Today the term “cultural competency” is showing up frequently in the medical and nursing literature. The reason seems to be a consensus among health care organizations, academic institutions and health professionals to make a statement. The statement is this: Achieving cultural competency in health care is top priority, because it is the right thing to do.
A 1996 article published in Advances in Nursing Science lists several reasons for the urgency to become culturally competent.1 These reasons include:
• Greater diversity, created by an increasing number of people from different cultures moving into the communities that health care facilities serve;
• Wider disclosure of demographic identity: In today’s highly technical information age, information about health consumers’ race, gender, age, religion and culture is easily obtained;
• Expanded use of home care: Hospitals are sending patients home earlier and using home health nurses to follow through with their care;
• Increased awareness of inequities in minority health care.
There are many definitions of cultural competency in the literature. Former President Bill Clinton’s Initiative on Race and Health Town Hall Meeting on July 10, 1998, defined cultural competency as being able to give care to people of different cultures. According to the U.S. Department of Health and Human Services, cultural competency consists of behaviors, attitudes and policies that when placed on a continuum will ensure diverse interaction. Most experts have adapted the definition of Cross, Bazron, Dennis and Isaacs, which states that cultural competency is a consistency of behaviors, attitudes and policies that come together in a system or organization to work in cross-cultural situations.2
It is essential that quality health care be provided to all people of all cultures. Culture has been defined as a set of processes that influence how we perceive and interact with each other.3 Everyone has a culture, and failure to understand and acknowledge a patient’s cultural needs can severely impact the quality of the care he or she receives.
Much of the literature lists changes in demographics as the primary reason why health care providers must become culturally competent. People from many different cultures are immigrating to the United States at an increasing rate and people are living longer. According to the most recent U.S. Census, the racial and ethnic minority population is increasing at a faster rate than the white population. But will there be enough minority nurses to care for them?
For once, minority nurses can take the advantage in health care if they have knowledge of their culture. Although many minority nurses do have knowledge of minority cultures, it should not be assumed that because a nurse is of a certain race, religion or gender, he or she should automatically know how to care for a certain group of people. For example, some nurses who are black are not aware of certain black cultural practices. Just as majority nurses must evaluate their ability to provide culturally appropriate care to people from a variety of backgrounds, minority nurses must also look inside themselves and do a self-evaluation of their cultural awareness and knowledge.
Quality health care and cultural competency are correlated. In other words, providing
the best nursing care is part of being culturally competent, and vice versa. Cultural competency occurs when nurses know what health and illness mean to patients in the context of their cultural heritage. Nurses must develop academic and interpersonal skills that increase their understanding and appreciation of culturally diverse groups of patients. Caring for patients means working with them at the most personal level. Patients’ cultural beliefs about disease, pain, family, birth and death must be considered when care is provided.
To cite just three examples, patients from Korean, Muslim and Asian Indian cultures have diets, methods of prayer and ways they prefer to be addressed that differ from those of the majority culture. The best advice for nurses is to sit down and talk with the patient and the patient’s family. Nurses need to learn from the patient and apply this knowledge to the nursing care plan. In the case of patients who speak little or no English, language barriers can create obstacles to this type of communication. Without adequate interpretation, these patients’ needs may not be met. Therefore, achieving cultural competency in health care must include providing linguistically competent services as well.
One recent article lists four challenges for practitioners who hope to achieve cultural competency: (1) to recognize the clinical differences among patients of different ethnic and racial groups; (2) to establish communication; (3) to develop a sense of ethics and (4) to gain trust.4 The issue of trust is especially important. Past experiments such as the Tuskegee Syphilis Study, conducted from the 1930s to the 1970s, caused many minority Americans, especially African Americans, to distrust the health care system. This was because the study was conducted on black men without their consent and treatment was not administered to the participants, even though it was available.
There is also a need to respond to the diversity among older adults, especially older African Americans. Researcher S. M. Geron states that becoming culturally competent provides an opportunity to correct the incomplete picture, to learn more about the health needs of aging patients of color and other historically underserved and undervalued populations.5 Geron recommends that the demographics of older patients and their families be evaluated, and adds that the civil rights of patients of color could be violated if these patients are not treated appropriately. In other words, failure to provide culturally competent care can lead to legal liability.
How can America’s health care system successfully meet the challenges of caring for an increasingly culturally diverse population? First, there is a need for a more culturally, racially and ethnically diverse health care workforce. And second, it is imperative for all health care providers and organizations to become culturally competent.
Unfortunately, the continued underrepresentation of racial and ethnic minorities in nursing and medicine is well documented. Because nurses of color are more likely to work with minority populations, it is critically important to increase the number of minority nurses in the RN workforce.
Therefore, minority nurses who are already in the profession must market nursing to students of color in high schools and colleges. Nurses must uplift their profession. If one nurse sees another nurse giving inadequate care to a minority patient, it is up to that nurse to intervene on behalf of that patient. While increasing the number of minority nurses in the workforce will help increase culturally sensitive care, it is the responsibility of all nurses, regardless of race and ethnicity, to learn cultural competence.
The first step in learning to become culturally competent is for health care organizations and practitioners to assess their level of competency. Cross et al. developed a cultural competence continuum that comprises six levels of cultural awareness.2
Cultural destructiveness is at the lowest end of the continuum. It is characterized by the belief that rights and privileges are for the dominant groups and other cultures are inferior. Cross-cultural training is discouraged and there is a lack of cross-cultural knowledge. An employer at this level of the continuum does not value diversity and only recruits employees from certain populations. The health care provider who is at this level will give inadequate care to patients because of a lack of awareness of other cultures.
