The Office of Minority Health’s national standards for Culturally and Linguistically Appropriate Services (CLAS) in health care have been a matter of public record ever since the final version was published in the Federal Register in December 2000. Getting the standards into the register was a milestone, but some nursing leaders are concerned that the next step in the process--the actual implementation of CLAS in the nation’s health care facilities--is having trouble getting off the ground. While some major hospitals and health insurers have indeed begun to implement the standards, it appears that many health care providers, including nurses, have still never heard of CLAS.
Josepha Campinha-Bacote, RN, PhD, CS, CNS, CTN, FAAN, president and founder of Transcultural C.A.R.E. Associates in Cincinnati, feels progress has been slow when it comes to spreading the word about CLAS among the nursing ranks. Campinha-Bacote, who was one of two nurses who sat on the 22-member National Advisory Committee on CLAS, has given over 1,000 lectures to health care organizations since 1991. Sixty percent of those, she estimates, are to nursing groups. Campinha-Bacote says she polls her audience, which can range from 300 to 6,000 people, on current nursing topics--and for the past year and a half, she has been asking about CLAS.
“Ninety-eight percent of the time, no one has heard about it,” she complains. “And when I do get people raising their hands, it is usually just one or two. The sad part is, here we are almost two years later, and nurses still don’t know about CLAS.”
Before it can be determined if health care providers are implementing CLAS in their institutions, Campinha-Bacote says, “the first thing we need to do is get nurses, as well as other health professionals, to know the standards exist.” Despite the easy-to-remember acronym, she argues, CLAS has not become a mnemonic that has registered in care providers’ minds.
Why is Campinha-Bacote, who is a black nurse of Cape Verdean descent, so concerned about this? Because, she points out, the federal government’s whole intent when it created the CLAS standards was to improve access to care, quality of care and, ultimately, health outcomes for members of racial, ethnic and cultural minority groups.
There are 14 CLAS standards, some of which are mandatory under Title VI of the Civil Rights Acts for any health care organization that receives federal funding, while others are voluntary. The standards are organized into three areas: culturally competent care, language access services for patients with limited English proficiency, and organizational support for cultural competence.
Guadalupe Pacheco, MSW, who was the project officer for the development of the CLAS standards, feels that the move to implement CLAS in America’s health care institutions is gaining momentum. “It is hard to gauge how much progress is being made,” admits Pacheco, the Office of Minority Health’s public health advisor and special assistant to the director. “But I think because of the changing demographics of this country, especially in those states where the growth of cultural diversity has been really phenomenal, health care facilities are starting to look at this as something that will add value to their service delivery programs.”
Pacheco, who is Latino, points to the state of North Carolina, which has had about a 400% increase in its Latino population since the 1990 census. “A lot of health care programs don’t have the structure in place to meet the demand right now, so they are a little behind the eight ball. They don’t yet have a bilingual or bicultural staff, or they don’t have interpreters or training programs for the interpreters,” he says. “But I also know one major HMO that is going to implement the standards and that is Kaiser Permanente in California.”
Pacheco agrees that there needs to be a greater push to get the word out to nurses--for example, through national nursing professional associations and minority nurse associations. “Those health care institutions that have been aggressive in implementing the standards recognize that CLAS applies to every health care practitioner,” he notes. “They are probably making sure when they do their in-service or their overview that they are approaching the standards, and I think nurses could be a major player in that process.”
Some experts in culturally competent care argue that health care facilities would be much more motivated to implement CLAS if the standards were 100% mandated by law. But, Pacheco contends, “OMH is not a regulatory agency. What we were trying to do in creating these recommended standards was to encourage policy-makers and federal, state and local legislators to take the lead. If they feel [the CLAS standards] should be mandates, they should go ahead and push for it, and then look at how they can start incorporating the principles into the accreditation and credentialing processes.”
Maria Teresa (Tere) Villot, RN, BSN, president of the Philadelphia Chapter of the National Association of Hispanic Nurses (NAHN), reports that since the December 2000 publication of the final report on the CLAS standards, there has been an effort to incorporate the guidelines in her region. Since she works for the federal government at the Philadelphia Veterans Affairs Medical Center, Villot became aware of CLAS when she read about it in the Federal Register. However, she adds, “I am not surprised that a lot of nurses in the private sector still don’t know about it.”
