Cultural Competency

## Contact Hours: 4

This educational activity is credited for 4 contact hours at completion of the activity.

## Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of cultural competence, self-assessment tools that may be used to identify bias, values, and beliefs that can influence care that is provided, and federal laws that relate to disadvantaged populations.

## Overview

Cultural competence is a process in which healthcare professionals strive to effectively work within the cultural context of an organization by respecting another’s difference and not allowing biases to influence the care that is provided. It essentially requires the knowledge, skills, and understanding of all diverse groups, as it is the healthcare professional’s moral and ethical commitment to patients, families, and communities. To improve cultural and linguistically appropriate care, organizations and their healthcare professionals must understand cultural competence, and conduct self-assessments to identify bias, values, and beliefs of the healthcare professional.

## Course Objectives

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

- Define cultural competence

- Summarize effective, validated self-assessment tools to assess for cultural competency within an organization

- Recognize how personal history, values, and beliefs can influence perceptions of communication abilities and patterns

- 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.

## Disclosures

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

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Nurses are at the frontline of patient care and are often the first healthcare professionals that patients and their families encounter when they enter the healthcare system. Given that 40% of the United States population currently consists of either first-generation Americans or immigrants, and in some parts of the country people of color are the majority, it is imperative for nurses and other healthcare professionals to be able to deliver culturally competent care. 2

Cultural competence is a process in which healthcare professionals strive to effectively work within the cultural context of an organization by respecting another’s difference and not allowing biases to influence the care that is provided. 4,21 It essentially requires the knowledge, skills, and understanding of all diverse groups, as it is the healthcare professional’s moral and ethical commitment to patients, families, and communities.

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 requires⁴:

- An organization and the 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 policy making, administration, practice, service delivery, and systematically involve consumers, key stakeholders, and communities.

Principles of cultural competence include¹:

- 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 patient’s cultural beliefs

Cultural assumptions and stereotypes may be based on the following:

The goal of cultural competence in healthcare is to have improved quality of care. ⁴ 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.

The United States Department of Health and Human Services’ (HHS) Office of Minority Health (OMH) responded to the need to ensure that all people entering the healthcare system receive equitable and effective treatment in a culturally and linguistically appropriate manner by developing the National Standards on Culturally and Linguistically Appropriate Services. 7,19 These standards were created to correct inequities that exist within the healthcare system, and to make these services more effective for the needs of all patients. The standards created are intended to be inclusive of all cultures, and not limited to any population or group. In addition, the standards were designed to address the needs of racial, ethnic, and linguistic groups that experience unequal access to healthcare services, and ultimately, assist in the eradication of racial and ethnic health disparities.

The National Center for Cultural Competence (NCCC) provides a variety of resources to organizations, trainers, families, and communities, including checklists, guides, and policy briefs that discuss the importance of policies, procedures, practices, and structures to support cultural and linguistic competence. 6,18 Several online self-assessment tools for cultural competence are offered to organizations, their personnel, and the community at large to measure outcomes. Cultural competence requires that organizations and their personnel have the capacity to value diversity, conduct self-assessments, manage the outcomes of the assessments, acquire and institutionalize cultural knowledge, adapt to the diversity and cultural changes recognized.

Having healthcare professionals conduct a self-assessment on cultural competence helps organizations to: 18

- Assign personnel and financial resources to enhance the delivery of cultural and linguistic services.

- Determine the healthcare professional’s strengths and areas for growth.

- Establish partnerships that will meaningfully involve patients, family members, and the community.

- Evaluate the degree that the organization is addressing the needs and preferences of culturally and linguistically diverse groups.

- Improve access to services.

- Increase patient satisfaction with services rendered.

- Plan for the incorporation of culturally and linguistically competent policies, structures, and practices.

Culture assessment is used to evaluate an organization’s current and desired culture. It includes analyzing an organization’s experiences, expectations, and philosophy, as well as the values that guide the healthcare professional’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 organization’s vision for itself and for the healthcare professionals who are associated with it.

Unfortunately, most of us are not even aware of our organization’s culture, or how culture represents “normal behavior.” Culture equates to collective assumptions, expectations, and values that reflect explicit and implicit rules in an organization. ⁷ 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. There are several cultural competence assessment tools that help measure outcomes. For instance, the Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPAA) was created to enhance the delivery of high-quality services to culturally and linguistically diverse individuals and underserved communities, and to promote cultural and linguistic competent healthcare professionals to help eliminate health disparities. 18 The CLCHPA is based on two assumptions: 18

- Cultural and linguistic competence are developmental processes at both the individual and organizational levels.

