1. Understanding Cultural
Understanding Cultural Diversity Improving Patient Outcomes: Keys to Providing Culturally Competent, Congruent, and Sensitive Care
Valera A. Hascup, PhD, MSN,RN,CTN,CCES
Nurse Researcher Somerset Medical Center
Assistant Professor Kean University
Former Director Transcultural Nursing Institute
Kean University, Union, N.J.

2. Permission
Permission to use any part of t his presentation must be obtained from the author, V.A. Hascup, PhD

3. Objectives
To define cultural terms including cultural competency and cultural sensitivity
To develop knowledge of culturally competent care and behavior strategies that lead to improved patient outcomes
To identify the relationship of culturally competent and sensitive care to patient satisfaction
To describe the 3 major worldviews and how they impact health care beliefs and practices

4. Definition of Culturally Competent Care
Care defined
Care is the central and dominant
purpose of nursing (Leininger, 2006)
Care that is beneficial is meaningful to the people being served (Leininger & McFarland, 2002)
views ‘caring’ as a feeling of compassion, interest and concern for people (Leininger 1970, Morse et al. 1990, Reynolds 1995, McCance et al. 1997). Care always occurs in a cultural context.

5. Cultural Glossary

6. Glossary Culture Worldview Acculturation Cultural Conflicts
Ethnocentrism, Prejudice, Discrimination
Cultural Imposition
Culture - Learned and shared beliefs, values and lifeways of a particular group that are generally transmitted intergenerational and influence one’s thinking and behavior.
Worldview - Cognitive framework that guides the interpretation of one’s experience as well directs one’s thoughts and actions that is based on one’s life context. Emic = Insider worldview
Acculturation – the process of adapting to another culture; takes on various aspects, but not all, of the majority group’s culture.
Dominant vs. variant - Dominant is mainstream culture that predominates in a particular society
Variant or subcultures – variant cultural patterns from the dominant culture of a society
Majority vs. Minority - Refers to status and power differences in society
Maybe based on skin color, religion, gender, socio-economic status, and possession of authority
Race = biological characteristics shared by groups of people
Ethnicity – shared affiliation by groups of people related to geographical location, religion, ethnohistory, language, etc.
Cultural Conflicts
Ethnocentrism – belief that one’s own way of life is better than others - Source of biases and prejudices
Bias/prejudice – mental attitude attributing negative or positive characteristics to
Discrimination – action on ones’ prejudices

7. Cultural Glossary CLAS Standards Cultural Awareness Culture Desire
Cultural Competency
Cultural Pain
Cultural Imposition
Cultural Sensitivity
CLAS – Culturally and Linguistically Appropriate Services – 14 CLAS standards were developed in 2000 by the OHM to promote culturally competence of health care providers and HC organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter.
Cultural Awareness – Appreciating and accepting differences.
Culture Desire – the desire to learn, know and understand other cultures. Camphina-Bacote states that culture desire must come first – without that there will not be cultural awareness or competency. Cultural competency is a process….
Cultural competency – A set of appropriate behaviors, attitudes, beliefs and policies, that enable an individual, agency or system to work effectively in cross-cultural situations based on the behaviors, attitudes and beliefs of the clients served.
Cultural Sensitivity – The state of being aware that there are many cultural differences between people. However, these differences are often not understood, and cultural sensitivity is one step in the process toward cultural competency.
Cultural Pain – when we act in a way that causes distress to a person from another culture
Cultural imposition – forcing one’s own values, beliefs and way of life on others

8. Why Do We Study Cultural Diversity?
Promote cultural competence and culturally congruent care to promote positive patient outcomes
Develop an awareness of the similarities and diversities across and within cultures
Avoid cultural clashes, cultural pain cultural blindness, and ignorance

9. Before We Begin… Impossible to know everything about every culture
Important to avoid “recipe-type” approaches
The caveat: we must take into consideration the intra-cultural , individual and family variations that exist within any ethnic group that give rise to its diversity and dynamism
“Recipe-type” approaches are misleading and lead to stereotyping. Transcultural nursing research has provided us with a body of knowledge that can assist us in understanding other cultures worldviews and lifeways so that we can develop CCC.

