With increasing diversity in the population, and the recognition that health disparities exist across ethnic groups, healthcare regulatory agencies recommend that cultural competency become a goal in the provision of health care. The Office of Minority Health developed standards and recommendations that apply to the institutional level as well as to the individual provider.¹ Institutions are mandated to provide adequate translation, and individual providers are encouraged to develop more culturally appropriate care.

The idea of developing cultural competence has been increasingly discussed in the literature. The National Center for Cultural Competency at Georgetown University developed an often cited conceptual framework created by Cross, Barzon, Dennis, and Issacs that describes a continuum from cultural destructiveness to cultural competency.² This continuum positions cultural destructiveness at the lowest level, with four intermediary steps to cultural proficiency at the top. This continuum can be viewed as corresponding to well-established values in medicine. Figure 30-1 illustrates this continuum along with parallel values in biomedicine with a recent value of evidence-based practice superimposed on the model.³

Cultural destructiveness, the lowest level of the continuum, corresponds to maleficence in medicine and this is countered through laws such as the Civil Rights Act of 1964 (Title VI), which mandates that healthcare providers do not discriminate
according to race, ethnicity, or creed. The ethic of nonmaleficence, or “do no harm,” also addresses this basic level. The second level of the continuum, cultural incapacity, corresponding to incompetence, refers to nonintentional practices that may be harmful to clients through ignorance, insensitive attitudes, or improper allocation of resources. Cultural blindness, the third level that corresponds to standardization, is exemplified by treating all patients alike without accommodating or recognizing cultural differences. Precompetence, corresponding to outcomes-focused care, is the next step toward cultural competence and proficiency. Providing translators, developing health education aimed at specific cultural groups, and creating programs that address diverse groups’ access to care are good examples of cultural precompetence, which is level 4. Cultural competence, level 5, is best described as an ongoing learning process for the provider, who can integrate cultural knowledge into individualized client-centered care. This eventually leads to the highest level of the continuum, cultural proficiency. These two levels correspond to the movement to patient-centered care, or what holistic nurses would identify as individually focused holistic care.

Evidence-based practice has been an important issue in healthcare delivery. It grew out of the outcomes-focused value, as an effort to incorporate the best research evidence in healthcare delivery. In the focus on applying these findings, many revert back to standardized care or cultural blindness. According to some of the leaders in the evidence-based practice field, practicing in a culturally competent manner incorporates three aspects of evidence-based practice (EPB): best evidence from valid and clinically relevant research, provider’s clinical expertise, and the client’s values, unique preferences, and situation.⁴ The emphasis on the client’s values, preferences, and situation moves EBP into cultural competence and proficiency. Much of the literature in cultural competency also tends to focus only on the evidence or the studies or the literature that describes particular ethnic groups. It is important for holistic nurses to recognize that applying that information to clients of a specific ethnic group is only at the precompetence level at best. However, at the individual patient-provider encounter, it must be individually based and patient-centered.

Culturally competent health care must be provided within the context of a client’s cultural
background, beliefs, and values related to health and illness to attain optimal client outcomes. To enhance one’s understanding of cultural issues, it is therefore important for nurses to continue their understanding of cultural diversity. In addition to the Transcultural Nursing Society, there is a corpus of literature in nursing about cultural competence.⁵,⁶,⁷,⁸,⁹,¹⁰

A plethora of sensitivity training and educational programs has been implemented, and curricula have been developed in nursing and other healthcare professions. Lipson and Desantis recently reviewed a number of approaches in nursing education and concluded that there is a lack of consensus on what should be taught and how it should be integrated into the curricula.¹¹ A recent systematic review of healthcare provider education was also conducted, concluding that cultural competence training shows promise for improving knowledge, attitudes, and skills of the healthcare professionals. However, there was little evidence in client outcomes.¹² Most educational approaches have addressed knowledge, attitudes, and skills. Knowledge has often focused on facts and characteristics about specific cultures. This “cookbook” approach has been criticized as leading to stereotyping. The approach of cultural sensitivity training attempts to address attitudes. What seems to be more valuable is for providers to learn a set of skills that enables them to provide high-quality client care to everyone.

In a literature review of cultural competence and the clinical encounter, Betancourt concludes that healthcare providers develop the skills for a client-centered approach that does the following: (1) assesses core cross-cultural issues, (2) explores the meaning of the illness to the patient, (3) determines the social context in which the patient lives, and (4) engages in a negotiation process with the patient.¹³ Cultural competence represents an important element of clinical care and skills that are central to professionalism across disciplines. The relationship between cultural competency and improvement in health outcomes is not yet firmly established and more research is warranted.¹⁴ Although there is much emphasis now on developing cultural competency, there is also a developing awareness that competency is always a growth process, which means that it requires more than an accumulation of facts about different cultures.¹⁵ The clinical encounter, in which cultural competency is most demanding, requires individual- or family-centered care.¹⁶

Despite the fact that human beings are 99.9% identical at the DNA level, there are differences in prevalence of illness between groups. This may be explained by genetic differences; dietary, cultural, environmental, and socioeconomic factors; or combinations thereof.¹⁷ Health disparities in the United States exist for multiple health outcomes. For example, in the United States, infant mortality is inversely related to the mother’s educational level. It is also highest for infants of non-Hispanic black mothers and is lowest for those of Chinese mothers.¹⁸ According to a recent Centers for Disease Control and Prevention (CDC) report, some of the key social determinants of health include education and income, inadequate and unhealthy housing, unhealthy air quality, and health insurance coverage.¹⁹ Socioeconomic status underlies three major determinants of health: access to health care, environmental exposure to health-related agents, and health behaviors.²⁰

