ONE
Overview of Key Issues and Concerns
with contributions from Kevin Antoine
Educators everywhere are challenged to learn how to lead the quest for culturally congruent health care by implementing creative, evidence-based educational activities that promote positive cultural competence learning outcomes for diverse students and health care professionals, aiming to reach beyond minimal competence to the achievement of optimal cultural competence.
SNAPSHOT SCENARIO
Carrie: I want to provide the best care possible to my patients. This goal has become increasingly challenging in such a rapidly changing world.
Hope: I hope I’m meeting the needs of my patients and their families. The patient population is becoming so much more diverse.
Minnie: It’s so overwhelming with all the changes in the health care system, globalization, new and different patient populations, and complex diseases. I try to give the standard care to everyone and that just has to be good enough. Meeting even the minimum requirements is challenging. I can’t do anything extra special.
Justine: Social justice demands cultural competence. Without culturally congruent care, disparities in health and health care will continue to exist. Cultural competence is a right, not a privilege. Therefore, culturally congruent care is not special; it’s an expectation. It’s part of quality and safety for every patient.
Maxwell: I agree. “Good enough” is just not good enough. Health care professionals should strive for developing optimal cultural competence. Everyone deserves the best. Would you want a minimum standard of care for yourself or for a loved one? Or would you opt for and expect optimal care?
Ernesto: I really want to provide high quality care that incorporates culture but I’m not at all sure about how to begin.
Desiree: I also desire to make a positive difference in health care through developing optimal cultural competence, but I’m not confident that I know key issues, obstacles, or solutions.
Barry: There are lots of barriers towards developing culturally competent health professionals. One of the biggest barriers is a lack of diversity within the professional workforce and academia.
Rainbow: I was raised to appreciate all types of diversity, so valuing diversity in the workforce is very important to me. I’m not confident about my role as a new graduate nurse or about how to shine amid the clouds of uncertainty and evolve from novice to expert. It’s all a new process.
Waldo: Who knows where I am in this process of developing cultural competence? I feel lost and alone in this, even though I’m always surrounded by many people (including other nurses) representing a “diversity of diversity.”
Dora: I think we could all benefit from exploring key issues, searching for answers, and discovering what resources are available to help us on this journey of self-discovery and learning.
Bob: Part of our discovery should be utilizing valid tools and toolkits effectively in a complementary and scaffold fashion in order to build a strong foundation that will support and sustain future growth and expansion toward optimal cultural competence.
Wanda: What are some key issues and topics? What resources are available? Where should I start? How can I become more confident in providing culturally congruent care and meeting the needs of diverse patients?
Meeting the health care needs of culturally diverse clients has become even more challenging and complex. In addition to acknowledging the cultural evolution (growth and change) occurring in the United States (and other parts of the world), it is imperative that nursing and other health care professions appreciate and understand the impending cultural revolution. The term cultural revolution implies a “revolution of thinking” that seeks to embrace the evolution of a different, broader worldview (1). Both cultural evolution and cultural revolution have the potential to bring about a different worldview regarding cultural care and caring by including key issues previously nonexistent, underrepresented, or invisible in nursing and health care literature. This new vision challenges all health care professionals to embark upon a new journey in the quest for cultural competence and culturally congruent care for all clients (1). This new journey also challenges health care professionals and organizations to go beyond the goal of achieving “competence” (minimum standard) toward the goal of achieving “optimal” cultural competence (standard of excellence). Educators everywhere are additionally challenged to learn how to lead the quest for culturally congruent health care by implementing creative, evidence-based educational activities that promote positive cultural competence learning outcomes for culturally diverse students and health care professionals who are aiming to reach beyond minimal competence to the achievement of optimal cultural competence.
This transformational journey begins by seeking to understand the key issues, concerns, and new challenges facing health care consumers and professionals today and in the future. This chapter evokes professional awareness, sparks interest, stimulates revolutionary thought, highlights vital information, and shares new ideas concerning the health care needs of culturally diverse clients and the development of cultural competence among culturally diverse health care professionals. Cultural competence has been described as a multidimensional process that aims to achieve culturally congruent health care (1–8). Culturally congruent health care refers to health care that is customized to fit with the client’s cultural values, beliefs, traditions, practices, and lifestyle (4). It is beyond the scope of this chapter to provide a summary review of the existing literature concerning cultural competence and health care. Rather, this chapter emphasizes select points from the literature, identifies future complexities and challenges in health care, discusses factors influencing cultural competency development, and proposes a construct involved in the process of cultural competence development and education.