10. General Principles
Six major steps for delivering culturally competent care (CCC)
Become aware of one’s own biases
Increase one’s cultural knowledge about the ethnic groups that comprise our communities
Develop relationships with individuals and agencies in our communities to facilitate entry into these communities
Discuss cultural rooting or self-assessment

11. General Principles continued…
Increase one’s second language capabilities and/or learn how to effectively use an interpreter
Conduct assessments to gather key background information on the population being served
Negotiate plans of care that consider the need for accommodation and negotiation

12. Understanding the Cultural Self

13. Understanding Your Culture
First step in promoting and delivering CCC
Using “therapeutic self”
Develops cultural competence
Imperative to understand your culture and subcultures
Therapeutic self defined as using and knowing your culture as a tool for understanding and working with people of other cultures.
– evolves from cultural desire, cultural awareness, cultural knowledge, assessment, and finally the encounter
Imperative to understand your culture and subculture – A person who is MA and a RN is considered a member of the MA culture and the nursing subculture, both of which have rules, values, and traditions. These shared cultures offer us a sense of purpose and direction in our lives and define a way of living.

14. Understanding Your Culture…
“American culture” largely made up of smaller ethnic groups
Incorporates these values; however, one set of values is generally dominant
Important to be aware of the cultural values that influence your life
Understand how they influence your attitudes toward health, well-being, illness
Your values will affect how you care for and help your patients. Here is where cultural clashes and misunderstandings arise: when we try to impose our cultural values and beliefs on someone from a different culture, perceiving our way is the better way, or the only way. This is seen in the healthcare setting

15. Cultural Rooting Assessment
Where do my people come from?
What language do I speak?
What do I value?
How do I communicate with others?
Do I have a philosophy of nursing and caring?
What is my definition of health?
What is my definition of well-being?
How do I define Care?
Do others in my family share my thoughts and feelings about the above?
What have I learned about myself through this assessment?
Being aware of your own culture will help you in interactions with culturally diverse patients.
Be open. Patients will recognize this and be more likely to share information about their health with you.
Be honest with yourself? How do you feel about people from different cultures, what are your beliefs? Do you have any racist or prejudicial feelings? Educate yourself about cultures, particularly those for whom you care.
You can then understand what is the most appropriate manner for caring for an individual or family.
Be real ( that is Recognize that the other person’s culture is different from yours but equally as valid) in your use of respect and concern for culturally different patients..

16. Evaluation
Do you feel differently or the same after exploring your culture?
What do you feel about your own culture?
Is it easier or harder to approach culturally diverse patients?
Are you surprised by what you learned from yourself?
Have you been open, honest, and real with your patients and families
Do you notice a difference in your relationship with culturally diverse patients?
Has becoming culturally self-aware changed the way you view nursing care?
Are your surprised by what you have learned from your culturally diverse patients and families

17. The Nursing Assessment: Sine qua non of nursing care
In delivering CCC, the focus must be on holistic nursing models that view the individual within a sociocultural context
Purnell’s Model (see handout)
Purnell, L., and Paulanka, B. (2008).
Transcultural health care: A culturally competent approach
(3rd ed.). Philadelphia: Davis.

18. Nursing Assessment
Initial gathering of data followed by a needs assessment
Individuals will approach their illness and healthcare practices from the perspective of their cultural traditions
Not every MA believes in curanderismo, not every Puerto Rican believes in espiritismo, no every Cuban in sanatoria, not every Haitian in voodoo

19. The Sociocultural Assessment
Forms the basis of the plan of care
Individual judgment call by the RN
Determined by the interview
Must avoid imposing our values on the plan of care
Accommodation/negotiation needed to meet cultural needs
Everyone by the last name of Sanchez will not require an extensive socio-cultural assessment, just as every patient does not need a full neurological assessment).
Leininger talks to us about accommodation, negotiation, and repatterning/restructuring…discuss further

