Culture and Cultural Competence
Pamala D. Larsen
Sonya R. Hardin
INTRODUCTION
Concepts of health and illness are deeply rooted in culture, race, and ethnicity and influence an individual’s perceptions and behavior. Additionally cultures are never homogeneous (Helman, 2007), as there are variations and subcultures within culture, affecting health and illness perceptions differently. So, although, one may know the “norms” of Chinese culture, Puerto Rican culture, or Indian culture, for instance, there will always be unique differences in each individual from that culture.
According to the Office of Minority Health (2005), culture (and language) influences:
Health, healing, and wellness belief systems
How illness, disease, and their causes are perceived; both by the patient/consumer and the provider
The behaviors of patients/consumers who are seeking health care and their attitudes toward providers compromising access and care for those of other cultures
The delivery of services by the provider who looks at the world through his or her own limited set of values, which can compromise access for patients from other cultures
There are factors other than culture that influence health and illness. Factors include, but are not limited to, environment, economics, genetics, age, previous and current health status, personality, social support, and psychosocial factors. Caring for the individual, family, and community is therefore influenced by numerous factors of which culture is only one. In Canada, culture is identified as one of the 12 determinants of health (Racher & Annis, 2007).
Currently in the United States there are continuing disparities in health care among those of different cultures, races, ethnicities, and socioeconomic status (Agency for Healthcare Research and Quality [AHRQ], 2010). Throughout the literature, becoming culturally competent is seen as the first step in decreasing and eventually eliminating those disparities. Although being culturally competent is important on an individual basis, becoming so as an organization is just as important. The National Center for Cultural Competence has identified six reasons that organizations should incorporate cultural competence into policy:
To respond to the current and projected demographic changes in the United States
To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds
To improve the quality of services and health outcomes
To meet legislative, regulatory, and accreditation mandates
To gain a competitive edge in the market place
To decrease the likelihood of liability/malpractice claims (Cohen & Goode, 2003)
Defining Terms
Culture
The literature provides many definitions of culture. Within the nursing literature, each individual with his or her model/theory of transcultural nursing has a different definition. Although there is value in those definitions, perhaps one from medical anthropology offers a broader perspective. Helman (2007) defines culture as “a set of guidelines (both explicit and implicit) that individuals use to view the world and tell them what behaviors are appropriate” (p. 2). Culture is shared, learned, dynamic, and evolutionary (Schim, Doorenbos, Benkert, & Miller, 2007). This evolution is described by Dreher and MacNaughton (2002): “People live out their lives in communities, where circumstances generate conflict, where people do not always follow the rules, and where cultural norms and institutions are massaged and modified in the exigencies of daily life” (p. 184).
Typically one thinks of culture as associated with race and ethnicity. However, other cultures exist if a broader definition of culture is used. Examples include the culture of poverty, the culture of cancer survivors, the culture of rurality, and the culture of chronic illness (see Chapter 2), to name a few. Each of these cultures has explicit and implicit guidelines that determine how their members view the world, decide upon appropriate behaviors, and perform those behaviors.
Cultural Competency
Many definitions of culture mandate that there are many definitions of cultural competence. Table 13-1 lists some of the more common definitions found in the literature. The National Prevention Information Network (2011) lists eight principles of cultural competence:
Define culture broadly.
Value clients’ cultural beliefs.
Recognize complexity in language interpretation.
Facilitate learning between providers and communities.
Involve the community in defining and addressing service needs.
Collaborate with other agencies.
Professionalize staff hiring and training.
Institutionalize cultural competence.
Cultural competence for systems and organizations may be seen on a continuum (Racher & Annis, 2007; Srivastava, 2007). The Cultural Competence Continuum was developed by the National Center for Cultural Competence (NCCC) at Georgetown University, in Washington, DC. There are six levels on the continuum, spanning from cultural destructiveness at level 1 to cultural proficiency at level 6, the highest level. When an organization is culturally proficient, it holds culture in high esteem and uses this perspective to guide its work (Racher & Annis, 2007, p. 263).
