Cultural Competence and Patient-Centered Care

Horblit Health Sciences Library

Objectives

At the end of this presentation, you will be able to:1. Define culture2. Define cultural competency3. Identify how cultural competency can improve health

communication4. Identify the cultural factors that influence cross-cultural

patient-provider interactions5. List ways to develop cultural competence and to assess

your own cultural competency development

Why Learn About Cultural Competence?

• Patients bring many varied and cultural backgrounds, beliefs, practices, and languages, requiring culturally competent communication to maximize the quality of care they receive.

• Providers also bring their own cultural backgrounds, values and beliefs, and biases to health care encounters. Culturally competent providers take into account how their own cultural orientation and background influence their perceptions and behaviors.

Cultural Bias is Everywhere• A review in Family Medicine found evidence that race,

ethnicity, and language impact the quality of the patient-provider relationship.

• Patients who are culturally different from their providers, especially those who are not proficient in English, are less likely to:– Have providers identify with and understand their situation– Establish a connection and trust with providers– Receive sufficient information– Be encouraged to participate in medical decision-making

What is Culture?

• Most people think of culture in terms of race, nationality, and religion, but culture is broader than that.

• Culture includes groups that we are born into, such as gender, race, national origin, sexual orientation, class, and religion.

• It also includes the social groups that influence our identity, including age, disability, social and economic status, and even career.

Characteristics of Culture

• Two people my have exactly the same cultural background but may respond differently to a given situation and have different values on similar issues.

• Culture may be affected by many factors, including:– Experience/time– Level of ability (physical and

mental)– Spirituality/religion– Social and economic status

– Personality– Gender– Age– Sexual orientation

What Does Culture Encompass/Impact?

• Communications• Language• Art• Religion• Diet• Environment

• Customs• Family obligations• Illness and death• Preventive care• Gender roles• Social groups

These are Cultural Groups, Too

• Gay/Lesbian• Transgender• Disabled

• Visually impaired• Mentally ill

The Importance of Culture

• Culture is a central issue in people’s lives. It influences their beliefs, values, attitudes, and behavior.

• Although people may share the same culture, the way in which that culture is expressed will differ from person to person and will vary over time.

Culture and Health Care

A person’s culture can affect:• What is considered to be a health problem• How symptoms and concerns about the problem are

expressed• Who provides the treatment for the problem• What types of treatment should be given• How and when health care information is received

Culture and Health Communication

• Patients may choose not to seek needed services• Providers may make errors in diagnosis because of

miscommunication• Patients may not follow medical advice because they

do not trust or understand the provider• Providers may order fewer or more diagnostic tests

for patients because they may not understand or believe the patient’s description of symptoms

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Social Structure

Egalitarian• All are equal

– All competent adults make decisions for their own health care

Hierarchical• Top down

– Husband makes decisions

– Patriarch makes decision– Provider may be

expected to make decision

What is Cultural Competence?• Developing an awareness of one’s own thoughts,

attitudes, and environment without letting it influence those from other backgrounds.

• Demonstrating understanding of a client’s culture. Understand the cause and control of specific diseases and the effectiveness of treatments in different populations.

• Accepting and respecting cultural differences.• Adapting care to accommodate the client’s culture.

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What is Cultural Competence?

The ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication of patients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.

What is Cultural Competence?

• It begins with an honest desire not to allow biases to keep us from treating every individual with respect.

• Learning to evaluate our own level of cultural competence must be part of our ongoing effort to provide better health care.

What is Cultural Competence?

Culturally competent providers consistently and systematically:•Understand and respect their patients’ values, beliefs, and expectations•Understand the cause and control of specific diseases and the effectiveness of treatments in different population groups•Adapt the way they deliver care to each patient’s needs and expectations

Why Provide Culturally Competent Care?

• Every patient-provider encounter is a cross-cultural encounter.

• Even patients with appearance and background similar to yours can be culturally different due to life experiences, personalities, interests, careers, etc.

Benefits of Culturally Competent Care

• Reduced health care disparities• Improved health communication and health

outcomes• Providing culturally competent care allows you to

develop trust and create partnerships with your patients, and helps to ensure effective, understandable, and respectful care for all patients.

Cultural Factors Influencing Patient-Provider Communication

There are several cultural factors that can influence the quality of patient-provider communication, including:•Personal biases•Nonverbal communication•Patients’ families and dynamics•Cultural values and beliefs

Why is Cultural Competence Important?