20. Using Nursing Theory in Clinical Practice to Deliver CCC
Leininger and Watson

21. Leininger’s qualitative ethnonursing method is defined as “…the study, documentation and analysis of the local or emic people’s viewpoints, beliefs, and practices about actual or potential nursing care phenomena within a particular culture to generate nursing knowledge (Leininger, 2002). The ethnonursing method uses both emic and etic data to obtain knowledge about nursing phenomenon.
The model is based on her theory of Culture Care Diversity and Universality – the result of over 40 years of research studying 87 cultures, discovering 172 care constructs. The Sunrise Model of the theory depicts several culture and social structure dimensions as you can see above. The model describes diverse health care systems ranging from generic or folk health care practices to nursing and professional care practices. According to Leininger’s theory, care is essential for the growth, health, and survival of humans.
Leininger (1991) describes two types of caring which exist in every culture. The first type is generic care, the oldest for of care, and is referred to as folk care practices of a particular culture (Leininger, 1991). The second type of care is professional care which is cognitively , and transmitted knowledge obtained through formal and informal professional education. Professional care includes nursing techniques and practices, ethical aspects of care, interpersonal communication techniques. Professional nursing does not always include ideas about folk care since it may not be known or valued by the nursing profession (Leininger, 1991).
Leininger maintains that if both professional and folk care are not used by nurses, this negatively affects client recovery, health and well being, and research is coming in regarding the impact on patient satisfaction as well.
In order to deliver culturally competent congruent care, RNs must link and synthesize general and professional care knowledge to benefit the client’s health. Nursing is the bridge between the professional and folk health care systems.
According to Leininger, three predictive modes of care are based on the use of generic (emic)care knowledge and professional (etic) care knowledge and this was discovered from her research based on the Culture Care Theory depicted in the model.
The three action modes that guide nursing care decisions and actions are 1)culture care preservation/maintenance; 2) cultural care accommodation/negotiation; 3) cultural care repatterning/restructuring.

22. Watson’s Theory of Human Caring
“The concept of a human care function of the nurse is threatened by the technology, the machines, the high-intensity pace of management, the administrative tasks, and the manipulation of people required to meet the needs of the systems (Watson as cited by Anderson, 1987, p. 7).

23. Watson…
Preservation of human care a critical issue today in our depersonalized society
Important to focus on concept of caring
Important not to lose “caring” in this age of technology

24. Watson… “What is caring”
“Human caring in nursing…is not just an emotion, concern, attitude or benevolent desire. Caring is the moral ideal of nursing whereby the end is protection….of human dignity” (Watson, 1987)

25. Watson… Transpersonal caring
RN enters into the lived experience of another person
The concept of “presence” – being “in the moment” with the patient, centered emotionally and physically with the patient.

26. Watson…
Not only client’s values but our (nurses) values come into play in the caring relationship
Very important when nurse and client are from different ethnocultural groups

27. Ten Tips for Delivering Culturally Competent Care –General Considerations
1. Know client’s birthplace – how long have they been in the US?
2. Know what language your client speaks at home.
3. Know culturally influenced dietary patterns.
4. Know clients religion.
5. Know level of independence before the healthcare visit.
Asking the client questions to pertaining to these ten tips allows the nurse to assess the degree of ethnic affiliation or what Rachel Spector has labeled “heritage consistency” or the degree of acculturation. The greater the ethic affiliation and heritage consistency, the greater the probability that the individual may be influenced by traditional beliefs and health care practices that are rooted in their cultural background. Therefore, the less acculturated an individual is, the more likely they are to adhere to their traditional practices and beliefs. Asking the patient their explanatory model of illness and their usual health practices will assist us with developing the appropriate plan of care.
What Know where your client was born and what the implications of birth place have on healthcare.
Know what language your client speaks at home which may be different than what is used in public.
If the client uses English as a second language, provider may want to ascertain the level of actual versus assumed language comprehension early in the encounter. Allowing family member or friend to accompany patient during exam and act as a translator should be a last resort.
3. Know whether your client has specific dietary patterns based on his or her culture.
4. Know client’s religion, and what treatments may be prohibited because of its teachings. Also know the level of faith and spirituality the client brings to the encounter since it may influence the approach to treatment. (Fatalistic perspective…God’s will).
5. Level of independence before encounter – Is independence a problem for the client, or a welcome asset to the patient’s QOL. Determine patients sick role behavior