Cultural Awareness and Sensitivity
Often times we hear the terms cultural awareness and cultural sensitivity. What is their relationship with cultural competency? Purnell (2008a, p. 6) explains awareness as an appreciation of the external signs of culture, whereas
sensitivity is one’s personal attitude toward others of different cultures. Although awareness and sensitivity are part of cultural competence, competency implies that awareness and sensitivity have been operationalized (Schim et al., 2007).
sensitivity is one’s personal attitude toward others of different cultures. Although awareness and sensitivity are part of cultural competence, competency implies that awareness and sensitivity have been operationalized (Schim et al., 2007).
Table 13-1 Cultural Competency Definitions | ||||||||||||||
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Myths of Culture and Diversity
Myths of culture and diversity must be challenged. Masi (1996) and Srivastava (2007) discuss six myths that can influence caring for culturally diverse clients.
The Myth of Equality
This myth describes that fairness means equal treatment for all (Srivastava, 2007, p. 42). Proponents of this myth cite success stories of individuals of varying ethnic, racial, and gender backgrounds who have overcome great obstacles and “made it” as individuals. However, this view reflects a lack of awareness of systemic barriers and institutional racism. It is a narrow view that places all responsibility on the individual without acknowledging systemic inequities.
The Myth of Sameness
The assumption of this myth is that someone who shares the client’s ethnicity and language will be able to more effectively provide health care and thus eliminate miscommunication (Masi, 1996; Srivastava, 2007). However this “sameness” may be only on the surface, as there may be many other differences that affect the client and healthcare professional relationship. This also presumes a narrow definition of culture (race and ethnicity) as opposed to a broader view.
The Myth That Cultural Differences Are a Problem
Health care has often viewed issues of culture and diversity from a negative perspective, that there are problems or barriers to overcome. Srivastava (2007, p. 46) suggests that culture should not viewed as a problem, but as a leverage point, a point that can affect the health outcome of the client if energy is focused on it.
The Myth That Everything Must Be Acceptable
There is a perception that if something is a cultural value that it must be “accepted.” Masi (1996) suggests that respecting an individual’s cultural value not be confused with acceptance. He describes that although society states that child abuse is unacceptable, the definition of child abuse may vary among individuals from different cultures. A practice known as “scratching the wind,” where bruises are caused by cupping and scratches are created by running a coin on the skin, is used to relieve fevers and illness in some cultures. Respecting this cultural value does not mean acceptance of this practice.
The Myth That Generalizations Are Unacceptable
Masi (1996) and Srivastava (2007) suggest that there is a large difference between generalizations and stereotypes. Generalizations are a necessary starting point to understand groups of individuals as they indicate trends and patterns. These generalizations may help a healthcare professional initiate a conversation with a client. In contrast, stereotypes close conversation and knowledge development (Srivastava, 2007, p. 47).
The Myth That Familiarity Equals Competence
Familiarity with cultural differences may make the difference invisible (Srivastava, 2007, p. 48). This myth dovetails with the one about generalizations, and means that being familiar with a certain culture does not make one competent, as familiarity may not allow for individual differences.
Transcultural Nursing
Transcultural nursing had its beginnings in the 1950s with Madeleine Leininger. With her work over more than 50 years, in addition to other theorists, transcultural nursing has evolved as a specific and unique specialty. Transcultural nursing is defined as “as a formal area of study and practice focused on comparative human-care (caring) differences and similarities of the beliefs, values and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people” (Leininger & McFarland, 2002, p. 6).
