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An Action Plan for Cultural Competence
By Gloria Kersey-Matusiak, PhD, RN
This course is 1 contact hour
Course must be completed by May 31, 2019
Goals and objectives: The goal of this cultural competence continuing education module is to help nurses, physicians, and social workers develop an individualized plan for becoming culturally competent. After studying the information presented here, you will be able to:
  1. Define cultural competence
  2. Identify barriers that inhibit the provision of culturally competent care
  3. Describe the components of a personal action plan for becoming culturally competent
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Caring for patients from culturally diverse backgrounds can prove challenging, even when the clinician and the patient share similar cultural backgrounds. According to the U.S. Census Bureau 2015 statistics, the American population continues to grow in its diversity, while shifting in its ethnic makeup.
Becoming culturally competent can be difficult for even the most conscientious healthcare professional. Even though the notion of transcultural nursing has been around since the 1960s, momentum in this area has been slowed by national trends and patterns, such as a lack of minority healthcare professionals, the dominance of the Western medical model, limited cultural knowledge, racism, and stressors in the managed-care work environment, and more recently, a political climate in which diversity has been challenged.

Today most schools incorporate culturally relevant content into their curricula.4 However, there’s disagreement about what content is important to include and a lack of clarity about cultural concepts. There’s also a lack of attention being paid to historical and social conditions that contribute to healthcare disparities.4
Having cultural competence means first having an awareness and appreciation of the influence that culture and other social factors have on behavior.15 Being culturally competent also means acquiring and balancing the specific knowledge, skills, and attitudes needed to provide care for clients from cultures or groups other than the clinician’s culture.3

Culturally competent healthcare professionals learn about different groups and the values that drive them. They develop nonjudgmental acceptance of cultural and noncultural differences in patients and coworkers, using diversity as a strength that empowers them to achieve mutually acceptable healthcare goals. The development of cultural competence focuses on enhancing self-awareness, gaining knowledge about culturally diverse groups, strengthening intercultural communication and assessment skills, and identifying and managing cultural conflicts. But to begin, clinicians need to evaluate themselves in view of those for whom they provide care. For example, if you are a clinician of color, how are your own healthcare practices and beliefs different from those of white patients of various ethnicities? If you are white, do you have personal healthcare beliefs and practices that may be alien to some of your patients from abroad?

By learning about and contrasting other cultures, healthcare professionals can broaden their perspectives and rethink attitudes about their own and others’ health beliefs and practices. The benefits of strengthening professionals’ skills in communication and cultural health assessment include helping to eliminate the shadow of ethnocentrism and racism and ultimately enhancing the quality of care given to all patients.
How to earn continuing education
THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing education article.
2.
This continuing education course is FREE ONLINE until March 27, 2019, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/an-action-plan-for-cultural-competence. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse

Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
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You can take this test online or select from the list of courses available. Prices subject to change.
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Most recent statistics indicate that whites (not identifying as Hispanic or Latino) constitute 77% of the population. Of minorities, Hispanics or Latinos make up 17.6%; blacks or African-Americans, 13%; Asians, 5.6%; American Indians and Alaskan Natives, 1.2%; and Native Hawaiians and other Pacific Islanders, 0.2%. This data is confounded because 2.6% of people report belonging to two or more races.1 According to the U.S census report, Asians remain the fastest-growing racial group.2 There’s much diversity among members of each ethnic and racial group, and each group brings its own cultural values, beliefs, and customs.3 Consequently, communicating with patients from diverse backgrounds challenges healthcare professionals to gain the appropriate cultural knowledge and skills to address the specific needs of their patients. Clinicians should conduct a comprehensive cultural assessment to determine important cultural differences that might exist with patients. Communicating across cultures is more than bridging language barriers, because many people speak English on some level. Language usage, dialects, and accents can all be sources of miscommunication. Cultural attitudes and practices are far more difficult to recognize, unless the healthcare professional is careful to include these considerations in the initial and ongoing cultural assessment.

Communicating with patients from diverse cultural backgrounds is only one challenge facing clinicians today. As the U.S. population rapidly becomes more diverse, healthcare professionals will need to think and act in ways that are culturally sensitive as they provide care. They will also need to find new and innovative ways to meet the needs of an increasingly diverse patient population.3