28. Ten Tips… 6. Determine client’s support system.
7. Have client describe role of family, and how health issues are handled.
8. Individualize each situation based on cultural values.
9. Assess emotional state of patient.
10. Determine patient’s explanatory model of illness.
6. Do cultural issues exist with in those support systems – give example of Hispanic child with dental caries
7. How are health issues handled at home? Are folk or traditional remedies used such as herbal treatments, traditional healers, etc.? Who is the spokes person within the family? What is the hierarchy?
8. We may know generalizations about a culture, but individual beliefs and practices may vary, so it is vitally important to individualize the healthcare.
Assess the emotional state of the client and try to determine the cultural dimensions that support it.
10. Allow the client to assist you in learning words that describe his/her illness or situation,

29. The Keys to Culturally Sensitive Care
Changing demographics in the US require we move from a monocultural perspective to that of a multicultural one.
There is a need to recognize our biases and ethnocentric beliefs which color the way we view the world and affect how we approach people from different cultural groups. Opening ourselves to other perspectives is exciting and rewarding. When we bring cultural diversity to the table, it enriches and enhances the exchange.

30. Quote…
“Nurses who are prepared to deal with differences are prepared to deal with diversity. The more sensitive we are to cultural differences in our patients, the more sensitive we are to all differences in our patients making us better at providing the unique care each of them deserves” (Malone, 1998).
Malone, B. (1998). The American Nurse, 1998:1. (Beverly Malone, PhD RN, past president of the ANA)

31. Cultural Barriers
Cultural barriers limit HCPs ability to meet patient needs
Not understanding the culture may contradict the beliefs and values
Providing CCC takes strong interpersonal skills, and time
Prejudices, fears and stereotypes interfere with open communication and trust. By understanding, valuing and incorporating the cultural differences with the diverse population, and examining one’s own health related values and beliefs, HCPs can respond appropriately, enhance the efficiency and cost-effectiveness of healthcare deliver, and increase positive patient outcomes/

32. Three Major Worldviews
Magico-Religious
Biomedical
Holistic

33. Magico-Religious Paradigm
In this worldview, supernatural forces dominate
Fate of humans and animals depends of God, or Gods, and supernatural forces of good and evil
The individual is at the mercy of these forces regardless of behavior in some cases

34. Continued… In other cases, gods punish for transgressions
Latino, African American and Middle Eastern cultures are grounded in magico-religious paradigm
Magic involves calling forth and control of supernatural forces

35. Continued…
African American & Caribbean cultures – Voodoo – an aspect of magic

36. Magico-religious: 5 events cause illness
Sorcery, breach of a taboo, intrusion of a disease object, intrusion of a disease causing spirit and loss of soul
Cause of illness or health is mystical “God’s will”
In this paradigm, health/illness belong to community first, individual second
Anyone or all may be offered to explain disease.
Eskimos refer to soul loss and breach of taboo (breaking a social norm, such as committing adultery)
African and American Black – malevolence of sorcerers is cause of illness
Mal ojo or evil eye, common in Latino cultures is intrusion of disease causing agent
Therefore one person may directly or indirectly influence another. This sense of community is absent from the other paradigms

37. Scientific (Biomedical) Paradigm
Newest and most removed; impersonal
Life is controlled by a series of physical and biochemical processes that can be studied and manipulated by humans

38. Continued… Symbolic thought processes: Determinism – cause and effect
Mechanism – life is related to structure and function of machines – can control life through mechanical processes
Reductionism - - all life can be reduced or divided into smaller parts – Cartesian dualism – mind and body can are two distinct entities
Objective materialism – that which is real can be observed and measured
By reductionism, the isolated parts is believed to reveal aspects or properties of the whole.

39. Bio-medical Paradigm…
Discounts the metaphysical
Ignores holistic forces of the universe
Paradigm is espoused by America and Canada dominant culture groups

40. Continued… Dominate Western medical thought
Must understand in order to appreciate modern health care
In this model, all aspects of human health can be understood in physical and chemical terms
Only organic is worth study
Physical and chemical interventions are highly valued

41. Machine Metaphor Disease is viewed as breakdown of human machine
Disease causes illness
Paradigm similar to external agents – supernatural forces are replaced by infectious agents
We have specialists to take care of the “parts” – fixing a part allows the machine to function
Discovery of DNA led to genetic engineering –a biomedical metaphor.
Symbols used to discuss health and disease = the values of mastery and aggression: microorganisms attack the body, war is ranged against t the invaders
Biomedical model defines health as the absence of disease . To be healthy one must be free of all disease.

