Cultural competence among cardiovascular healthcare providers with Black patients in Rock Island County, Illinois

Transcription

1 University of Iowa Iowa Research Online Theses and Dissertations Summer 2010 Cultural competence among cardiovascular healthcare providers with Black patients in Rock Island County, Illinois Alesia J. Grice-Dyer University of Iowa Copyright 2010 Alesia J Grice-Dyer This thesis is available at Iowa Research Online: Recommended Citation Grice-Dyer, Alesia J.. "Cultural competence among cardiovascular healthcare providers with Black patients in Rock Island County, Illinois." MS (Master of Science) thesis, University of Iowa, Follow this and additional works at: Part of the Community Health Commons

2 CULTURAL COMPETENCE AMONG CARDIOVASCULAR HEALTHCARE PROVIDERS WITH BLACK PATIENTS IN ROCK ISLAND COUNTY, ILLINOIS by Alesia J. Grice-Dyer A thesis submitted in partial fulfillment of the requirements for the Master of Science degree in Community and Behavioral Health in the Graduate College of The University of Iowa July 2010 Thesis Supervisor: Professor Joe Dan Coulter

3 Copyright by ALESIA J. GRICE-DYER 2010 All Rights Reserved

4 Graduate College The University of Iowa Iowa City, Iowa CERTIFICATE OF APPROVAL MASTER'S THESIS This is to certify that the Master's thesis of Alesia J. Grice-Dyer has been approved by the Examining Committee for the thesis requirement for the Master of Science degree in Community and Behavioral Health at the July 2010 graduation. Thesis Committee: Joe Dan Coulter, Thesis Supervisor Linda Snetselaar Anne Baber Wallis Faryle Nothwehr

5 To James and Gertrude Grice, Dorothy Grice, and Willie Earl Dyer. ii

6 Birds of a feather flock together, eagles fly alone. Isaiah 40 iii

7 ACKNOWLEDGMENTS The completion of this thesis would not have been possible without the support and guidance of God and the Professors in the Department of Community and Behavioral Health, who consistently challenged me to aim high and reach even higher. My deepest gratitude to Professors Mary Aquilino and Anne Baber Wallis, who, in spite of myself, kept me grounded and within normal limits and Professor Linda Snetselaar, who brought sanity to this process. I want to thank The Nursing Education and Research Department at Trinity Medical Center, Rock Island Campus and Mary Petersen, who helped and guided me through the IRB process, they are very gracious. Thank you to The Nursing Education Department at Genesis Medical Center, Illini Campus, who were very helpful and gracious. I would also like to thank all of the nurses who participated in the study and made this thesis possible. A Very Special thanks to Amy Engelmann, who started the whole ball rolling iv

8 TABLE OF CONTENTS LIST OF TABLES...vii LIST OF FIGURES...viii LIST OF ABBREVIATIONS...ix CHAPTER I INTRODUCTION...1 Background...1 Statement of the problem...4 Research Aim...6 Organization of the Study...7 CHAPTER II REVIEW OF THE LITERATURE...8 Introduction...8 Culture and Cultural Competency...8 Constructs of Cultural Competency...9 Cultural Awareness...10 Cultural Knowledge...11 Cultural Skill...12 Cultural Encounters...12 Cultural Desire...13 Cultural Mistrust...13 Perceptions of Racism and Mistrust in Health Care Model (PRMHC)...15 Cardiovascular Disease Prevalence and Health Disparities...16 The Process of Cultural Competence in the Delivery of Health Care Services...19 Health Behavior Theory...19 CHAPTER III METHODS...20 Research Aim...20 Hypothesis...20 Design...21 Setting...22 Subjects...22 Data Collection Instruments...22 Methodology...24 Data Collection...24 Analysis...25 Results...26 Deomgraphis Flysheet...26 Questionnaire Results...39 CHAPTER IV CONCLUSION...48 Discussion...48 v

9 Summary Study Limitations Recommendations REFERENCES APPENDIX A DEMOGRAPHICS SHEET APPENDIX B GENESIS INSTITUTIONAL REVIEW BOARD APPENDIX C TRINITY INSTITUTIONAL REVIEW BOARD APPENDIX D UNIVERSITY OF IOWA INSTITUTIONAL REVIEW BOARD APPENDIX E POSTERS/FLYERS FOR PARTICIPATION vi

10 LIST OF TABLES Table 2.1 Trinity Demographic Age Range Scoring Key for Demographics Age Range Illini Demographic Age Range Scoring Key for Demographic Age Range Illini and Trinity Race/Ethnicity of Nursing Workforce vs. Race/Ethnicity of Rock Island County Hospital Nurses Racial Demographics of Rock Island County Population Study Participants Job Title/Level of Nursing Study Participants Years of Training (Schooling) Study Participant s Years in the Nursing Profession Number and Percentage of Black Patients Treated in Rock Island County Cultural Competency Scores for Trinity Regional Health System Cultural Competency Scores for Genesis Medical Center, Illini Campus Illini and Trinity Cultural Competency Scores vii