Similar expectations permeate American corporations, educational institutions, and other organizations within our society that must now serve an increasingly diverse clientele. Fortunately, healthcare providers are in an excellent position to meet this healthcare imperative.
What does cultural competency mean?
Healthcare professionals can use the Cultural Competency Staircase Model to assess their cultural competence and track their growth.18 The “steps” of the model categorize professionals based on cultural competence, with Step 1 representing the lowest competence and Step 6 the highest. Step 1: These clinicians fail to recognize the significance of cultural influences when planning patient care. They might have completed school before cultural content was introduced or have limited previous exposure to culturally diverse patients. Step 2: Clinicians in this group have a growing awareness of culture’s influence on health but limited self-awareness of personal attitudes or biases or knowledge about other cultural groups. Step 3: These healthcare professionals are increasingly self-aware, have acquired cultural knowledge about one or two culturally diverse groups, and attempt to include cultural information in care planning. Step 4: Clinicians in this category have a strong cultural self-awareness, recognize their own biases, and have an expanded social network from which they derive cultural information about diverse groups. They consistently incorporate that knowledge into their care planning. Step 5: These practitioners are highly self-aware, seek appropriate resources, readily apply cultural knowledge to care planning, and anticipate potential culturally related patient problems or staff issues. Step 6: These healthcare professionals have attained a high level of self-awareness, a wide knowledge of other cultures, as well as intergroup and intragroup differences, and have an ability to solve problems across cultural groups and to coach other professionals.
Using the Staircase Model
Barriers to cultural competence
EDITOR’S NOTE: Gloria Kersey-Matusiak, PhD, RN, is a professor of nursing and coordinator for diversity at Holy Family University, Philadelphia. The author has declared no relevant conflict of interest that relate to this educational activity.
Sources for cultural assessment models
Giger JN, Davidhizer RE. Transcultural Nursing: Assessment & Intervention. 6th ed. St Louis, MO: Mosby; 2013.
Kersey-Matusiak G. Delivering Culturally Competent Nursing Care. New York, NY: Springer Publishing; 2013.
Purnell LD. Transcultural Health Care: A Culturally Competent Approach. 4th ed. Philadelphia, PA: FA Davis; 2014.
Spector RE. Cultural Diversity in Health and Illness. 9th ed. New York, NY: Pearson; 2016.
Lack of minorities: Despite the increasing diversity of the U.S. population, the RN population remains ethnically disproportionate with that of the U.S. population. While the numbers are gradually changing, nurses and other healthcare providers continue to be largely monocultural. That is, according to U.S. Census Bureau workforce data, 75% of the more than 2.8 million American RNs are white, while only about 10% are black/African-American, 8% are Asian/native Hawaiian/Pacific Islander, 5% are Hispanic or Latino, and 0.4% are American Indian/Alaskan Native.5 Consequently, healthcare beliefs, values, and practices of many healthcare professionals may differ dramatically from those of their patients. The lack of minority representation among these professionals may further limit their access to those who might provide information about the cultural or ethnic groups they represent. However, keep in mind there can be as many differences among members of the same ethnic group as there are differences between ethnic groups.

Second-generation immigrants to the U.S., who are acculturated to this country’s values and norms, may share the attitudes and beliefs of other Americans, while more recent immigrants from the same country may hold fast to their own traditions.
The Western model: Many clinicians’ professional values remain entrenched in the Western medical model. They learn to depend on that model to guide their healthcare decision making, unaware that other cultural groups use their own traditional orientations. For example, among Muslims found in the U.S., there are indigenous African-Americans who practice Islam, and Muslim immigrants from South Asian and Middle Eastern countries. Each group will bring its own ethnic and cultural diversity and healthcare needs, based on the country of origin.6

People from immigrant groups can have difficulty trading traditional beliefs about healthcare for those that are foreign to them. When they face clinicians who are insensitive to their traditional orientations, several things can undermine health services, including misdiagnoses, unnecessary ED visits, longer hospital stays, canceled diagnostic or surgical procedures, suffering, and potentially harmful complications.7
Ignorance and racism: Unfamiliarity with culturally diverse groups and persistent racism, which restricts access to services based on race, haunts healthcare. Results from a 2010 study conducted by the Pew Research Center for the People & the Press and the Pew Forum on Religion and Public Life indicated that favorable opinions of Islam have declined since 2005.8 For example, according to one study, Arabs and Muslims living in the U.S. continue to experience racism and discrimination as a result of the 2001 terrorist attacks.9 (Level B)

In this study, women described their post-September 11 experiences and reported being discriminated against, being treated rudely or unfairly, and being ignored by service personnel in stores and restaurants. In another study of diabetic care to Arab-Americans, investigators found that most Arab-Americans were treated less aggressively with pharmacological agents compared with 18% of the national population, and they also had worse blood pressure control. The researchers concluded that diabetic care in an Arab population demonstrated suboptimal quality of care.10 (Level B)

Despite increasing numbers of Muslims in the U.S., there continues to be a gap between the care Muslim patients require and that which they receive.5 A 2012 Australian study of prejudice against Muslims suggests this is a global problem that has intensified since Sept. 11.11 Further, the Brookings Institution found in a 2015 poll that as a result of bombings on American soil and the current polarized political climate, Americans have heightened fears of Islamic extremists that have negatively influenced their attitudes toward Islam.12