What do you already know about cultural competence and health care? What do you seek to learn about cultural competence and health care? What are some key issues that contribute to complexities, changes, and challenges in health care?
COMPLEXITIES, CHANGES, AND CHALLENGES IN HEALTH CARE
Rapid increase in global migration, changes in demographic patterns, varying fertility rates, increased numbers of multiracial and multiethnic individuals, and advanced technology contribute to cultural evolution. For the purpose of this book, cultural evolution refers to the process of cultural growth and change within a society (1). In the existing nursing literature, cultural growth, change, and the need for culturally congruent nursing care has been reported across the world. Although this book features cultural changes in the United States, readers should recognize that globalization is a worldwide phenomenon, with populations now moving more frequently than ever before. Because more people are migrating to several different places, the acculturation experience may include cultural values and beliefs (CVB) assimilated from more than one source, resulting in new ways of expressing traditional CVB and/or resulting in new cultural values and belief patterns. Consequently, health care professionals are challenged to meet the needs of changing societies in new and different ways.
The U.S. Census Bureau (9) and Healthy People 2020 (10) provide valuable data about select population characteristics; however, they are limited to providing information about cultural values, beliefs, behaviors, and practices associated with the many diverse cultural groups existing within the United States. For example, it is helpful to know that minority populations are increasing more rapidly than White, non-Hispanic, nonimmigrant populations (as determined by such variables as age and fertility rates), further justifying and demanding increased population-specific resource allocation (11–16). It is also crucial to have identified health disparities, high priority areas, goals, and proposed strategies for improvement; however, nurses and other health care professionals must become actively aware of the diverse cultural groups comprising each designated minority category if Healthy People 2020 goals (and beyond) are to be met (8, 12, 13, 17, 18). For example, the “Hispanic” category may include individuals whose heritage may be traced to Cuba, Nicaragua, Mexico, Puerto Rico, Peru, Spain, and/or other countries, each also representing much diversity within and between groups. Diversity may exist based on birthplace, citizenship status, reason for migration, migration history, food, religion, ethnicity, race, language, kinship and family networks, educational background and opportunities, employment skills and opportunities, lifestyle, gender, sexual orientation, socioeconomic status (class), politics, past discrimination and bias experiences, health status and health risk, age, insurance coverage, and other variables that go well beyond the restrictive labels of a few ethnic and/or racial groups. The diversity of diversity recognizes that culture is more than just “labels” and necessitates individualized appraisal to incorporate culturally congruent care and achieve optimal outcomes.
The projected increase of multiracial and multiethnic (multiple heritage) individuals in the United States (19–27) and throughout the world demonstrates a growing change in demographic patterns, adding to this new cultural evolution. Forced single category choices and/or the “other” category make the unique culture of the multiracial and multiethnic individual invisible (1, 28, 29). In the 2000 U.S. Census, 6,826,228 individuals identified as being of more than one race (9), and by 2050 it is estimated that one in five Americans will identify as being multiracial (30). Although the 2000 U.S. Census permitted individuals to select more than one racial/ethnic category, the lateness of this option demonstrates the reluctance of society to acknowledge and appreciate the existence of mestizo (mixing) in the United States (31). The late repeal of the last laws against miscegenation (race mixing) in the 1970s attests not only to societal reluctance, but also to political resistance reflecting the racial ideologies of some White Americans (32). Current politics and policies have not kept pace with changing demographics and raise questions about attitudes toward multiracial people, prevalence of anti-discrimination policies directed at individuals who identify with a single race, and other disparities that keep multiracial and multiple heritage individuals “invisible” (26, 27, 29, 33, 34).
Inconsistent use of data from individuals selecting more than one census category is confusing and typically favors the antiquated process of assigning individuals to one category only; usually the minority status or politically advantageous category is selected. For example, when reporting the number of “minority” individuals within a public school system for the purpose of demonstrating integration within a predominantly White school, someone selecting “Black” and “White” would be assigned as being “Black.” In reality, it may be impossible for a multiethnic and/or multiracial individual to choose one ethnic or racial identity over the other (25, 34–36). Multiple heritage identity can include membership within one select group, simultaneous membership in two or more distinct groups, synthesis (blending) of cultures, and/or fluid identities with different groups that change with time, circumstance, and setting (24, 25, 37–39). Moreover, multiple heritage individuals often describe being “multiracial” or “multiethnic” as a separate and unique culture (24–26, 34, 39). Culturally congruent care must begin by openly acknowledging the uniqueness of multiple heritage individuals and seeking to learn about their lived experience. Multiple heritage individuals present unique concerns and challenges for transcultural nurses, other health care professionals, and educators because of little related research and few published studies in nursing and health care (1, 25–29, 34).