11 LIST OF FIGURES Figure 2.1 Trinity Demographic Age Range Illini Demographic Age Range Percentage of Black Patents Treated Cultural Competency Scores for Trinity Regional Health System Cultural Competency Scores for Genesis Medical Center, Illini Campus Illini and Trinity Cultural Competency Scores viii

12 LIST OF ABBREVIATIONS 1. The Perception of Racism and Mistrust in Health Care Model PRMHC 2. National Association for the Advancement of Colored People NAACP 3. Department of Health and Human Services DHHS 4. The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised IAPCC-R 5. Institute of Medicine IOM 6. Perceptions of Racism and Mistrust In Health Care Model PRMHC 7. Registered Nurses RNs 8. Licensed Practical Nurses LPNs 9. Nurse Practitioner NPs 10. Bureau of Labor Statistics BLS 11. Nursing Workforce survey NRC 12. Health Resources and Services Administration HRSA 13. National Sample Survey of Registered Nurses NSSRN 14. Center for Disease Control and Prevention CDC 15. Society for Public Health Education SOPHE ix

13 1 CHAPTER I INTRODUCTION Background This study details a plan of applied research using a cross-sectional survey methodology to identify the multi-dimensional aspects of cultural competence. Identifying a wider conceptualization of cultural competence that embraces cultural knowledge, cultural selfawareness, cultural skills and cultural encounters; the theoretical framework was based on The Process of Cultural Competence in the Delivery of Healthcare Services Model1 (Campinha- Bacote, 1999), Health Behavior Theory, and a mid-range theoretical model entitled Perceptions of Racism and Mistrust in Health Care 2 (Benkert, Peters, Clark, and Keves-Fostor, 2006). These theories address the lack of cultural competence within the health care profession, resulting in mistrust and directly influencing the delivery of quality health care to Black 3 patients. For purposes of this research study, the population sampled was nurses who treat Black patients with cardiovascular conditions. Recent trends in the nursing population in the United States are encouraging with the overall representation of non-white nurses increasing from 7% in 1980 to 12.2% in Yet, the nursing workforce diversity remains far below minority representation in the general 1 According to Campinha-Bacote (1999), this model views cultural competence as an ongoing process that the health care provider (nurse) continuously strives to attain the ability to effectively work within the cultural context of the client and involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. 2 The Perception of Racism and Mistrust in Health Care Model (PRMHC), according to its authors, hypothesize that perceived racism influences cultural mistrust, which affects trust in providers (Benkert et al., 2006). 3 For purposes of this study, Black was defined as Black, non-hispanic.

14 2 population, which was nearly 33% in 2004 (Health Resources and Service administration, (2006). A study by Betancourt, Green, and Carrillo (2000) found many barriers to the delivery of culturally competent care, including the lack of a diverse healthcare leadership and workforce, a deficient system of care designed for diverse patient populations, and reduced cross-cultural communication between providers and patients. The inability of a provider to understand socioeconomic or other differences may lead to patient noncompliance, which can affect health outcomes. Disparity in health outcomes based on culture has been recognized as a phenomenon in both access to and quality of health care, but there is not an understanding and agreement regarding definitions. According to a report by Walker & Avant (2002), antecedents of the concept of health care disparity are a positive or negative experience with a health care establishment or service and a measurement of the quality of health care received or access to health care services. Antecedents are events that must be present for the concept to occur (Walker & Avant, 2005). Antecedents of the concept of health disparity are a positive or negative state of health or physical, psychological, and socio-cultural well-being, and the measurement of a health variable that includes incidence, prevalence, mortality, burden of disease, or other adverse health conditions. A health care disparity may lead to a disparate treatment of disease (Walker & Avant, 2005). A study by Spector (2002), using a theory developed by researchers Estes and Zitzow (1980) describes the impact of cultural competence. Spector (2002) cites Estes and Zitzow s theory to describe the degree to which one s lifestyle reflects his or her respective tribal culture. The values indicating heritage consistency exist on a continuum and a person can

15 3 possess value characteristics of both a consistent heritage (traditional) and an inconsistent heritage (acculturated- modern). Spector (2002) details the concept of heritage consistency, which includes a determination of one s cultural, ethnic, and religious background. The perception is that the deeper a person identifies with a traditional heritage, the greater the chance they will follow traditional health and illness beliefs and practices derived from their ethnocultural heritage. The concept of cultural sensitivity, defined by Fonda (2008), is a term that is interchangeable with cultural competence, dependent upon the researcher conducting the study. For purposes of this study, cultural competence was used with the understanding that cultural sensitivity is encompassed within the definition of cultural competence. The use of the term cultural competence, in this study, includes the broadest audience possible. The application of the concept of culturally competent care historically has operated from a predominately White 4, dominant culture perspective (Canales and Bowers, 2001). Studies by Canales and Bowers (2001), Betancourt (2006), Benkert, Peters, Clark, and Keves- Foster (2006), and Campinha-Bacote (1999) indicate a strong correlation between cultural competence and cardiovascular health care among Black patients. The link to racial/ethnic disparities in cardiovascular health is relevant because of the connection between cultural competence of effective communication, trust, and healthy outcomes (Betancourt, 2006). Betancourt (2006) asserts in his commentary that poorly handled cross-cultural issues result in negative clinical consequences. Another part of the problem is the collective memory among Blacks about their exploitation by the medical establishment (Gamble, 2002; Erlen, 2003). 4 For purposes of this study, White was defined as White, non-hispanic.

