare professional with tools and education relating to cultural competency. For instance, the healthcare professional can complete a self-assessment to identify individual biases and beliefs that could negatively impact care that is provided. If any biases are identified, they should be acknowledged, and training and additional education resources should be provided to the healthcare professional. An organization could also consider seeking funding for ongoing professional development of cultural competence. Through understanding of cultural competence, the healthcare professional will be able to truly demonstrate respect for the patient regardless of age, disability, ethnicity, gender identity, race, or sexual orientation, and they will be able to integrate the patientā€™s values, beliefs, and traditions into healthcare, and in turn, be able to appropriately assess and treat a patientā€™s unique needs. Through cultural change within an organizational, the healthcare professional will be better prepared, and better capable of caring for diverse populations of patients, thereby improving patient outcomes, and patient satisfaction with the care that is received.

References
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