Similarly, other underrepresented, invisible, unpopular, or new issues present complexities and challenges to health care professionals because of the lack of substantive research, resources, and expertise specifically targeting such topics related to culture and changing populations (cultural evolution). With the rapid changes and influx of new populations from around the world, nurses are, more than ever before, faced with the challenge of caring for many different cultural groups. Changes are occurring more rapidly in urban, suburban, and rural areas, often with cultural groups clustering together in ethnic neighborhoods. This means that there is less time for nurses to learn about and become accustomed to new cultural groups. Lack of nurses with transcultural nursing expertise presents a severe barrier in meeting the health care needs of diverse client populations (4–7, 40–42).
Political changes throughout the world have resulted in large migration waves from former socialist, communist, monarchal, and dictatorship nations. Too many choices (in health care planning options) may overwhelm individuals who are not used to such freedoms (43). Mismatches in expectations between health care professionals and clients can cause poor health outcomes, stress, and dissatisfaction. Nurses unfamiliar with various political systems and the potential impact on clients’ perceptions may be unprepared to provide culturally congruent care for these clients. Understanding the ethnohistory, especially the influence of politics, economics, discrimination, and intergroup and intragroup conflicts, is an important cultural dimension that warrants further attention (4–8, 13, 17–19, 43–46). Despite the commonality of national origin, cultural experiences may be quite different for persons seeking asylum, refugees, and immigrants, and may vary at different points in history, necessitating an accurate and individualized appraisal.
Health care professionals are also challenged to differentiate between numerous minority groups around the world (who may have been victims of overt and/or covert stereotyping, prejudice, discrimination, and racism) and dominant groups. Within the United States, it has been well documented that discrimination, stereotyping, prejudice, and racism has existed and continues to exist in nursing and health care (47–59). This unpopular topic has not gained the sufficient attention and action necessary to actively dismantle stereotyping, prejudice, discrimination, and racism. Raising awareness is insufficient; taking appropriate and definitive action through well-planned positive innovative interventions followed by evaluation strategies will help in moving beyond complacent “passive advocacy” to positive “active innovative advocacy.” Such innovative actions require the development of cultural competence and sincere commitment on the part of health care professionals.
Groups referred to as “subcultures” have been identified as “vulnerable populations”; such populations present complex scenarios to health care professionals today and will continue to do so in the future (11–18, 46, 60, 61). For example, undocumented individuals, migrant workers, tenant farmers, and the homeless often present unique health care challenges due to lack of health insurance, illiteracy, poverty, and fear. In addition, tenant farmers, migrant workers, and landowners of varying socioeconomic levels may be grouped together under the heading of “rural health”; thus, the truly unique culture(s) and needs within and between groups across various geographic regions may remain undiscovered. Because tenant farmers may receive food and housing as part of their wages, they may not be eligible for food stamps; Medicaid; Women, Infants, and Children (WIC) services; public assistance; or other social services. Employee benefits such as health insurance and dental insurance are usually nonexistent. Funds for clothing, soap, toothpaste, toothbrushes, and other toiletries may be scarce, making tenant farmers susceptible to preventable diseases. Geographic isolation and lack of transportation are barriers encountered within rural communities, thus presenting another barrier to health care access. Within the United States, health insurance diversity presents inconsistencies in health care, especially in health promotion and illness prevention. Consequently, primary care for treatment of acute and advanced problems is not routinely accessible with delayed entry into the health care system occurring. Evaluating the short- and long-term effects of U.S. health care reform on access, quality, cost, health promotion, illness prevention, management of chronic illness, and life span for vulnerable and/or marginalized populations will yield new information for future informed decision making (see Exhibit 1.1).