Population ChangesHispanic populations Increase to 23% by 2050Asian populations Increase to 10% by 2050African American Double in size to 15.7% (62m)Non-Hispanic Whites Decline by 20% by 2050

www.census.gov, Population projections 2008

Why is Cultural Competence Important?

Languages• Over 44 million Americans speak a language other

than English at home.• Over 300 different languages are spoken in the U.S.• Over 48 languages are spoken in Danbury

www.usinfo.gov Language Use and English-Speaking Ability: 2000

Aging and Health

2008 38.7 million2050 88.5 million

Number of people over the age of 65

www.census.gov2008 age projections; National Academy on an Aging Society 1999

• Over age 65: up to 3 chronic conditions• Over age 85: at least one disability

What can culture influence?

• Health, healing and wellness belief systems• How patient and consumer perceive illness, disease,

and their causes• Patients’ behaviors seeking health care and their

attitudes to healthcare providers• The delivery of services by the provider who looks at

the world through his or her values• Compliance to medication and treatment plan

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Healthcare Disparities

• Health disparities and minority and foreign-born populations are increasing

• African Americans’ infant mortality rates are 2 – 5 times higher than for European Americans

• Influenza death rates are higher for African Americans than for European Americans

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The Asian American Patient• Diverse population – Chinese, Filipino, Vietnamese, Korean,

Japanese• Traditional definition of causes of illness is based on harmony:

balance of hot and cold states or elements• Modesty highly valued• May be too polite to disagree• Communication based on respect; familiarity is unacceptable• Eldest male is head of family and may take the lead in health

decision making

Hispanic Health Beliefs and Practices• Preventative care may not be practiced.• Illness is God’s will and recovery is in His hands.• Hot and Cold Principles apply.• Expressiveness of pain is culturally acceptable.• Obesity may be seen as a sign of good health and well

being.• Diet is high in salt, sugar, starches and fat.• High respect for authority and the elderly.• Provide same sex caregivers if at all possible.

Cultural Groups

• Anglo American– Direct eye contact– Informed about details– Aggressive approach– Killing germs– Antibiotics even when

unnecessary– Belief in technology

• Native American– Anecdotes/metaphors– Avoid eye contact– Don’t speak to loudly– Traditional healing very

important– Never touch or casually

admire a ritual object.

No Stereotyping

• Culture is expressed through the individual• Not all members of a cultural group will believe the

same thing• Variation within cultural groups.

Tips for Communicating

Basic Strategies• Speak clearly and slowly without raising your voice,

avoid slang, jargon, humor, idioms.• Use Mrs., Miss, Mr. Avoid first names which may be

considered discourteous in some cultures.• Avoid gestures – they may have a negative

connotation.• Many carry or wear religious symbols – Sacred

threads worn by Hindus, native Americans-medicine bundles. DO not touch them.

How would you make your practice culturally competent?

Culturally Competent Care

• Treat people uniquely• Listen respectfully• Gender sensitivity• Educate yourself• Be aware of different

cultures

• Know your comfort level

• Establish trust

ScenarioA nurse, working as a community case manager, visited the home of a toddler with severe physical and developmental delays. She explained to the parents that with their consent she would refer the child to a physiotherapy and occupational therapy program that would help the child be more independent. The parents refused, saying that it was their duty to care for their child because the child’s condition is punishment for having conceived before they were married. They were not supportive of a program to increase independence. The nurse was upset and felt the parents were not acting in the child’s best interests.

DiscussionThe nurse did not understand the family’s initial refusal of treatment. After reflection and discussion with colleagues, she realized that her personal and professional values of independence were causing her to feel upset with the parents’ refusal. She decided to explore with the family their goals for their child. In doing this, she learned that the parents wanted their child to become stronger and have fewer infections. When the same therapies were described as a means of meeting these goals, the parents were quite willing to participate. The program was developed to meet the goals that the family identified as important.

Scenario

A couple comes to a walk-in clinic with a young child who is crying and tugging at his ears. The couple has recently arrived in the country but understands English well enough that the nurse feels language is not an issue. An assessment reveals that the child has an infection in both ears, and the couple is given a prescription for an antibiotic and Tylenol drops for fever and pain. The situation is fairly routine, and an interpreter is not considered necessary. The parents are informed about the diagnosis and treatment, and they nod in understanding.