16 4 These memories cultivate fears of genocide and create barriers that impede the process of health promotion within the Black population and other racial/ethnic populations. Statement of the Problem Cultural competence plays an important role when addressing racial/ethnic health disparities. Cultural competence is defined as a set of attitudes, skills, behaviors and policies that enable health professionals to work effectively in cross-cultural situations, taking into account the client s health beliefs, cultural values, disease prevalence, and treatment efficacy (Edwards and Erwin-Johnson, 2003; Richardson and Jacobs, 2002; Kim-Goodwin, Clark, and Barton, 2001). Without awareness of cultural differences, the Western values of individualism, autonomy, independence, self-reliance, and self-control may conflict with families of other cultures that may not have such values (Kim-Godwin, Clarke, and Barton, 2001). Professional interest in cultural competence among nurses and health care professionals is predated by a rich and varied history on the subject and many decades of debate regarding the profession s response or lack of response to the service needs of diverse clients (Jackson, 2005). The concept of cultural competence has moved through a progression of ideas and theoretical constructs favoring cultural pluralism, cultural sensitivity, multiculturalism, and a trans-cultural orientation to the health care profession (Gould, 1995). The majority of health care providers perceive themselves as culturally competent, aware and knowledgeable. The lack of cultural diversity especially in the cardiovascular health care field may influence the delivery of health care to Black clients as evidenced by the Black population s perceptions and complaints about discriminatory treatment from health care providers (Gould, 1995). Cultural health disparities are represented in the high levels of incidence and prevalence of cardiovascular disease, in equally high morbidity and mortality rates among Black patients. All health care providers need

17 5 to master culturally competent knowledge, awareness and skills because the pluralistic and multicultural society is a social reality according to Gould (1995). A pluralistic society is one where different groups can interact while showing a certain degree of tolerance for one another, where different cultures can coexist without major conflicts, and where minority cultures are encouraged to uphold their customs (Kellan, 1915). Cultural pluralism is the dynamic by which minority groups participate fully in the dominant society and maintain their cultural differences. Black/African American culture necessitates freedom from total assimilation and retains their cultural heritage in the face of demands for cultural conformity (Kellan, 1915). In a report to the National Association for the Advancement of Colored People (NAACP) (Edwards and Erwin-Johnson, 2003), it was noted that of the 15 leading causes of death, Blacks have the highest incidence rates in 13 of them. It is known that all persons respond culturally to sickness and disease, so if a health care provider ignores the cultural influences at work, these limitations will be barriers to success. In this context, the term institutional racism was defined as differential access to goods, services and opportunities of society by race. Institutional racism is normative, sometime legalized, and often manifests as inherited disadvantage. It is a structural and unmentioned code within the medical institutions, a perpetrator using the guise of customs, practices, and unwritten laws (Jones, 2002). One consequence of this persistent and continuous racism, discrimination, and cultural insensitivity is an unequal burden of illness and premature death experienced by racial and ethnic minorities according to an article by Thomas (2001). Thomas notes that in a study by Freeman and Payne (2001), there is a subtle form of racial bias on the part of medical care providers. The level and extent of these problems is unknown, but are real and potentially harmful, even though predominately unintentional. Medical care

18 6 providers must place a greater emphasis on people s cultural and behavioral attitudes, beliefs, lifestyle patterns, diet, and environmental living conditions (Erlen, 2003). In the findings of the 108 th session of Congress (2004), the Senate identified 12 points that need immediate attention, several of which are blatant and include the following concepts; (a) as medical science and technology have advanced at a rapid pace, the health care delivery system has not been able to provide consistent high quality care to all Americans; (b) recent studies have raised significant questions regarding differences in clinical care provided to racial and ethnic minorities and other health disparity populations, which are often grouped under the broad heading of health disparities ; (c) despite considerable efforts by the Department of Health and Human Services (DHHS), data collection efforts governing racial, ethnic, and health disparity populations remain inconsistent and inadequate. These efforts often quantify disparities, but shed little light in their causes; there is a need to ensure appropriate representation of racial and ethnic minorities and other health disparities populations in the health care professions and in the fields of biomedical, clinical, behavioral and health services research. Research Aim The specific aim of this study was to examine the level of self-perceived cultural competence of the health care providers treating Black patients with cardiovascular disease and the resulting comorbid conditions, assessed by The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised [(IAPCC-R ) Campinha-Bacote, 2002]. All items included Likert scale responses to assess the direction and intensity of perception and actual concepts of the respondents. This questionnaire incorporated a four-point scale to eliminate the availability of a middle option of "Neither agree nor disagree"

19 7 Cardiovascular health care providers in Rock Island County perceive themselves as culturally competent, as evidenced by institutional mission statements, online job descriptions and program goals. I hypothesized self-reported cultural competence levels, measured by the IAPCC-R (Campinha-Bacote, 2002), will not be as high as believed by the healthcare providers. Organization of the Study The study proceeds in three chapters. Chapter Two regards key definitions of cultural competence and includes a literature review addressing cultural competency, cultural mistrust, and the effect of cultural mistrust upon disparities in cardiovascular health, methodology, identification of the study population of health care professionals in Rock Island County, Illinois, instrumentation, data collection, and data analysis of the survey. Chapter Three provides an evaluative summary, future directions, and implications of this research.