The global economic crisis, rising unemployment rates, loss of (or changes in) health insurance coverage, job and retirement uncertainty, increased housing foreclosures, and general economic unrest present multifaceted problems that political leaders, financial advisers, and the general public are poorly equipped to address effectively and with which they are inexperienced. Within a multicultural society, different CVB concerning economic stability, lifestyle expectations, and acceptance of charity, debt, and profit further complicate these problems. Stress associated with periods of economic uncertainty and doubt may present greater numbers of individuals seeking and/or needing mental health services and/or other health services for diseases often triggered or exacerbated by stress. Inability to pay for medical services, medications, housing, and food may aggravate health and social problems as well as intensify personal debt, thereby broadening deficits in the overall economy. The global economic crisis has spurred the forced, rapid movement and lifestyle changes of individuals, families, and even whole communities.
Rapidly moving populations bring unfamiliar diseases, new diseases, treatments, and medicines, challenging health care professionals to become quickly proficient in accurate diagnosis, treatment, and prevention. For example, nurses unfamiliar with malaria may be suddenly faced with several refugees from Africa who require treatment for malaria. New diseases, reappearing or re-emerging “old” diseases, and/or new resistant strains of old diseases can cause epidemics if not identified early and then properly controlled. Medicines and treatments considered “alternative” or “complementary” within the culture of Western medicine may actually be considered “routine” in other cultures. Medicines considered “routine” within the culture of Western medicine may have varying and adverse effects on different ethnic or racial groups due to health beliefs and/or due to genetic differences in body processes (e. g., metabolism) and/or anatomical characteristics (e. g., sun absorption based on skin color). The growing new field of ethnopharmacology attests to the urgent need to investigate the pharmacokinetics, pharmacodynamics, and overall pharmacological effects of drugs within specific cultural groups. Unfortunately, insurance company approval for a drug therapy regimen is often guided by drug studies among primarily homogeneous populations, rather than taking into account new, however sparse, empirical evidence provided by ethnopharmacological studies.
Inconsistencies in the expected roles of the nurse may vary from culture to culture, therefore confounding the therapeutic nurse-client interaction, nurse-nurse interaction, nurse-physician interaction, and nurse-family interaction. Differences in nursing practices throughout the world influence how the nurse views power, autonomy, collaboration, and clinical judgments (2, 4–8, 62–67). Whether the nurse is viewed as a well-educated professional, vocational service provider, paraprofessional, uneducated worker, or servant will greatly impact the therapeutic and working relationship (8, 67). Furthermore, whether the nurse is viewed as an outsider, “stranger,” “trusted friend,” or insider will significantly influence the nurse–client relationship, the achievement of culturally congruent care, and optimal health outcomes (5–7, 68). The mismatch between the diversity of registered nurses and U.S. populations presents one large barrier to meeting the needs of diverse populations. For example, White nurses of European American heritage represent approximately 83% of all registered nurses (69).
Expected roles and perceptions about other health care professionals will also vary from culture to culture, thus necessitating an accurate appraisal of clients’ baseline knowledge, beliefs, and expectations, if culturally congruent care is to be achievable by the multidisciplinary health care team. Gender roles and expectations about members of the health care team are variable. Within certain cultures, it may be unacceptable (or less acceptable) for women to become physicians and provide care for male patients; conversely, it may be unacceptable (or less acceptable) for men to become nurses and provide care for female patients (67, 70). In some cultures there may not be a word or concept for “psychologist,” “psychiatrist,” “dietician,” “social worker,” “physical therapist,” “occupational therapist,” “respiratory therapist,” or “recreational therapist,” thus presenting new challenges for health care professionals in Western society. For example, there is no word in Korean for psychologist or psychiatrist; mental illness remains highly stigmatized, with clients and families encountering great difficulties when mental illness occurs (71, 72). In some countries, nurses may be trained to perform radiologic procedures and physical therapy interventions (73). This broad diversity calls for students, nurses, the nursing profession, and other health care professionals to become active participants (and partners) in the process of developing cultural competence and actively seek and embrace a broad (even revolutionary) worldview of diversity.
Which topics or issues in the previous text presented you with the most new learning? Which topics and issues do you routinely consider within your current professional role? How will your new and/or expanded learning influence your future educational, research, networking, collaborative, and practice roles?