Philadelphia’s Latino population is growing, Villot says, and there is a big push to hire more Hispanic nurses who are bilingual and bicultural. She cites the city’s Temple University Hospital, which has a unit that is completely bilingual and bicultural, from the housekeepers to the nurse managers, as a good example of an organization that is being proactive about providing culturally and linguistically appropriate services to meet changing community needs.
Like Pacheco, Villot thinks nursing leaders and associations could play a key role in disseminating information about CLAS to the nation’s RN workforce. Raising the public’s awareness is important as well, she adds. “Our organization does a lot of community health fairs and lectures. We go to churches and senior citizens’ homes and to the schools. Any way we can get the word out would be good.”
One way to increase nurses’ awareness of the CLAS standards within the health care setting, Villot suggests, is through in-services. Her position at the VA facility requires her to do 40 hours of mandatory classes a year. “That would be an excellent way to deliver information about CLAS,” she says.
The NAHN chapter president believes it is appropriate that the majority of standards are not mandated by law. “I think when people are mandated to do things, you get more resistance,” she argues. “If you are a conscientious health care professional, you know what your community needs, what your patients need and how to deliver it.”
Prior to being interviewed for this article, Cora C. Munoz, RN, PhD, was under the impression that all 14 CLAS standards were mandatory for health organizations receiving federal funds. She first heard about the standards in 1998 when they were being drafted. During the public comment period, as a commissioner with the Ohio Commission on Minority Health, she facilitated a focus group that reviewed the proposed standards and provided feedback that was forwarded to the CLAS regional task force in Chicago.
Munoz, who is a member of several nursing associations, including the Philippine Nurses Association of America, believes the reason why many working RNs are unaware of these new standards is because their hospital administrations have not shared the information with them. She agrees that there is a critical need for staff training in this area, but stresses that the CLAS standards should be taught in the context of overall cultural competency training, not as a stand-alone entity.
“This training needs to be mandatory for all health care providers,” she says. “We need nurses to share this information with other nurses so that its implication to practice can be emphasized. These standards are so important because for a long time, there has been a lack of clarity in the definition of cultural competence. These standards give health care organizations some directions and very specific guidelines to follow on how to provide culturally competent services.”
Unlike Villot, Munoz feels the CLAS standards should be adopted as law. The biggest challenge, she explains, is how to ensure that health care institutions will comply with the standards.
“There must be a mechanism in which organizations become accountable if they do not progress towards cultural competence,” she says. “Accrediting agencies that include this in their criteria are commendable. All health care providers and educators in the helping professions need to incorporate this information into their curricula to ensure that our future health professionals are knowledgeable about how to enhance cultural competence in providing health care services.”
Cheryl Nicks, RN, CNNP, president of the New Orleans Chapter of the National Black Nurses Association, is one of the nurses who had not heard of CLAS by its formal name prior to an interview request from Minority Nurse. After reading up on the standards, she thinks that one reason why nurses might not know about them is that many health care facilities follow parts of the standards but are not looking at the whole picture of how to deal with cultural and linguistic differences. “I feel that if people think they have one piece of the puzzle, they are achieving their goal,” she adds.
In her work as a neonatal nurse practitioner, Nicks has seen many examples of how health professionals’ failure to understand a minority patient’s culture can have a negative impact on the care that patient receives. She points to a recent case that involved a premature baby. When it was time for the baby to be discharged from the hospital, the child’s mother was in jail, but the baby’s uncle said he and his wife would take the child home. “The child had some minor medical problems and needed somebody who was able to care for a baby at home,” she recalls. “The uncle, who was African American, was very religious and said he believed in healing through burning candles and laying on of hands.”
When he made this statement to a Caucasian nurse, Nicks continues, the nurse thought the man was crazy. “She wasn’t comfortable letting the baby go home with him, and she talked to her manager. They wanted the man to take all of these courses and get certified in CPR. They asked my opinion, and I said I didn’t see anything wrong with [what he said].”