Leininger and McFarland (2002) summarize eight factors that led to the development of and need for transcultural nursing:
Increase in immigration and migration of people across the world
Implicit expectation that nurses and other healthcare providers need to know, understand, respect, and respond appropriately to care for others of diverse cultures
Increase in the use of technologies in caring or curing, with different responses and effects on clients of diverse cultures
Increased signs of cultural conflicts, cultural clashes, and cultural imposition practices between nurses and those from diverse cultures
Increase in number of nurses who travel and work in different places in the world
Anticipated legal defense suits against nurses resulting from cultural negligence, cultural ignorance, and cultural imposition practices in working with diverse cultures
Rise in gender and the issues and rights of special groups
Growing trend to care with and for people, whether well or ill, in their familiar or particular living and working environments (Leininger & McFarland, 2002, pp. 13-18)
The Transcultural Nursing Society, founded in 1974 by Leininger, is a worldwide organization for nurses and others interested in and prepared to advance transcultural nursing. The society provides a forum to bring nurses together worldwide with common and diverse interests to improve the care for culturally diverse people.
The goals of the society include:
To advance cultural competencies for nurses worldwide
To advance the scholarship (substantive knowledge) of the discipline
To develop strategies for advocating social change for cultural competent care
To promote a sound financial non-profit corporation (www.tcns.org)
IMPACT
Changing Demographics
According to the 2010 U.S. Census, approximately 35% of the U.S. population is defined as racial and ethnic minorities. Currently four states—Hawaii, New Mexico, California, and Texas—as well as the District of Columbia have minority populations that exceed 50%. Texas is the newest addition to this short list. In 2050, 20% of the population aged 65 and older is projected to be Latino. (U.S. Census Bureau, 2010a)
The North American healthcare system(s) is based on Western culture, and that includes using a biomedical model. With an increasingly diverse society, this narrow view continues to create a mismatch with clients and their healthcare needs and services.
As we age, the potential for having one or more chronic diseases increases significantly, thus the need to look at demographics of aging Americans is paramount. Currently non-Latino older adults account for approximately 83.5% of the older adult population. Projections for 2050 indicate that this percentage will decrease significantly. Given these projections, a culturally competent workforce will be needed to meet the needs of individuals from many cultural and ethnic groups (see Table 13-2).
Table 13-2 Projected Distribution of the Population, Age 65 and Older, by Race and Hispanic Origin: 2010, 2030, and 2050 | ||||||||||||||||||||||||||||||||||||||||||||||||
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Health Disparities
Although the focus of this chapter is culture and its influence on individuals with chronic illness, health disparities that occur with individuals from different cultures must be noted as well. Race, ethnicity, and culture sharply divide the health and health care of the population in the United States. Although such disparities have been noted for some time, the Institute of Medicine report, Unequal Treatment (Smedley, Stith, & Nelson, 2003), was a landmark publication that put these disparities in the forefront. This report demonstrated that racial and ethnic disparities in health care, with a few exceptions, are consistent across a range of illnesses and healthcare services.
The same year that Unequal Treatment was published, the AHRQ released the first annual National Healthcare Disparities Report.
Their seventh report was released in March of 2010. Overall, three themes emerged from that report:
Disparities are common and uninsurance is an important contributor.
Many disparities are not decreasing.
Some disparities merit particular attention, especially care for cancer, heart failure, and pneumonia. (AHRQ, 2010, p. 1)
Some of the biggest disparities noted in this latest report include:
Blacks had a rate of new AIDS cases 10 times higher than Whites, for Latinos more than 3 times as high, and for American Indians/Alaska Natives 1.4 times as high.
Black older adults and older adults of multiple races were more likely than White older adults to delay care due to cost.
In small metropolitan areas, the heart attack death rate was higher for Latinos than for Whites: 97.2 per 1,000 admissions compared with 70.8 per 1,000 admissions. (AHRQ, 2010)
Another national document that addresses health disparities is Healthy People 2020. The document has four overarching goals, two of which address health disparities: 1) achieve health equity, eliminate disparities, and improve the health of all groups; and 2) promote quality of life, healthy development, and healthy behaviors across all life stages. As healthcare professionals, the need is paramount to incorporate appropriate strategies into clinical practice with an awareness of different cultures to allocate resources fairly within society. Efforts to address racial, ethnic, and other disparities in health care requires nurses to employ creative interventions to assure culturally competent care for these populations.