Scenario, continuedThe next day the couple returns with the child whose condition seems to have worsened. There is now a pink discharge from both ears, and the entire family is in distress. An interpreter is called to assist. Through the interpreter, the nurse learns that the parents had the prescription filled promptly, and they understood the child was to be given the medicine every 4 hours. They had been administering the antibiotic orally, but since they had treated previous infections with ear drops, they had administered the Tylenol drops in the child’s ears.

Discussion

This example illustrates the importance of confirming that accurate communication has been achieved. To reduce the chance of confusion, the nurse could have demonstrated how to measure, and then administer, both medications. Culturally appropriate client education materials would also have been helpful.

Scenario

A woman, 35, is admitted to the general medical unit. While in the hospital, she expresses concern about her partner’s ability to care for her children. She also appears worried about how she will manage at home after she is discharged. The nurse suggests that perhaps a family meeting is necessary and offers to contact her husband. The nurse further suggests that maybe the patient’s mother, who has called often to inquire about her daughter, should be involved in the meeting.

Discussion

The nurse has made an assumption that the patient’s partner is male and that the relationship with the mother is one that will be supportive to the entire family. For many couples in a same sex relationship, the issue of family can be sensitive. For some people, “family” is often their chosen family as opposed to kin. By using the word “partner,” and asking the patient who would be appropriate for a family meeting, the nurse shows openness and a nonjudgmental attitude.

Scenario

A nurse is providing direct care to an elderly woman newly diagnosed with angina. She has been prescribed nitroglycerine to manage her angina attacks. The patient reveals to the nurse her firm belief that her illness is caused by the “evil eye,” a glance cast upon her by another to cause this condition. She shows the nurse her own remedy, which she claims will life the curse of the evil eye and cure her.

DiscussionThe nurse assesses the patient’s remedy for possible health risks, such as high sodium content. As well, the nurse negotiates with the patient to take the nitroglycerine. In doing so, the nurse will need to be vigilant to the potential objections the patient may have to taking the medication. The goal is to have a plan of care that includes the remedy for the evil eye, but also includes the appropriate use of the nitroglycerine. The nurse and the patient may not fully understand each other’s preferences, but are willing to accommodate both interventions.

The 4 C’s

• What do you call your problem?• What do you think caused your problem?• What have you done to cope with your problem?• What concerns do you have about your problem,

about my recommendations?

Kleinman’s 8 Questions1. What do you think caused the problem?2. Why do you think it started when it did?3. What does your sickness do and how does it work?4. How severe is your sickness/ How long do you expect it to

last?5. What problems has the sickness caused you?6. What do you fear about your sickness?7. What type of treatment do you think you should receive?8. What are the most important results you hope to achieve

from this treatment?

Kleinman et al 1978

Benefits of Cultural Competence

• Greater patient compliance• Fewer harmful drug interactions• More appropriate testing and screenings• Increased likelihood that minorities will seek health

care• More successful patient education

Developing Cultural Competence

Attitude/skill-centered approach• Recognize your own biases; understand how race,

ethnicity, gender, etc. play a role in healthcare delivery and perception of health care.https://implicit.harvard.edu/implicit/

• Acquire and apply culturally competent skills.

Developing Cultural Competence

Fact-centered approach• Learn specific information, such as an ethnic groups’

history, their concepts of illness and disease, their health-seeking behavior, disease patterns, etc.

Developing Cultural Competence

Organizational• Build a foundation• Collect and use data to improve services• Accommodate the needs of special populations• Establish internal and external collaborations

Developing Cultural Competence

Physician-specific• Key stakeholders• Programs and training• Agents of change

Developing Cultural Competence

Educational Opportunities• Films/videos and CDs• CMEs• Lectures• Presentations on specific cultures• Unit cultural gatherings

ReferencesAmerican Academy of Pediatrics. Plain Language Pediatrics. 2009. ElkGrove

Village, IL: American Academy of Pediatrics.Arnold TL, Davis TC. Frempong JO et al. 2006. Assessment of newborn

screening parent education materials Pediatrics 117(5pt2): S341-s345.HRSA Unified Health Communications Addressing Health Literacy, Cultural

Competency, and Limited English Proficiency.Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care:

Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258.

Lenningert, M., & McFarland, M.R. (2002). Transcultural Nursing: Concepts, theories, research & practice (3rd ed).New York: McGraw-Hill

National Academy on an Aging Society. Chronic Conditions : A challenge for the 21st century, November 1999.

Pew Research Center.US Populations Projections 2005-2050.