ETHICAL AND LEGAL ISSUES
Culturally congruent health care is a basic human right, not a privilege (4, 14–16, 74–81); therefore, every human should be entitled to culturally congruent care (see Exhibit 1.1). In addition, empirical findings clearly document the strong link between culturally congruent care and the achievement of positive health outcomes. Increasing numbers of lawsuits with clients claiming that culturally appropriate care was not rendered by hospitals, physicians, nurses, and other health care providers attest to the complicated legal issues that may arise from culturally incongruent care. Furthermore, clients are often winning their cases in court (5). The International Council of Nurses’ Code for Nurses (76), the American Nurses Association’s Code of Ethics (74), and the National Standards for Culturally and Linguistically Appropriate Services in Health Care (80, 81) are several important documents that serve as direct reminders and provide guidance to health professionals. Not only are nurses and other health care providers ethically and morally obligated to provide the best culturally congruent care possible, but nurses and health care providers are also legally mandated to do so. Within the scope of professional practice, nurses and other health professionals are expected to actively seek out ways to promote culturally congruent care as an essential part of professional practice. For example, the discipline of social work recognized that the “shifts in the ethnic composition of American society in the coming 45 years … and the realities of racism, discrimination, and oppression combine to make cultural competence essential to effective social work practice, and thus to social work education” (82). The essential inclusion of cultural competence from an ethical and a legal standpoint is addressed at varying levels within the disciplines/fields of dentistry, medicine, occupational therapy, physical therapy, physician assistant, psychology, rehabilitative counseling, social work, and speech-language pathology (14, 15, 73, 83–100). The goal of including cultural competence necessitates a systematic, empirically supported action plan.
To “assist, support, facilitate, or enhance” culturally competent care, Leininger (4) proposed three modes for guiding nursing decisions and actions: (a) culture care preservation and/or maintenance; (b) culture care accommodation and/or negotiation; and (c) culture care repatterning and/or restructuring that also have multidisciplinary relevance. Because culturally congruent care can only occur when culture care values, expressions, or patterns are known and used appropriately, a systematic, thorough cultural assessment is a necessary precursor to planning and implementing care (101). Assessing, planning, implementing, and evaluating culturally congruent care requires active, ongoing learning based on theoretical support and empirical evidence. The goal of culturally congruent care can only be achieved through the process of developing (learning and teaching) cultural competence (102, 103).
EXHIBIT 1.1
Tracing the Legal Right to Health Care, International and U.S. Law, Changing Demographics, and Implications for Cultural Competence
Kevin Antoine, J.D.
Assistant Vice President for Diversity & Inclusion
Assistant Professor of Health Law & Policy
State University of New York (SUNY) Downstate
Brooklyn, NY
More than 60 years ago, emerging from the end of World War II as the leader of the free world, the United States was the driving force in drafting the international treaties that would establish the United Nations (UN), the World Health Organiztion (WHO), and the Universal Declaration of Human Rights (UDHR). The United States ratified the constitution of the WHO, which recognized health care as a fundamental right (1). The UN Charter and the UDHR also recognized a legal right to health care and advocated the involvement of many sectors of society in removing barriers to health care access and treatment (2).
In 1992, the United States also ratified the International Covenant on Civil and Political Rights (ICCPR), which established universal standards for the protection of basic civil and political liberties and recognized a fundamental right to health care (3).
Ratification of an international treaty is the only act under the U.S. Constitution that gives an international treaty legal status in the United States. The U.S. Constitution requires that the Senate give its advice and consent with a two-thirds vote in favor of a treaty (4). A treaty becomes domestic law in the United States after the president ratifies it by signing it (5). Therefore, after the Senate’s advice and consent and ratification by the president, a treaty is equivalent to federal law.
Accordingly, under U.S. Constitutional law, these treaties—the UN Charter, the WHO Constitution, and the UDHR—have been the law in the United States since the 1940s, and the ICCP has been the law since 1992. Only under the last in time rule can a later enacted federal statute supersede a treaty subsequent to its ratification.
The last in time rule was established by the U.S. Supreme Court in the case of Ping v. U.S. (1889) (6). In 1858, the United States and China ratified a treaty addressing immigration between the two countries, granting reciprocal rights of unrestricted travel between them. In 1888, subsequent to the discovery of gold in California, the United States Congress enacted a federal statute severely limiting Chinese laborers from entering the United States, which violated the terms of the 1858 treaty.