Beidler (2005) states that health disparities occur in vulnerable patients who are uninsured, racially and ethnically diverse, and frequently speak languages other than English. Maze (2005) refers to health disparities existing among individuals who are disenfranchised, living in poverty, stigmatized, homeless, immigrants, victims of crimes, children, women, prisoners, persons with AIDS, persons with mental illness, and those who have little social support or education. These individuals make up a vulnerable population and may present with a variety of ethical issues for the healthcare professional. For example, illegal immigrants may be hesitant to provide a name, address, and phone number for follow-up care. Should the healthcare provider try to obtain this information from the illegal immigrant? Remember, the client may be fearful that you will “turn them in” to the authorities.
In 2009, the number of people without health insurance decreased overall and for most racial and ethnic groups, but Asian Americans experienced an increase in uninsurance. Overall out-of-pocket healthcare costs increased by 4.3%, which resulted in the rate of delaying medical care increasing by 5.4% (The Opportunity Agenda, 2009).
Racial and Ethnicity Classification
In 1997 the Office of Management and Budget (OMB) identified the following categories to be used by federal programs when reporting data: American Indian or Alaska Native; Asian; Black or African American; Hispanic or Latino; Native Hawaiian or other Pacific Islander; and White. American Indian or Alaska Native refers to people of North and South America and those who maintain tribal affiliations (Wallman, 1998). An Asian is a person with origins in the Far East, Southeast Asia, or the Indian subcontinent. Black or African American refers to individuals with origins from any Black racial groups of Africa. Hispanic or Latino is an individual of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin. Native Hawaiians or other Pacific Islanders have origins in Hawaii, Guam, Samoa, or other Pacific Islands. White is a person having origins in any of the original people of Europe, the Middle East, or North Africa. However, with individuals from mixed origins, it may be difficult to assign an individual to one specific ethnic group. In 2007, the Department of Education added a seventh category of “two or more races” for the purpose of collecting and maintaining racial and ethnic data from students and staff, which was to be used starting in 2010 (Department of Education, 2007).
Examples of Different Cultures
The following examples of the Haitian culture, Mexican culture, and Japanese culture are brief overviews and generalizations of what is known about each culture. Disease labels in each of these cultures have different influences and meanings among clients (Turner, 1996).
In addition, the longer that one is a resident in this country (or other countries), subcultures of the original culture evolve, with each one being more unique.
Haitians
Haitians are from Haiti, an island between Cuba and Puerto Rico about the size of the state of Maryland. The Haitian population in the United States is approximately 830,000 (U.S. Census Bureau, 2010b), or approximately 0.3% of the total population.
The influence of France’s rule of Haiti from 1697 to 1804 identified two distinct categories of Haitians. Members of the upper class used the marker of mulatto (color), the French culture, and the French language to differentiate themselves from the lower class. Those speaking French rose within the social system. The lower class was mostly black and spoke the Haitian Creole language, which is a combination language of multitribe slaves of Africa. Today, Creole is the official language of Haiti (Colin & Paperwalla, 2008).
Traditionally, the man has been considered the head of the household, the primary income provider, the decision maker, and the sexual initiator, whereas women are to be faithful, honest, respectful, and oversee the house (Dash, 2001). However, this may be changing, as a number of families are becoming matriarchal today (Colin & Paperwalla, 2008). The family unit remains an important concept of Haitian culture.
Haitian people are openly demonstrative in their emotions and typically speak loudly. They have a close personal space and may ignore territorial space. Many may pretend to understand, when in reality they are nodding to be nice and to avoid showing a lack of understanding. The use of simple and clear instructions is needed when providing education to enhance the health of the individual. Haitians are private, and if they do not understanding something, will more than likely choose to use a professional interpreter over a family member (Colin & Paperwalla, 2008).
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