- With appropriate support, individuals can enhance their knowledge and skills over time.

The assessment tool is based on the understanding that achieving cultural and linguistic competence is a developmental process, where both individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum. The CLCHPA has three factors: 18

- Factor 1: Knowledge of culturally and linguistically diverse populations

- Factor 2: Adapting practice for culturally and linguistically diverse patient populations

- Factor 3: Promoting the health of culturally and linguistically diverse communities

The Competing Values Framework (CVF)¹⁰ is also 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 toward 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 model⁴ 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:

- Where were you born? Where were your parents born?

- What pronoun do you use (he, she, they)?

- In what language are you most comfortable speaking and reading?

- Did you grow up in a city or a town or a rural setting?

- When you were growing up, who lived with you and your family?

- Are your friends from the same cultural background as you?

- What is your religious preference?

- Do you have any dietary preferences related to your religious or cultural beliefs?

- In your culture, how do you celebrate the birth of a baby? A wedding?

- When a woman is pregnant, are there any special customs she needs to follow? Any special foods?

- 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?

- What home remedies might be used if someone is ill?

- As a family member is approaching death, what actions do you find comforting?

- After a loved one dies, what rituals are performed?

- What do you think a nurse should know about your culture if a family member is hospitalized?

- Who makes the decisions in your family?

- How are elders viewed in your culture?

- Are there any special beliefs regarding organ donation or blood transfusions that are held in your culture?

- Is your culture known for any special customs (rites of passage, foods, holidays)?

A self-assessment involves assessing one’s own culture, bias, values, and assumptions, and how they influence one’s perceptions and behaviors. 17 There are numerous benefits to a self-assessment, as it can lead to the development of an organizational plan with clearly defined short-term and long-term goals, and measurable objectives. The following are supportive strengths for a self-assessment: 17,19

A strengths-based model – The self-assessment identifies strengths and promotes growth of healthcare professionals within an organization and improves their ability to deliver culturally and linguistically competent services. The process also allows organizations to identify and acknowledge the internal strengths and assets of healthcare professionals who may be inadvertently overlooked.

Safe and non-judgmental environment – Self-assessments are most productive when they are conducted in an environment that offers healthcare professionals a forum to answer questions honestly, provides an opportunity for healthcare professionals to share their perspectives candidly, and assures that information provided will be used to effect meaningful change within the organization.

Assures meaningful involvement of healthcare professionals within the organization – Principles of self-determination and cultural competence assure that healthcare professionals participate in the processes to plan, deliver, and evaluate services they receive.

The results of self-assessment are used to improve the organization – The intent of the self-assessment process is to provide a view of where a healthcare professional or organization is at a particular point in time. The results should be used to plan objectives to improve the organization’s ability to deliver culturally and linguistically competent services.

Diverse dissemination strategies are essential to the self-assessment process – Self-assessment results should be shared the healthcare professional and the organization in a manner that meets their unique needs through: 17,19

- Comprehensive reports and executive summaries

- Power point presentations

- Conference calls

- On-site program and workgroup consultations

- Strategic planning sessions

The process of self-assessment is as important as the outcome. The following steps can be used in self-assessment processes: 17,19

- Leadership within an organization should establish a rationale for self-assessment as an organizational goal and priority.

- Establish a shared vision that conveys the importance of the self-assessment process to the overall organization, its personnel, and the population it serves. When people participate in the creation and use of knowledge, different groups of people will be emboldened to act collectively.

- Create a committee, work group or task force that will assume responsibility for the self-assessment process. The committee should also reflect the diversity of the organization and the community at large.

- Conducting a self-assessment process requires a dedicated budget and level of effort for organizational personnel. Budgetary considerations may include the use of consultants, and facilities for meetings, and interpretation and translation services. The self-assessment process depends on a well-crafted allocation of personnel and fiscal resources.

- The task force or workgroup should ensure sufficient time to plan and prepare and allocate time for the dissemination of information.

- The active involvement of the personnel within an organization is a highly valued and an integral part of the self-assessment process. Task force and workgroup members should plan their involvement in data collection, analysis, interpretation, presentation, and dissemination of information.

- The self-assessment process can yield a wealth of information about organizational strengths and areas for growth. Careful consideration should be given to: Establish organizational priorities.

- Develop a plan with goals and objectives to sustain strengths and address areas for growth.

- Allocate resources to accomplish plan goals.

- Sustain and maintain partnerships with the community.

- Incorporate self-assessment results into the planning and development process.