Additionally, a 2016 U.S. News & World Report report on views on race and inequality and a 2015 Pew study found gaps in several measures of social and economic well-being between black and white Americans; however, these groups differ significantly on their perceptions about racial equality.13 (Level B), 14 For this reason, healthcare professionals must be vigilant in monitoring their own and other healthcare workers’ attitudes and behaviors toward clients from culturally diverse groups that may differ from their own. Denying that differences exist between the clinician and patients of diverse backgrounds can result in discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping. The same attitudes caused people to dismiss or ignore the needs of patients and to attribute offensive client behaviors to their cultural or ethnic backgrounds.
Additional factors: In today’s managed healthcare environment, clinicians must make quick, accurate decisions that critically impact patients’ survival, quality of life, and satisfaction with the healthcare experience. Often stressed out and frustrated by that environment, clinicians are hard pressed to find the time to learn new practices and alter their behaviors to become culturally competent. Furthermore, there are various definitions of cultural competency. Most definitions include cultural knowledge, skills, and attitudes among new competencies clinicians must acquire to provide quality care.15 (Level B)

In addition, 10 universally applicable guidelines for implementing culturally competent nursing care, based on principles of social justice, were published in 2014.16 The standards address knowledge of cultures, education and training, communication, culturally competent practice, cultural competence in healthcare organizations, patient advocacy, multicultural workforce, cross-cultural leadership, and evidence-based practice and research.  
Finally, to ensure healthcare professionals gain the knowledge and skill they need to become culturally competent, the process must begin during their preliminary education and continue throughout their careers. However, research suggests that while curricula integrates various cultural competency models into theory and clinical experiences, these efforts do not necessarily ensure students’ mastery of the content.4
Special issues
Cultural perceptions of illness: Culture influences patients’ perceptions of illness, pain, and healing. These perceptions may conflict with clinicians’ views based on the medical model. Keep an open mind and listen actively to what patients say about their illness. Active listening involves restatement of what’s being said to ensure accurate interpretation of the message and to clarify patients’ issues and concerns. Also, discuss alternatives to the proposed treatment plan and establish mutually determined goals and interventions.
Attitudes toward authority: Many Asian and Native American group members refrain from making direct eye contact out of respect. Also, while a smile or nod might seem to indicate agreement, this may simply be another indication of respect. To ensure patients’ adherence to the treatment regimen, make sure you include them in the process by asking questions that clarify information.
Nonverbal communication: When a patient doesn’t speak English and there is no interpreter, spend more time visiting to allay patients’ anxiety. Learn key phrases from the family and use flash cards to enhance communication. When all else fails, sign language does work. Remember that making the effort shows the patient that you care. You are using the language of the heart and building trust. Don’t assume you know what culturally diverse patients intend by gestures or silence, as these are often misinterpreted. For example, the tendency to initiate or desire tactile contact varies among culturally diverse groups. If you tend to reach out and touch or hug the depressed or frightened patient, recognize that your patient may be uncomfortable with that approach. Conversely, an overly businesslike approach may be a turnoff to some patients. Watch for nonverbal indications of the patient’s feelings, but validate your evaluations through discussions with family members or professional interpreters.
Style of verbal communication: Basic rules can guide a healthcare professional through the process of using an interpreter. Remember that interpreting is more than just communicating words. The patient’s emotional needs, including the need for privacy and confidentiality, must be considered. Therefore, the selection of a nonfamily member with a medical background is ideal.

Both the clinician and the interpreter must pay particular attention to nonverbal feedback during communication with the patient to ensure understanding of the patient’s concerns and desires. During the exchange, the clinician and the interpreter must be able to convey caring and support to gain patients’ confidence and trust, particularly when they are revealing sensitive information.17 Differences in communication style can influence clinician-patient interactions. A primary care physician complained about a loud Russian immigrant woman whose angry-sounding tone was perceived by the staff as being entirely too aggressive. Other staffers had commented, “Yes, they are all like that — very domineering.”

Sometimes when our experiences with members of a particular cultural group are limited, we generalize the behaviors or personality traits of one or two to all members of that cultural group. This is stereotyping. In this case, a family member later stated, “She is like that at home, too. She yells a lot when she talks.”

Because of their interaction, the clinicians were unwilling to negotiate options that might have better met the patient’s needs. Consequently, the patient left dissatisfied with the service she received, and the clinicians were frustrated with the care they provided. When intercultural interaction breaks down, no one wins. Be flexible. Listen to the message being conveyed, not just the style in which it is expressed.
In responding to a survey, 60 rehabilitation nurses reported that their greatest concern when caring for culturally diverse patients was communicating effectively, particularly in the presence of a language barrier. One of them lamented, “With so many diverse groups of immigrants and other minorities, how can I be expected to learn several languages?”

But language is only part of the problem, and healthcare professionals can’t be expected to learn multiple languages. They must consider other cultural variables that influence communication between patients and clinicians. At times, conflict can arise from culturally diverse attributes about patients’ perceptions about illness and the status of healthcare providers, attitudes toward authority figures, and nonverbal and verbal communication.3
Use this action plan for cultural competence
Earn 1 credit hour with this free continuing education course
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