20 8 CHAPTER II REVIEW OF THE LITERATURE Introduction A review of selected literature provides rationale for the need for cultural competence in a multicultural society. The first section of this chapter defines cultural competency in relationship to the health care profession, the context in which contact with Black patients originates. The definition of cultural mistrust and the impact on disparities in cardiovascular health concludes the literature review. Culture and Cultural Competency Culture, according to Carrillo, Green, and Betancourt (1999), is defined as a shared system of values, beliefs, and learned pattern of behavior and not simply defined by ethnicity. Every culture has health components of health preservation, prevention, illness, treatment, coping styles, and beliefs about death and dying (Carrillo, Green, and Betancourt, 1999). Culture provides the beliefs and values that give individuals a sense of identity, self-worth and belonging, as well as providing the rules of behavior along with the values, beliefs, and practices that their cultural group has about health promotion and illness prevention (Cortis, 2003). Culture is dynamically affected by social transformation, social conflicts, and migration, which, allowing for intra-and intergenerational chance can change over time (Cortis, 2003). Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups. Department

21 9 of Health and Human Services (n.d.) notes cultural competence also focuses on populationspecific issues including health-related beliefs and cultural values (the socioeconomic perspective), disease prevalence (the epidemiologic perspective), and treatment efficacy (the outcome perspective). According to studies by Campinha-Bacote (Campinha-Bacote, 1995, 1999, 2002), the definition of cultural competence is a process, not an endpoint, in which the health care provider continuously strives to achieve the ability to work within the cultural context of an individual family, or community, from a diverse cultural/ethnic background. Cultural competence require awareness of and sensitivity to how patients experience their uniqueness, deal with their differences and similarities, and cope with a sociopolitical environment that is commonly unconcerned with the welfare of its people, however diverse their needs will be. Although the dialogue of culture isolates people by virtue of race, ethnicity or nationality, in reality people represent intersections of these various cultural groups (Jackson, 2005). Cultural competence requires the capacity to recognize the interaction of these multiple identities at the individual, family, group, neighborhood, and community levels and recognizes the important cultural issues within these relationships. Cultural competence requires a heightened consciousness of how clients experience their uniqueness and deal with their differences and similarities within a larger social context (Jackson, 2005). Cultural competence is an important building block of clinical care, an expansion of patient-oriented care, and a skill set that is basic to professionalism, delivery, and quality of care (Betancourt, 2006). Constructs of Cultural Competency In studies by Campinha-Bacote (1995, 1999, 2002), the author defines cultural competence as the sum of four collateral constructs; awareness, knowledge, skill, and

22 10 encounters. Because these constructs are interdependent. the intersection of these constructs represents the true process of cultural competence (Campinha-Bacote, 1999). Cultural Awareness Cultural awareness requires that health care providers are sensitive to the beliefs, values, practices, and lifestyles of their client s culture and ethnicity (Campinha-Bacote, 1995, 1999). The cultural awareness process involves in-depth examination of an individual s own prejudices and biases toward other cultures as well as self-examination of their own cultural background. Campinha-Bacote (1999) finds that without being aware of the influence of self values and beliefs, the risk is that health care providers may impose their own cultural values, beliefs, and practices. Respect for the client s culture is directly related to respect for the health care provider s own inherent culture in tandem with adapting the inherent perspective and beliefs of Black patients. According to Campinha-Bacote (1995, 1999), the four stages of cultural awareness are identified as; unconscious incompetence, conscious incompetence, conscious competence, and unconscious competence, which are directly related to an individual s level of awareness regarding interactions outside of their personal culture. Unconscious incompetence is when the health care provider is unaware that cultural differences exist because a client may look and behave much like the health care provider, which is an erroneous assumption based on the concept of intra-ethnic variation. The health care provider is unaware of the biological variations, diseases and health conditions, and variations of drug metabolism of Black or ethnically diverse populations. Conscious incompetence is being aware that cultural differences exist or as Campinha-Bacote (1995, 1999) describes as, health care providers who possess the know that knowledge but not the know how knowledge, to effectively communicate with