Burning candles and the laying on of hands are part of the African-American culture, Nicks says. “Had these nurses had some knowledge of other people’s cultures, they would not have become so alarmed by this man.”
Mental health nurse Marvel Davis, RN, BSN, MSN, the immediate past president of the Southern Connecticut Black Nurses Association, says she too had not heard of CLAS by its official name. But, she adds, at Yale New Haven Psychiatric Hospital, the facility where she works, cultural competence is something that is supported and encouraged: “Staff members all up and down the scale are acknowledging the importance of being culturally competent and aware when giving care to patients from any setting.”
The health care industry in general, Davis says, is finally realizing that it needs to ask patients from diverse cultures what their perspective is, rather than always assuming it has the answers. “We may have the medical answers, but the patient doesn’t come here in isolation,” she points out. “To arrive at those answers, we need to have some understanding of all the other pieces of what is going on with the patient, including the social and cultural ones.”
Like the other experts interviewed for this article, Davis believes the best way to get nurses involved in implementing CLAS is to inform them about the standards through nursing organizations, credentialing bodies and nursing schools’ curricula. At her hospital, Davis is a liaison for nursing students from several area schools, including Yale University, her alma mater. She plans to talk about the CLAS standards with the professors and recommend that they promote them in their classes.
“That’s how it becomes a reality,” she maintains. “If you are teaching it, they will learn it and use it.” Davis, who is the historian of the National Black Nurses Association, also plans to promote CLAS at the association’s next board meeting.
Ronald Greene, RN, BSN, a case manager at Massachusetts General Hospital in Boston (a member of Partners HealthCare System) and chairman of the Association of Multicultural Members of Partners, also admits to never hearing about CLAS in a formal sense. But after looking over a copy of the standards, he says Mass General follows the principles.
“The institution is really addressing these standards, and some of the changes that have occurred as a result are truly phenomenal,” states Greene, who is also president of the New England Chapter of the National Black Nurses Association. As an example, he points to some eye-opening workshops on cultural sensitivity that have been held at the hospital.
For almost six years, Deborah Washington, RN, MSN, has served as the director of diversity for patient care services at Mass General. Even though this was a newly created position, she notes that “the hospital has been paying attention to cultural diversity for much longer than that.”
Washington, who is African American, participated in one of the public comment meetings on the draft version of the CLAS standards. Today, she says, “I use the standards to reinforce for people that the reason we provide culturally appropriate services is not just because it is a nice thing to do, or because diversity helps improve the bottom line. [Having federally recommended guidelines] puts some punch behind it. And it also makes a difference for people to know that the government is paying attention.
“What I like about the CLAS standards is that they not only address the tangible benefits of diversity but also the intangibles,” she continues. “I think that is very powerful.”
Still, Washington has found that many of the nurses at Mass General have not heard about CLAS. “When I bring it up, it is news to them,” she says, adding that she would question how effectively the standards have been promoted to the nation’s nursing population.
Rick Zoucha, RN, APRN, BC, DNSc, CTN, president of the Transcultural Nursing Society (TCNS), also attended one of the national hearings held during the public comment period for CLAS. Culturally competent care, he believes, has not been given the priority it deserves. For example, he has met many health professionals who have never heard of transcultural nursing, and he suspects the same is probably true for CLAS.
With more than 2.6 million licensed RNs currently practicing in the United States, Zoucha feels nurses should be taking the lead in carrying the banner for CLAS.
“We are the largest health care provider group in the country when you look at sheer numbers,” he explains. “We are the ones who spend the intimate time with the patients. We are with patients 24 hours a day and we are the ones that go into the home. Nursing is all about building relationships with patients, and what better way to do that than by understanding, accepting and actually going beyond acceptance of another person’s culture? I think nurses are a natural [to get the word out about CLAS] just because of the nature of the work we do.”
Washington agrees. “Not every health care organization has a formal diversity program,” she says. “But even if there isn’t someone setting the stage organizationally, a nurse can promote cultural competence as a personal commitment. It’s important for nurses to know about these federal standards so they’ll know that they are not alone. If you want to be an advocate for culturally and linguistically competent care, CLAS gives you a tool.”