Cultural incapacity is the next position on the cultural continuum. While an organization at this level does not intentionally seek to be culturally destructive, its staff will have only token minority representation. Also noted at this level is discrimination against people of color and an assumed paternalistic position toward other cultures. There is no effort to recruit employees from other cultures or provide cross-cultural training. The facility’s services and hours of operation fail to accommodate a diversity of religious and cultural needs.
Cultural blindness is the midpoint on the continuum. An organization at this level tries to be unbiased or colorblind, stating that culture or color does not matter. Differences are ignored. The organization treats everyone the same but only meets the needs of the dominant group.
Cultural pre-competence is moving toward the positive end of the continuum. The organization realizes its weaknesses and makes plans to improve. However, organizations and individuals at this level may become complacent. They believe that what they are doing or have done is all that is needed and they do not feel they need to move further up the continuum.
Cultural competence occurs when there is acceptance and respect for other cultures. An organization at this level works to hire unbiased employees and establish policies that enhance services for diverse populations. It will also have a mission statement that includes all people and cultures in the framework of care, and has a system in place to constantly monitor adherence to this mission statement.
Cultural proficiency is the most positive end of the continuum. All cultures are
held in high esteem. Proactive is the key word for organizations at this level: They will conduct research to develop new approaches based on culture. Nurses can develop cultural proficiency by attending courses or seminars on cultural awareness and sharing the knowledge they obtain with their fellow nurses.
In recent years, study after study has documented widespread disparities in health outcomes between Americans of color and the majority population. Not only do racial and ethnic minorities have disproportionately high rates of serious diseases such as cancer, diabetes, cardiovascular disease and AIDS, they are also less likely to receive the same quality of health care as whites. Contrary to the popular belief that minority health disparities exist only among persons of low socioeconomic status and/or those who live in medically underserved areas, a 2002 Institute of Medicine study shows that the inequities remain even when access to care is unlimited and adjustments are made for socioeconomic differences.6
For example, this study reveals that there are gross differences in cardiovascular care options offered to black Americans as compared with whites, especially in the use of angiography. African Americans are 1.3 times more likely than whites to have cardiovascular disease, yet they receive CVD diagnostic tests and procedures at a far lower rate than whites. African Americans are given angiographies at a 2.5% rate while Caucasians receive angiographies at a 5.4% rate. The same study shows that medical follow-up for African-American patients is lower than for the white population.
There must be zero tolerance for inequality in health care for anyone, regardless of race, ethnic background, gender, age or religion. Everyone deserves equal access to the best possible health care. To ensure that all patients from all backgrounds and cultures receive quality health care, America’s health care system must become culturally competent.
What can be done to foster a climate of cultural competency among the nation’s health care organizations and individual health care practitioners? Many government agencies and professional groups, including the Institute of Medicine, the Department of Health and Human Services, the Office of Civil Rights and the American Medical Association, have spent a great deal of time addressing this issue. Here are some of their recommendations, along with suggestions for how nurses can implement them:
1. Strengthen the stability of the patient-provider relationship. For nurses, this means getting to know your patient and not just thinking of him or her as a disease or a room number. If a patient trusts you, that is the beginning of a stable relationship.
2. Increase the proportion of underrepresented minorities in the health care professions. As stated previously, minority nurses can help make this happen by recruiting minority students into nursing.
3. Eliminate the fragmentation of health care services and health insurance plans along socioeconomic lines. For example, this occurs when a low-income patient is receiving care under a funded program and that care is cut from the budget. Nurses must serve as advocates for these patients by helping them seek care elsewhere.
4. Support the use of interpreter services at health care organizations that serve limited-English-speaking populations.
5. Empower patients by increasing their knowledge. In order to empower patients, nurses have to be and feel empowered.
6. Provide cultural competency education and training. Nurses can take cultural competency classes on their own or request that their employers offer classes.
To elaborate on this last point, I would strongly suggest that health care facilities require their nurses to attend classes or seminars on health disparities and cultural competence every year. The facility should be responsible for providing the classes or paying for nurses to attend seminars given by outside providers. This is the least that can be done. The certificate of attendance for the class or seminar should be placed in the
nurse’s personnel file. I would further recommend that promotions be based on attending these seminars.
Another way to increase cross-cultural knowledge among a health care facility’s nursing staff is to award nurses certificates for reading journal articles about minority
cultures. The nurse can read the article and then bring it in to share with the rest of the nursing staff.
Providing cultural competence education and training for medical students, residents, nurses, nursing students and other health care practitioners is essential to providing quality care for minority populations and eradicating health disparities. Should attendance at these classes be mandatory? Speaking as one minority nurse to another, I ask you this question: What do you think?
1. Meleis, A.I. (1996). “Culturally Competent Scholarship: Substance and Rigor.” Advances
in Nursing Science, Vol. 19, No. 2, pp. 1-16.
2. Cross, T.L., Bazron, B.J., Dennis, K.W., and Isaacs, M.R. (1989). Toward a Culturally
Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed (Vol. 1). National Technical Assistance Center for Children’s Mental Health, Georgetown University Child Development Center, Washington, D.C.
3. Barrera, L., & Corso, R.M. (2000). “Cultural Diversity and Early Childhood: A Critical Review of Literature With Implications for ECSE Research, Evaluation, and Practice.” Research roundtable presented at The Division for Early Childhood national conference, Albuquerque, N.M.
4. Setness, P.A. (1998). “Culturally Competent Healthcare: Meeting the Challenges Can
Improve Outcomes and Enrich Patient Care.” Postgraduate Medicine, Vol. 103, No. 2, pp. 1-5.
5. Geron, S.M. (2002). “Cultural Competency: How Is It Measured? Does It Make a
Difference?” Generations, Vol. 26, No. 3, pp. 39-45.
6. Smedley, B.D., Stith, A.Y., and Nelson, A.R. (2002). Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care. Institute of Medicine, National Academy Press, pp. 1-26.