23 11 clients from different cultural backgrounds. Health care providers at this stage know that culture plays an important role in treating a diverse patient population, but do not know how to effectively use this knowledge. Conscious competence is the conscious act of learning about the client s culture and providing culturally relevant interventions. Often health care providers at this stage are overly conscious about being politically correct, which can interfere with effective communication with the client. The unconscious competence health care provider will automatically provide culturally congruent care to the diverse client population and interacts naturally with patients from diverse cultures. Health care providers, in the process of awareness, move along a continuum (Campinha- Bacote, 1995) beginning at avoidance and progress to protection, in which the health care provider feels that cultural differences threaten their own self-identity and minimize cultural differences while emphasizing the unifying aspects of humanity. Health care providers that reach the other end of the continuum reflect a perspective that adapts, accepts, and integrates cultural differences into practice. Cultural Knowledge Campinha-Bacote (1995, 1999) defines cultural knowledge as the process of seeking and obtaining a sound educational foundation concerning the various world views of different cultures. Obtaining the knowledge base involves a focus on the integration of three specific issues; health related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy (Campinha-Bacote, 1995, 1999). Cultural knowledge about the client s health related beliefs and values involves understanding their worldview, which will explain how the client interprets illness and how this knowledge guides their thinking, doing and being (Campinha- Bacote, 1995, 1999). Cultural knowledge about disease incidence and prevalence among

24 12 minority populations is varied. It is essential that the knowledge base includes accurate epidemiological data to guide decisions about treatment, health education, and prevention programs to positively impact health outcomes. Treatment efficacy involves knowledge about variation in the biological process, hereditary, endemic and topographic diseases, home environment, and psychological affect that can affect healthy outcomes (Campinha-Bacote, 1995). Specific knowledge on therapeutic barriers formed by specific biological variations present among different ethnic groups, identified as bio-cultural ecology, an area of biological variations, disease and health conditions, and variation in drug metabolism also known as ethnic pharmacology (Campinha-Bacote,1999) is a relatively new area of research. Cultural Skill Cultural skill is defined as the ability to collect relevant and accurate cultural data of the client s health history and chief complaint combined with a culturally based physical assessment. This process involves learning how to conduct a culturally based physical assessment (Campinha-Bacote, 1995, 1999). Cultural assessment is a systematic appraisal to determine a client s values, beliefs, and practices to determine the needs and interventions that are applicable to the client. In a culturally based physical assessment, the acquired cultural knowledge of physical, biological, and physiological variations are used to perform a physical evaluation. Cultural Encounters Cultural encounters, according to Campinha-Bacote (1995, 1999), are defined as a process that encourages the health care provider to directly engage in cross-cultural interactions with clients from culturally diverse backgrounds. Direct interaction will refine or modify existing beliefs of the health care provider about a cultural group and prevent stereotyping. Due to intra-ethnic variation, an encounter with just three or four members of a specific cultural or

25 13 ethnic group may not represent the expressly defined beliefs, values, or practices of that particular group and will not make the health care provider an expert of the cultural group. Campinha-Bacote (1995) states that health care providers must be cognizant that sometimes good intentions and usual (self) nonverbal communication styles can be interpreted as offensive and insulting to a specific cultural group. Cultural Desire Cultural desire as an operational fifth construct is the motivation of health care providers to engage in the process of becoming culturally aware, culturally knowledgeable, culturally skilled, and proficient with cultural encounters (Campinha-Bacote, 1999, 2002). Health care providers must possess a genuine desire to work with a culturally diverse population that is reflected by their words and actions congruent with their true inner feelings. Genuine caring is an inherent quality of health care providers and is keenly perceived by Black patients, which will influence all interactions involving the health care process. Cultural Mistrust There is a general sense of mistrust by Blacks of White institutions and health care providers because of their unfamiliarity with the minority culture and insensitivity to nonwhite cultures that creates barriers to the delivery of quality health care. Cultural mistrust is defined as a tendency to distrust Whites based upon a history of direct or vicarious exposure to racism and discrimination. In response to discriminatory treatment, Blacks have developed a mistrust of many structural aspects of society. In the United States, White individuals who have historically mistreated Blacks, dominate all of the structural or institutional systems. Healthcare has a legacy of poor treatment and abuse of Blacks (Benkert, 2006). Few studies have focused on the perception of differential treatment due to race when receiving health care services held by

26 14 Blacks or other ethnic minority groups (Hobson, 2001). Individuals reported a perceived negative attitude as one of the main expressions of race based treatment in a health care setting (Hobson, 2001). According to Hobson (2001), the perceived negative attitudes exhibited by health care providers were uncaring or rude, not hostile. Several individuals used the term belittle to describe their experiences. Individuals reported that the manner and actions of some health care personnel made them feel less than significant compared to other patients due to their race. Benkert (2006) points out that no study using cultural mistrust as a distinct psychological aspect of health care delivery could be found, so it is plausible to expect that high levels of mistrust would affect the level of adherence with prevention interventions, medical plans of care and treatment, and any follow-up recommendations. In a report released by the Institute of Medicine (IOM, 2002) titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the panel of experts concluded that the health provider s prejudice and the resulting patient mistrust are a fundamental cause of racially and culturally based disparities in healthcare. According to the Institute of Medicine (IOM, 2002), It is reasonable to speculate, however, that if patients convey mistrust, refuse treatment, or comply poorly with treatment, providers may become less engaged in the treatment process, and patients are less likely to be provided with more vigorous treatments and services. However, these kinds of reactions from minority patients may be understandable as a response to negative racial experiences in other contexts, or to real or perceived mistreatment by providers. Survey research, for example, indicates that minority patients perceive higher levels of racial discrimination in healthcare than non-minorities. Patients and providers behavior and attitudes may therefore influence each other reciprocally, but reflect the attitudes, expectations, and