In upholding the federal statute, the U.S. Supreme Court held that a federal statute could supersede a treaty if enacted after ratification of the treaty, and a treaty could supersede a federal statute if ratified after the enactment of a federal statute. A ratified treaty becomes self-executing enforceable law (7). However, if the treaty requires the U.S. Congress to enact implementing legislation then the treaty is non-self executing (8). With respect to the UN Charter, the WHO Constitution, and the UDHR, there have been no later enacted federal statutes that repealed the United States’ ratification of these treaties. In addition, the UN Charter, the WHO Constitution, and the UDHR were self-executing treaties that required no implementing of U.S. congressional legislation. Therefore, arguably, Americans have had a right to health care since the late 1940s when the United States ratified the UN Charter, WHO Constitution, and the UDHR.
With the right to health care established as a fundamental right in the late 1940s, access and treatment to health care must comply with the U.S. Constitution’s equal protection clause of the Fourteenth Amendment (9). In addition, health care is a major commercial entity in the U.S. and as such is subject to regulation via the commerce clause of the U.S. Constitution. The commerce clause grants the U.S. Congress the authority to regulate commerce between the states, notwithstanding whether the suppliers of commerce are government or private commercial suppliers. For example, it is through the commerce clause that Title VII of the Civil Rights Act of 1964 allows federal agencies to sue both government and private employers for workplace discrimination. The shipping of goods and products, as well as engaging in commercial business across state lines, is interstate commerce that is subject to federal regulation via the commerce clause. Likewise, health care is a major commercial industry engaged in interstate commerce subject to federal regulation via the commerce clause.
The commerce clause can be used to ensure that the fundamental right of access and treatment to health care is not denied much in the same manner the commerce clause is used by civil rights laws to enforce federal nondiscrimination laws. This would ensure national uniformity in addressing fair access and treatment to health care.
The United States recognized a legal right to health care when it ratified the WHO’s Constitution, the UN Charter, and the Universal Declaration of Human Rights more than 60 years ago. Access to health care in the United States already is a fundamental right as an extension to the ratification of these treaties.
PATIENT PROTECTION AND AFFORDABLE CARE ACT
In 2010, the Patient Protection and Affordable Care Act, more commonly cited as the Affordable Care Act (ACA), was signed into law in the United States. Goals of the ACA, include making health insurance affordable by expanding government and private insurance, lowering the uninsured health care rate, increasing health care quality, not denying coverage based on pre-existing medical conditions, addressing nondiscrimination in access and treatment of health care, improving patient demographic data collection and recording, improving the quality of care by addressing cultural and linguistic competence, and increasing diversity throughout the health care workforce.
Although the ACA offers additional coverage for many who previously did not qualify for, or could not afford, medical coverage, the ACA still does not guarantee health care as a constitutional right. Instead, it mandates Americans to purchase health insurance from a private or government provider.
Several states challenged the ACA’s mandate that Americans had to purchase health insurance from a private or government provider. The U.S. Supreme Court ruled that the ACA is constitutional as a tax (mandating individuals to purchase health insurance or pay penalty tax). The irony is that Americans who are too poor to purchase health insurance will be fined the penalty tax which they probably will not be able to pay either, resulting in more government fines, penalties, or prosecution. Arguably, in some instances the ACA may hurt the same Americans it was designed to help. To date, the United States remains the lone industrialized nation without universal health care coverage.
ACA GOALS, CHANGING DEMOGRAPHICS, AND CULTURAL COMPETENCE
The Census Bureau projects a far more diverse population by 2060. Therefore, the goals of the ACA must necessarily keep pace with the changing demographics in the United States in the next 45 years. Several examples include population increases among Hispanics (56 million to 128 million); African Americans (41 million to 61 million); Asian Americans (15 million to 30 million); Native Americans and Alaska Natives (5.2 million to 11.2 million). Meanwhile, the non-Hispanic White population is the only population projected to shrink, decreasing by 20 million and accounting for 43% of the U.S. population (10). In addition, more than one in five Americans are projected to identify as being multiracial (11).
Presently, according to the Health Profession for Diversity Coalition, Hispanics, African Americans, and Native Americans only account for 9% of physicians, 7% of dentists, and 12% of nurses (12). As the nation’s general population becomes more diverse, there will be a correlation in the demographics of the patient populations. Therefore, addressing the cultural and linguistic competence of the health care workforce will be essential in order to improve the quality of health care provided to the increasingly diverse patient population. The ACA’s health care workforce provisions address both present and future needs of increasing diversity within both the health care workforce and the diverse patient population.