Ethnicity refers to values, perceptions, feelings, assumptions, and physical characteristics associated with ethnic group affiliation. Often, ethnicity refers to nationality—a group sharing a common social and cultural heritage. In contrast, race typically refers to a biological, genetically transmitted set of distinguishable physical characteristics. In some literature, however, race has often been misused to describe differences in people that have no basis in biology or science. Demographic data are commonly gathered with no differentiation of ethnicity or definitions of race. Both skin color and country of origin have been used to classify race. For example, many natives of India (considered racially Caucasian) have darker skin than do many natives of Africa.

Race and culture have significant relationships to illness states because biological differences can make certain groups of people vulnerable to specific diseases. For example, genetic predisposition
for sickle cell disease affects people of African and Mediterranean descent; predisposition for Tay-Sachs disease affects Ashkenazi Jews. Also, certain diseases that may be attributable to a combination of genetic predisposition and lifestyle, including nutritional patterns, are more prevalent in some groups. One example is the disproportionately high prevalence of diabetes in Native Americans and Hispanics. Some diseases are connected to lifestyle risks, such as substance abuse and human immunodeficiency virus (HIV) infection, which are related to particular social behaviors. An emerging body of information on the differences in response to pharmaceuticals by ethnic and racial groups has led to a new field of pharmacogenomics.²¹ Cultural subgroups can be identified by virtue of shared experiences or circumstances that may influence values, beliefs, and behaviors. Ethnicity is the most common cultural demarcation, but intraethnic variations may be more pronounced than interethnic variations, especially in a culturally pluralistic society. Other variables that have been proposed as influencing cultural groupings are religion, socioeconomic status, geographic region, age, common beliefs, and professional orientation, such as nursing and medicine.

Errors of stereotyping are common among those who define the world by strict categories
of ethnicity or race. It is also problematic to presume that all members of another culture conform to a common pattern without regard to individual characteristics or the variety found within one cultural grouping. For example, some people assume that all African Americans eat soul food or that all Hispanics are Catholic. Failure to recognize that values from a particular cultural group can vary across time and location leads to stereotyping cultures with values that no longer guide the group’s or the individual’s thinking or behavior. Stereotyping is less obvious in some cases, such as a nurse manager assigning all Hispanic clients to the Mexican American nurse. Such action does not take into account the differences within the Hispanic group, presumes that all Hispanics are alike, and disregards the individual.

The heterogeneity of ethnic groups is often underestimated, but as mentioned earlier, the variations within ethnic groups may be as great or greater than those between ethnic groups. For example, the Hispanic culture includes persons of Puerto Rican, Cuban, Spanish, and South and Central American origins. These people are from many different socioeconomic backgrounds and represent the Caucasian, Mongoloid, and Negroid racial groups. Sometimes Asians from different countries and backgrounds are grouped together and treated as generic Asians, an attitude that totally ignores the historical differences among Asians. Kipnis relates a clinical incident that occurred in Hawaii in which a Korean client with a serious medical condition refused a treatment that promised a better than 50% recovery with minimum risks.²⁵ Clinical staff were puzzled by his refusal of treatment coupled with his request for life support if he experienced cardiopulmonary arrest. On further investigation, he mentioned that all his physicians were Japanese. In the early 1900s, Japan had ruthlessly tyrannized Korea, much as the Nazis in Germany tyrannized Poland prior to and during World War II. Thus, the Korean gentleman very much wanted to live, but his cultural history caused him to refuse treatment directed by the Japanese physicians.

Ethnocentrism is the tendency, usually unconscious, for individuals to take for granted their own values as the only objective reality and to look at everyone else through the lens of their own cultural norms and customs. Ethnocentric views often result from a lack of knowledge of other cultures and the presumption that one’s own behavior is not influenced by culture. Many people of the dominant culture falsely assume that they have no cultural practices and beliefs. This restrictive view of the world perceives people and cultures with different beliefs and behaviors as culturally inferior. An extreme and more conscious form of ethnocentrism is xenophobia, an inherent fear of cultural differences, which often leads people to bolster their security in their own values by demeaning the beliefs and traditions of others. This attitude often takes the form of prejudice or racism.

Cultural imposition is the perception that successful cultural adaptation involves a change to the cultural views of the dominant group, regardless of an individual’s cultural heritage. This posits an inherent view that the dominant culture is superior, and its values are imposed on others.

Often disguised as equal treatment for everyone, cultural blindness ignores cultural differences as if they did not exist. This view overlooks real diversity and the importance of other perspectives. The concept of the “melting pot” assumes that, in the process of acculturation and assimilation, everyone takes on significant aspects of the dominant culture such that the original culture is largely lost. This assimilation or melting pot view is challenged by concepts of heritage consistency, which is the degree to which one maintains practices and beliefs that reflect one’s own heritage.

Anthropologists have studied practices among cultures in relation to the universal experience of being human. Their major focus has been on the variation of ways that humans organize and structure their social world. Some of the factors that contribute to the development of cultural patterns and behavior are geography and migration, gender-specific roles, value orientations and cultural beliefs, and technological development.