42. Holistic Paradigm Similar to magico religious paradigm
Forces of nature must be kept in balance or harmony
Everything in the universe has a role
Disturbance of harmony creates imbalance, chaos and disease
Holistic paradigm has existed for centuries

43. Continued…
Holistic paradigm gaining acceptance in US – realization biomedical view fails to account for most diseases as they naturally occur
This paradigm seeks to maintain a sense of harmony between humans and the universe
Explanations of health/illness based on imbalance and disharmony among all forces in nature

44. Continued… Whole person is viewed in context of total environment
In this paradigm health viewed as a positive process
Involves sociocultural, behavioral and diseases of civilization
Diseases of civilization are : unemployment, racial discrimination, ghettos, suicide

45. Metaphors Healing power of nature Health foods Mother earth
All reflect connection t the cosmos and nature
Florence Nightingale – Holistic paradigm
Nightingale believed in control of the environment so that the pt. could heal.

46. Continued…
Yin Yang – Chinese concept – forces of nature in balance to produce harmony
Yin – female force – negative pole (darkness, cold, emptiness)
Yang – male force – positive pole – (fullness, light and warmth)
Imbalance causes illness
Illness is the outward expression of disharmony; disharmony can result from seasonal changes, emotional imbalances or other events
Illness is perceived as a natural event that happens throughout the lifecycle
Because illness is inevitable perfect health not the goal. Living by society rules and taking care of one’s body is the goal. Emphasis placed on prevention and maintenance more so than Western paradigm.
Restoring humoral balance is done by adding or subtracting substances that affect each of these humors.
Foods, beverages, herbs, drugs and diseases are classified as either hot or cold. Disease conditions are also classified as hot or cold.
Each cultural group defines what are the hot and cold entities. This concept is found in Asian, Latino, Black, Arab, Muslim and Caribbean societies.

47. Continued…
Hot/Cold theory – founded on ancient Greek concept of the 4 humors: yellow bile, black bile, phlegm and blood
These are balanced in healthy person
Treatment of disease is based on restoring the humoral balance

48. Health and Illness Behaviors – Culturally Determined
Behaviors that typify the health seeking process -
Expressed in roles people assume when ill
Health behavior – action by individual to maintain health
Illness behavior – action undertaken to remedy the problem

49. Group Family Spiri- tuality Com-muni- cation Auth-ority Work Style
Black
American
Magico-Religious
Strong family ties/
kinship; Extended family an asset; Respect for female control; Strong sense of respect and duty of parental figures
Strong connection to God, seen as control of all people, places and things; Belief in the hereafter
Reliance on perception; Prefer nonverbal style; Their use of direct approach may be viewed as hostile/aggressive; Very expressive; Humor used frequently
Distrustful of most majority culture authority figures; Age is a sign of respect; Moderate respect for positions and titles.
Task oriented; Inter-dependent; Does not like to politic for every favor; Action oriented

50. Hispanic American Magico-Religious
Large extended families who play important role in HC decisions, and with cooperation and support familismo; Like closeness; touching; Male dominant culture
Majority are Catholic; Believe in continuum of mind, body, spirit; Seek alternative and traditional healing at same time
Curanderismo
“Yes” can mean “No” to be polite; rely on non-verbal cues; avoid eye contact; prefer personal relationships personalismo prefer smooth, harmonious relationships simpatia; Varying concepts of time
Deferential based on respect to age, status, education, position; Provider can win their trust
confianza
Inter-dependent; Most often have no health insurance; Hard-working in many service and industrial jobs

51. Asian American Holistic
Family honor is important; Control of emotions; Male centered; Strong discipline with children
Various concepts of God
Silence is respectful; Words used economically; Friendship more important than money (or business)
Politeness is the key social harmony
Extreme respect for authority; Seek advice; Service personnel are problem solvers
Work hard, but impolite to draw attention to oneself; Personal relationship greater than the process; Quiet/passive; Inter-dependent

52. Culturally Competent Communication
Is Your Message Getting Through?
Organize your thoughts
Simplify your language
Highlight important sections of written material
Use visual tools, when appropriate
Avoid jargon, idiomatic expressions
One of the most insurmountable issues in working with culturally diverse people is the language barrier.
If material is provided, make sure the patient can read it. Many minority patients cannot read, so providing written material will be useless.