The ACA’s health care workforce provisions aim to increase diversity in the health care workforce and encompass all major health care professions and settings; these include but are not limited to: medicine, nursing, dentistry, physical therapy, emergency care, mental health, primary care, and public health. Pursuant to the ACA, the National Health Care Workforce Commission (the Commission) was established to provide data on the health care workforce. Although the Commission has yet to be funded by Congress, the framework is in place to provide much needed information on the nation’s health care workforce. Additionally, the ACA’s federal workforce diversity grants were created to develop a culturally competent workforce through cultural competence education within academic, employee, and continuing education settings. Targeted focus areas include provision of culturally congruent care with regard to patients’ religious and nonreligious preferences, dietary habits, access to transportation, preferred language in discussing a patient’s medical condition, gender identity, sexual orientation, and end-of-life preferences.
A diverse health care workforce, educationally prepared to provide culturally competent care to diverse patients, improves access to health care, increases patient satisfaction, and builds respect and trust between the patient and the health care professional (13). The cultural competency provisions and nondiscrimination provisions of the ACA and global health initiatives of the WHO offer the United States a new approach from a legal and constitutional perspective to address nondiscrimination in access to health care and treatment, to improve the quality of care by addressing cultural and linguistic competence, and to increase diversity throughout the nation’s health care workforce.
Hopefully the ACA is laying the foundation for the United States to join the WHO and other industrialized nations in recognizing health care as a fundamental right.
1. World Health Organization’s Constitution.
2. Articles 55 and 56 of the UN Charter, Article 25 of the UDHR, Article 1 of the WHO Constitution.
3. Jimmy Carter, U.S. Finally Ratifies Human Rights Covenant. The Carter Center (1992).
4. Article 2 Section 2 of the U.S. Constitution.
5. Article 6 of the U.S. Constitution.
6. Ping v. US, 130 US 581 (1889).
7. Martin, Schnably, Wilson, Simon, Tushnet. International Human Rights and Humanitarian Law: Treaties, Cases and Analysis (2006).
8. Ibid
9. The laws of a state must treat an individual in the same manner as others in similar conditions and circumstances.
10. U.S. Census Bureau and Center for Diseases Control and Prevention.
11. Farley, R. (2001). Identifying with multiple races. Report 01-491. Ann Arbor, MI: University of Michigan, Population Studies Center. (As cited in Shih, M., & Sanchez, D. T. (2009). When race becomes even more complex: Toward understanding the landscape of multiracial identity and experiences. Journal of Social Issues, 65(1), 2.)
12. U.S. Census Bureau, Census 2000 Special Equal Employment Opportunity (EEO) Tabulation.
13. American Medical Student Association. Enriching Medicine Through Diversity (2015).
To what extent are ethical and legal guidelines concerning cultural competence influencing cultural competence education and practice within and across disciplines? What else can be done?
BARRIERS
Professional goals, societal needs, ethical considerations, and legal issues all declare the need to prioritize cultural competence development, necessitating a conscious, committed, and transformational change in current nursing practice, education, and research (104). Although nursing and other health care professions can be transformed through the teaching of transcultural nursing (5–7, 40–42, 101, 105–107), two major barriers prevent a rapid effective transformation. One major barrier is the lack of faculty and advanced practice nurses formally trained in transcultural nursing and in the teaching of transcultural nursing (104–113). The second major barrier is the limited research evaluating the effectiveness of teaching interventions on the development of cultural competence (13–15, 42, 104, 110–117). These two barriers are further complicated by the (a) changing demographics of students and health care professionals and (b) severe shortages of nurses and nursing faculty. Other health professions have also acknowledged the lack of diversity within their respective fields, as well as the lack of faculty prepared to incorporate substantive cultural competence education within professional education as severe barriers to effective transformation (84–94, 96–99, 118). Several of these factors are highlighted in the following sections.
Parts III, IV, and V of this book present action strategies, innovations, and practical examples for cultural competence education and evaluation aimed at overcoming barriers and invigorating an effective transformation that reaches beyond “minimal” competence to “optimal” cultural competence. The goal of optimal cultural competence recognizes that cultural competence is not an end product, but an ongoing developmental process; therefore, individuals, groups, and organizations can continually “improve,” striving for “peak performance” outcomes or standards of excellence. Steps essential for optimal cultural competence development include: self-assessment, active promotion, systematic inquiry, decisive action, innovation, measurement, and evaluation. These seven steps are integrated throughout Parts III, IV, and V of this book and the accompanying toolkit (119).