Age

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 ageing. 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 behavior¹:

- 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 person’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 organization’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 child’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 child’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 child’s first language

- Talking, eating, and singing songs from various cultural traditions, including the child’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 child’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. ¹² Effective use of language is important to understand a patient’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 to¹²:

- 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 professional’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. ⁷ 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 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 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 their impact on the overall health and well-being of military veterans make 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 member’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 it impacts a patient’s illness.

· 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 of 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 a 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.²˒¹⁴ Common race and ethnicity categories are as follows:

The healthcare professional’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. ¹⁴ An example of this would be a healthcare professional who disregards an Asian male’s complaint of chest pain because he doesn’t “look “like 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 as to 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 non-minority 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

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 patient’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 patient’s religious and spiritual needs by tailoring the patient’s treatments, as necessary. The following is a list of the religious and spiritual groups most encountered in a healthcare environment. ¹¹

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 patient’s beliefs to provide culturally sensitive healthcare. The following are recommendations to help the healthcare professional to provide culturally competent care: 5

- 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.³

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.⁶ 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 person’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 patient’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.⁶ 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. Terminology in the LGBTQ community is fluid, and identity labels mean different things to different people. The following definitions list may be used as a resource, but it is not intended to define or describe any person, as everyone’s experience with identify varies. 16,20,21

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 shaped differently 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. ¹³

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

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. ⁴ 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 is an ongoing process. It involves the healthcare professional’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 by¹⁰:

- 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 professional’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 professional’s expertise, and empirical evidence in clinical decisions.

Specific steps in the development of cultural competence are identified based on a healthcare professional’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 patient’s language, experience, history, and alternative sources of care.

· Developing a dynamic definition of what constitutes culture that allows for change.

· Demonstrating respect for the cultural background of patients by integrating the patient’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.

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. ⁸

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 Actprohibits 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 disability, which is defined by the ADA as a physical or mental impairment that limits one or more major life activities; have 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.

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 patient’s values, beliefs, and traditions into healthcare, and in turn, be able to appropriately assess and treat a patient’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.

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- Cultural competence in the care of LGBTQ patients – NCBI bookshelf. (2020, October 9). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK563176/

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- Religious competence as cultural competence. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4230460/

- Slayter, E. (2021, November 10). What do you know about disability cultural competence? SWHELPER. https://swhelper.org/2021/11/19/what-do-you-know-about-disability-cultural-competence/

- Stereotypes & bias in cultural competence training. (2018, October 8). Commisceo Global Consulting Ltd. https://www.commisceo-global.com/blog/stereotypes-bias-in-cultural-competence-training

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To access Cultural Competency, purchase this [course](/checkout/?add-to-cart=187205) or a [Full Access Pass](/cart/?add-to-cart=18311). If you already have an account, please [sign in here](/login).

To access Cultural Competency, purchase this [course](/checkout/?add-to-cart=187205) or a [Full Access Pass](/cart/?add-to-cart=18311). If you already have an account, please [sign in here](/login).

## FAQs

### How many Nursing CEUs can I earn from this cultural competency course?

This course provides 4 Nursing CEUs (contact hours), helping nurses meet continuing education requirements for license renewal. It’s ideal for maintaining compliance with state board of nursing CEU mandates.

### Is this cultural competency course approved for nursing continuing education?

Yes, the course is designed to meet nursing CEU requirements and aligns with continuing education standards for registered nurses (RNs) and licensed practical nurses (LPNs). It supports professional development in culturally competent nursing care.

### Why is cultural competency important for nursing CEUs?

Cultural competency is essential for modern nursing practice, helping nurses deliver patient-centered care in diverse populations. Many states now emphasize cultural awareness CEUs as part of ongoing nursing education.

### Can this course help with nursing license renewal requirements?

Yes, completing this course can count toward nursing license renewal CEUs, depending on your state board guidelines. It ensures you stay compliant while improving clinical communication and patient care skills.

### What nursing skills will I improve with this CEU course?

This course enhances cross-cultural nursing communication, patient advocacy, and bias recognition. These skills are critical for providing equitable healthcare and improving patient outcomes in diverse clinical settings.

### Is this an online self-paced Nursing CEU course?

Yes, this is a 100% online, self-paced Nursing CEU course, allowing you to complete your continuing education anytime. It’s ideal for busy nurses needing flexible CEU options.

### Does this course address health disparities in nursing practice?

Yes, the course explores health disparities, social determinants of health, and cultural barriers in healthcare. It helps nurses deliver inclusive, culturally sensitive nursing care in real-world scenarios.

### Will I receive a certificate for my Nursing CEUs after completion?

After completing the course, you’ll receive an instant Nursing CEU certificate. This can be used for license renewal documentation, audits, and continuing education records.