27 15 perceptions that each has developed in a context where race and ethnicity are often more salient than these participants are even aware of. Three mechanisms might be operative in healthcare disparities from the provider s side of the exchange: bias (or prejudice) against minorities, greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or health of minorities. Patients might also react to providers behavior associated with these practices in a way that also contributes to disparities (IOM, 2002). Measuring cultural mistrust when minorities are in the health care setting is a necessary first step to determining the role of cultural mistrust in minorities health-seeking behaviors (Mosley, 2007). Perceptions of Racism and Mistrust In Health Care Model [(PRMHC) Benkert, Peters, Clark, and Keves-Fostor, 2006] hypothesize that trust is crucial to the patient/provider relationship to reduce health disparities (Benkert, Peters, and Clark et. al, 2006). Black patients experience racism in their interactions with health care providers and the health care system (Benkert et. al, 2006), which has been supported by past studies citing health care providers and health care systems whose behavior has been untrustworthy. This has resulted in an overwhelming sense and perception by Black patients that health professionals will overlook important health concerns based on racial bias and lack of cultural knowledge (Benkert et. al, 2006). This results in a trust dilemma perpetuating barriers to delivery of quality health care. According to Benkert et al. (2006), the PRMHC model hypothesizes that: 1) perceived racism would have a positive and direct effect on cultural mistrust; 2) cultural mistrust would have a negative and direct effect on trust in the health provider; 3) trust in the health provider would

28 16 have a positive and direct effect on patient satisfaction, and 4) that cultural mistrust or trust would mediate the influence of racism on satisfaction. Cardiovascular Disease Prevalence and Health Disparities Disparities in survival rates among the minority population in the United States have been widely documented with respect to heart disease, cerebrovascular disease, malignant neoplasms, diabetes mellitus, and other chronic conditions. For example, in the United States, Blacks have a higher incidence of stroke, more severe strokes, and higher stroke mortality according to a study by Gillum (1998). This ethnic disparity has been attributed to a higher prevalence or severity of stroke risk factors in Blacks, biological differences between Blacks and Whites, and a lower socioeconomic status in Blacks as compared to Whites (Gillum, 1998). According to the American Stroke/Heart Association (2004), compared with Whites, Blacks develop high blood pressure earlier in life and their blood pressure is much higher when diagnosed. As a result, Blacks have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease death, and a 4.2 times greater rate of end-stage kidney disease as reported by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, Seventh Report (2003). The term health disparities, is defined by National Institutes of Health Working Group on Health Disparities (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005) as differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions. These disparities have been documented in the United States throughout most of the past two centuries as outlined in separate studies by various researchers. A health disparity should be viewed as a chain of events signified by a difference in environment, access to utilization of and quality of care, health status, or a particular health outcome that deserves scrutiny (Baquet,

29 ). This inequality is strongly depicted in the area of minority health with the health care status of Blacks as a function of their marginal position to the United States health care system and a direct result of multiple factors that include the social determinants of lower levels of education, overall lower socioeconomic status, inadequate and unsafe housing, and housing in close proximity to environmental hazards (Betancourt, 2006). The Institute of Medicine Panel (IOM, Betancourt, 2006) found in a 2002 study focused on health care for Black patients by providers that health disparities that are not a direct result of social determinants and are valid due to persistent racial and ethnic discrimination in many sectors of American life. The IOM (Betancourt, 2006) reports find that many sources within the health care system, health care providers, and patients themselves contribute to health disparities. Health care providers within the system can be biased, stereotypical, prejudiced and clinically uncertain, while patients are likely to refuse treatment due to these beliefs. The Healthy People 2010 Report (US Department of Health and Human Services, 2000) found that Blacks along with other minority populations would be observant of the socioeconomic effects increasing health disparities to a greater degree than the dominant White population. This report also indicates that the differences in survival and health between Blacks and Whites are not exclusively explained by poverty, but by unique experiences and cultural orientations of a diverse population. An IOM study committee (Betancourt, 2006) reviewed well over 100 studies that assessed the quality of healthcare for various racial and ethnic minority groups, while holding constant variations in insurance status, patient income, and other access-related factors. Many of these studies also controlled for other potential confounding factors, such as racial differences in the severity or stage of disease progression, the presence of co-morbid illnesses, where care is received (e.g., public or private hospitals and health systems) and other patient demographic variables, such as age and gender.