What are the demographic characteristics within your current work setting? To what extent is the diversity of diversity representative of local neighborhoods, nearby regions, and national demographics? (Note: The diversity of diversity recognizes that diversity may exist based on birthplace, citizenship status, reason for migration, migration history, food, religion, ethnicity, race, language, kinship and family networks, educational background and opportunities, employment skills and opportunities, lifestyle, gender, sexual orientation, socioeconomic status (class), politics, past discrimination and bias experiences, health status and health risk, age, insurance coverage, and other variables that go well beyond the restrictive labels of a few ethnic and/or racial groups.) What impact does/could the match or mismatch of varying demographic characteristics make on the development of and the provision of cultural competence in health care? What suggestions or ideas do you propose?
CHANGING DEMOGRAPHICS OF STUDENTS AND HEALTH CARE PROFESSIONALS
The projected increase in immigration, globalization, and minority population growth has the potential to enrich the diversity of the nursing profession and to help meet the needs of an expanding culturally diverse society (8, 13–17, 49–59, 111, 113, 120–130). What has actually occurred is that the dramatic shift in demographics, the restructured workforce, and a less academically prepared college applicant pool have created a more diverse nursing applicant pool. Nursing students today represent greater diversity in age, ethnicity and race, gender, primary language, prior educational experience, family’s educational background, prior work experience, and enrollment status than ever before (59, 129–133).
TABLE 1.1 Select Nursing Student Trends and Potential Future Impact on the Nursing Profession
Variable | Select Nursing Student Trends | Potential Future Impact on the Nursing Profession |
Age | Consistent with global and multidisciplinary trends, the enrollment of older students in nursing programs has increased over the past decade with projected increases to persist in the future. | Age at entry into the nursing profession will be older, resulting in decreased number of work years until retirement. |
Ethnicity and Race | Enrollment: Recent nursing enrollment trends suggest a steady increase among some minority groups; however, no increase has been noted among Hispanic groups. Retention: Minority groups incur higher attrition rates than nonminority groups. | Currently, White, non-Hispanic nurses of European American heritage represent approximately 83% of all registered nurses in the United States. Mismatches between the cultural diversity in society and diversity within the nursing profession will persist into the future unless strategies for recruitment and retention are more successful. |
Gender | Men: Although the numbers of men in nursing are increasing, they remain an underrepresented minority (11%). Women: Support for women entering the workforce has shifted away from encouraging traditional female professions. | Men will continue to be disproportionately underrepresented in nursing. Many academically well-qualified male and female high school students with a potential interest in nursing may never enter the nursing profession. |
Language | Enrollment: Consistent with global and national trends in higher education, nursing programs in the United States and Canada have experienced an increase in ESL populations over the past decade. Retention: ESL student populations have unique learning needs and incur higher attrition rates. | Although individuals with personal lived experiences in other cultures and languages can potentially meet the needs of linguistically diverse and culturally diverse client populations, they will still be disproportionately represented within the nursing profession. |
Prior Educational Experience | Consistent with trends in higher education worldwide, prior educational experiences are increasingly diverse with an academically less-prepared applicant pool. Increases in the number of second-degree individuals have been noted. Retention: Academically underprepared students incur higher attrition rates. | Nurses with degrees in other fields can enrich the nursing profession by blending multidisciplinary approaches into nursing. Nurses with academically diverse experiences may broaden the overall perspective, especially with socioeconomic and educationally diverse client populations. |
Family’s Educational Background | Nursing programs have also seen an increase in first-generation college students, especially among student groups traditionally underrepresented in nursing. Retention: First-generation college students incur higher attrition rates. | First-generation college students who become nurses have the potential to enrich the diversity of the nursing profession and reach out to various socioeconomic and educationally diverse client populations. |
Prior Work Experience | A restructured workforce, welfare-to-work initiatives, displaced homemakers, popularity of midlife career changes, and health care career ladder programs have expanded the nursing applicant pool, increasing its diversity in prior work experience. Many students work full- or part-time. Retention: Work–family–school conflicts may interfere with academic success and retention. | New graduate nurses may enter the nursing profession with a variety of prior work experiences that have the potential to enrich the nursing profession. |
Enrollment Status | Almost half of all college students attend part-time. The number of part-time nursing students, especially those with multiple role responsibilities (work and family), has increased. Retention: Work-family-school conflicts may interfere with academic success and retention. | Part-time students will take longer to complete their education. Entry into practice will be delayed and total number of potential work years in nursing will be decreased. |
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