53. The message… Keep instructions short
Make sure you know who the spokesperson for the family is
Ask patient/or spokesperson to repeat instructions
Make the instructions relevant to the patient
Each culture has a hierarchy for whom is the spokesperson in the family. Many times it is not the patient (give Chinese illustration – woman with cardiac disease, etc.) You must address you instructions to that person in order for the instructions to be followed.

54. High Context-low Context Cultures
High-context cultures
Long-lasting relationships
Exploiting context
Spoken agreements
Insiders and outsiders clearly distinguished
Cultural patterns ingrained, slow change
Low-context cultures
Shorter relationships
Less dependent on context
Written agreements
Insiders and outsiders less clearly distinguished
Cultural patterns change faster
In High context cultures, there are many contextual elements that help people to understand the rules, and as a result much is taken for granted. This is confusion for someone who doesn’t understand the “unwritten” rules of the culture.
Low context, very little is taken for granted. This means that more explanation is needed, but it also means that there is less chance of misunderstanding particularly if one is a visitor.

55. Cultural Classification- Edward Hall
Low-Context Cultures - What Is Said Is More Important Than How or Where It Is Said
U.S.
Germany
High-Context cultures - What Is Said and How or Where It is Said Are Significant
Asia
Latin America
Middle East
Anthropologist at Northwestern University, Evanston, Illinois – wrote a book on Understanding Cultural Differences to help American businessmen understand German and French behavior e.g. give illustration of American business man performs poorly, manager will praise and criticize; German manager will confront employee directly; praise and criticism confuses the German; the French will simply remove a support system – but each employee gets the message loud and clear

56. Cross-cultural Values
Individualistic Society
Freedom
Independence
Self-reliance
Equality
Individualism
Competition
Efficiency
Time
Directness
Openness
Group Centered Society
Belonging
Group harmony
Collectiveness
Age/seniority
Group consciousness
Cooperation
Quality
Patience
Indirectness
Go-between

57. Cultural Competence and Evidence-Based Practice
Cultural Competence is important contemporary concern for healthcare
AMA, ANA, OMH, as well as regulatory agencies have published standards and position statements promoting CCC
Clinical application remains challenging
Challenges include the abstract nature of the concept of cultural competence

58. The cultural competency continuum developed by Cross, Bazron, Dennis and Issacs (1989) illustrates cultural competence on a scale from cultural destructiveness to cultural proficiency. This can be translated into biomedical values. For example Nonmaleficense (do no harm) coupled with beneficence represents the cornerstone of medical ethics. Maleficense is equivalent to cultural destructiveness. Incompetence or lack of competence is equivalent to cultural incapacity. Cultural incapacity refers to nonintentional destructives from practices or actions that may be harmful to patients and their families through ignorance, insensitive attitudes. Consistent with these ethical principals laws and regulatory standards have identified these harmful behaviors as inappropriate in the hc industry.

59. Continued…
Integrating the cultural competency continuum with components of evidence-based care (best research practice, clinical expertise, patient’s values and circumstances) can promote EBP culturally competent, congruent and sensitive care and positive patient outcomes.

60. The End!

61. References Cross, T., Bazron, B., Dennis, K., &
Isaacs, M. (1989). Towards a culturally
Competent system of care, Washington,
D.C.: Child and Adolescent Service System
Program Technical Assistance Center,
Georgetown University Child Development Center.

62. References
Engebretson, J., Mahoney, J., & Carlson, E. (2008). Cultural
competence in the era of evidence
based practice. Journal of Professional
Nursing, 24(3), pp

63. References Hall, E. (N/D). Hall’s cultural factors.
accessed 3/4/2009 from
minds.org/explanations/culture/
hall_culture.htm
Leininger, M., & McFarland, M. (2005).
Culture care diversity and universality.
New York: Jones and Bartlett