30 18 Some studies that employed more rigorous research designs followed patients prospectively, using clinical data abstracted from patients charts, rather than administrative data used for insurance claims. The study committee was struck by the consistency of research findings: even among the better-controlled studies, the vast majority indicated that minorities are less likely than whites to receive needed services, including clinically necessary procedures. These disparities exist in a number of disease areas, including cancer, cardiovascular disease, HIV/AIDS, diabetes, and mental illness, and are found across a range of procedures, including routine treatments for common health problems. The use of the term health disparities is the United States has the tendency not to distinguish between the differences in health outcomes that are unavoidable, potentially available and acceptable, and potentially avoidable unfair and inequitable (Carter-Pokras & Baquet, 2002). In a study by Bolton, Giger, and Georges (2003), racial and ethnic disparities in health care are consistent and persistent regardless of the nature of the illness or the type of health care received. There are three broad domains that help to clarify and promote understanding of the origins and persistence of racial and ethnic health disparities (Ibrahim, Thomas, and Fine, 2003). The first domain involves patient-level variables such as biology, individual disease status, and psychosocial characteristics of cultural or individual preferences. The second domain entails the characteristics and practices of health care professionals that include racism, stereotyping, racial discrimination, and cultural or professional incompetence. The third domain involves the system of health care delivery, the racial and ethnic diversity of the workforce, proximity of health care facilities to communities in greatest need, accessibility of medical care regardless of income.

31 19 The Process of Cultural Competence In the Delivery of Healthcare Services Model This model developed by Campinha-Bacote in 1998 defines the process of a health care provider s self-awareness of becoming culturally competent as opposed to being culturally incompetent. This model views the interdependent constructs of cultural knowledge, skills, awareness, encounters, and desire as a process of becoming culturally competent. Health care providers can enter this process at any construct, but all five constructs must be experienced or addressed in order to improve a balance. Campinha-Bacote (1998) notes in her study that the intersection of these constructs reflect the true process of cultural competence. Health Behavior Theory The Health Belief Model (Rosenstock, 1974) is a useful tool to help predict health related behaviors based on the attitudes and beliefs of individuals, understanding that the individual will take a health related action to avoid a negative health condition, believes that the recommendations of a health professional will be effective to avoid the negative health condition, and that the person can perform the recommended action. Out of the six concepts; perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy; perceived barriers are the greatest challenge facing minority populations in the delivery of quality health care.

32 20 CHAPTER III METHODS Research Aim The purpose of this study was to examine the level of self-reported cultural competence of the health care providers treating Black patients with cardiovascular disease and the resulting comorbid conditions, based on The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R, Campinha-Bacote, 2002). Permission to use the survey for the study was obtained from the author, Dr. Josepha Campinha-Bacote. Hypothesis The two medical center sites where the research study was conducted emphasize a high level of cultural competence. According to Genesis Medical Center s online job description, the job details its purpose as: Provides and directs safe, effective, and culturally-competent patient care for all age groups requiring stabilization, and/or resuscitation. Key accountabilities include assessment, diagnosis, outcomes identification, planning, implementation, and evaluation of care using critical thinking and evidenced-based practice; triaging and prioritizing care needs; crisis intervention for unique patient populations (e.g., sexual assault survivors); and emergency operations preparedness; adherence to the Professional Practice Standards as defined by ANA; and active participation in quality monitoring and performance improvement activities (Genesis Medical Center, 2010). Trinity Regional Health System 5 Department of Nursing s philosophy of nursing 5 Formerly known as Trinity Medical Center, Rock Island Campus.

33 21 practice (2010) emphasize in its mission statement: We uphold the sanctity of life and recognize the multi-dimensional aspects of our roles, where the whole person is respected and honored. Cultural, spiritual, psychosocial, physical, environmental and emotional aspects are considered in delivering holistic care. We respect the patient s right to an individualized plan of care that reflects evidence-based thinking and mutual decision-making. Recognition of diversity and beneficence in practice supports the individuality of care, demonstrating a personal difference to those we serve. Trinity College of Nursing and Health Sciences provide a quality higher learning environment preparing competent practitioners for healthcare professions. Continuous quality improvement guides the educational process as students prepare to deliver culturally congruent healthcare, perform as responsible citizens within the global community and seek avenues for lifelong learning (Trinity Regional Health System, 2010). Within Trinity Regional Health System is the Trinity College of Nursing and Health Sciences, an educational and employee resource base, has as part of its program goals of culture care values: ability to preserve/maintain cultural identities; ability to accommodate/negotiate diverse life ways; Ability to repattern/restructure health-care delivery methods; and ability to apply ethical and legal principles to health care (Trinity Regional Health System, 2010). Cardiovascular health care providers in Rock Island County perceive themselves as culturally competent as evidenced by direct quotes from online job descriptions, institutional mission statements and programs goals. I hypothesized that the self-reported cultural competence levels based on the IAPCC-R (Campinha-Bacote, 2002) may not be as high as believed at the institutional level of each facility.

34 22 Design This was a cross-sectional, survey-based study to examine the scope of cultural competence of nurses and health care professionals. Their level of cultural competence directly influences the delivery of health care to the Black population because of cultural mistrust and perceived racism during patient to provider interactions. This was an exploratory study using an integrated quantitative research and evaluation method to determine the scope of self-reported cultural competence of cardiovascular nurses and health care providers. Setting This study focused on health care professionals in two locations. The first group of nurses consisted of cardiovascular health care professionals who work at Genesis Medical Center Illini Campus, located at 801 Illini Drive, Silvis, Illinois. The second group of nurses consisted of cardiovascular health care professionals at Trinity Regional Health System West Campus, Rock Island, Illinois. Subjects The participants at both locations were all licensed nurses of three levels, Nurse Practitioners, Registered Nurses (Diploma and Graduate), and Licensed Practical Nurse. Data Collection Instruments The Inventory to Assess the Process of Cultural Competence among Healthcare Professionals-Revised, [(IAPCC-R ), (Campinha-Bacote, 2002), ] was designed to measure cultural competence among health care professionals based on The Process of Cultural Competence in Healthcare Services Model measuring the constructs of cultural awareness, knowledge, skill, and encounters. The IAPCC-R is a pencil/paper self-assessment tool that measures the level of cultural competence in healthcare delivery. It consists of 25 items that

35 23 measure the five cultural constructs of desire, awareness, knowledge, skill and encounters. Five items address each construct. The IAPCC-R uses a 4-point Likert scale reflecting the response categories of strongly agree, agree, disagree, strongly disagree; very aware, aware, somewhat aware, not aware; very knowledgeable, knowledgeable, somewhat knowledgeable, not knowledgeable; very comfortable, comfortable, somewhat comfortable, not comfortable; and very involved, involved, somewhat involved, not involved. Completion time is approximately minutes. This questionnaire is designed to measure the level of cultural competence among health care professionals and specifically intended for health care clinicians (Campinha-Bacote, 2002). Their level of cultural competence directly influences the delivery of cardiovascular health care to the Black population because of cultural mistrust and perceived racism during patient to provider interactions. This was an exploratory study using integrated quantitative research and evaluation methods to determine the scope of self-reported cultural competence of nurses and health care professionals. Cronbach s alpha a statistic used as a measure of the internal consistency reliability of a psychometric instrument, of the IAPCC-R was established at.81 (Campinha-Bacote, 2002). Internal validity and consistency of the IAPCC-R was confirmed using Guttman Split-half 6 (.76) and Spearman-Brown (.76), (Mabunda, and White, 2006). Content validity was established that the items on the IAPCC-R clearly reflect the review of the literature of cultural competence 6 Split-Half Reliability, An alternative way of computing the reliability of a sum scale is to divide it in some random manner into two halves. If the sum scale is perfectly reliable, we would expect that the two halves are perfectly correlated (i.e., r = 1.0). Less than perfect reliability will lead to less than perfect correlations. We can estimate the reliability of the sum scale via the Spearman-Brown split half coefficient or the Guttman split-half: r sb In this formula, r sb is the split-half reliability coefficient, and r xy represents the correlation between the two halves of the scale = 2r xy /(1+r xy ).

36 24 in healthcare delivery that identifies awareness/attitudes, skill and knowledge as domains of cultural competence (Kattner, M. 2006). Face validity was established by reviews of national experts in the field of transcultural healthcare (Campinha-Bacote, 2002). A demographic flysheet was attached to the questionnaire to establish demographics of the participants (Appendix A). Methodology Data Collection Telephone contact was initiated by the researcher 7 to the Nursing Research Coordinators at Trinity Regional Health System, Rock Island Campus, IL and Genesis Medical Center, Illini Campus, Silvis, IL, to explain the study, to obtain initial verbal consent for nursing staff participation, and to identify the contact person for each location. Meetings were arranged with the Nursing Research Coordinator and their respective department members to detail the study, research aim, hypothesis, and survey questionnaire. Permission to conduct the research was obtained from Genesis Institutional Review Board (Appendix B), Trinity Institutional Review Board (Appendix C), and the University of Iowa Institutional Review Board (Appendix D) after submitting a research proposal and meetings at each location with administrative members of the nursing department. The Nurse Managers of each location distributed informational flyers of my research study to their respective cardiovascular health care providers/nurses located in the cardiovascular units and the emergency room departments. Posters/Flyers were placed in the common areas (bathrooms and break rooms), and near time clocks announcing the details of the research study (Appendix E). The nurses were not chosen, but up to the first 50 nurses at each location who volunteered to complete the questionnaire at their leisure were included. I distributed the 7. The researcher is identified as Alesia Grice-Dyer

37 25 questionnaires and demographic flysheet at both locations. To ensure complete anonymity, each participant deposited the completed responses in a sealed box. The returned questionnaires were reviewed to count for missing or suspicious data. Completed questionnaire and demographic data of less than 50% would have been deleted from statistical analysis and retained for record keeping. Completed demographic data of more than 50% were included; the missing data were incorporated using the mean answers of the completed questionnaires. Data considered suspicious, for example, all of the answers on a questionnaire are either yes or no, or the answers displayed an obvious pattern, were subject to rejection, but none of the questionnaires met this criteria. The total number of participating nurses were ninety-two (n = 92). At the Trinity Regional Health System, forty-five nurses (n = 45) participated. Of the 45 participating nurses, 38 nurses returned the questionnaire with the demographics flysheet; seven did not return the demographic flysheet. Missing demographic data was not included in the analysis. At Genesis Medical Center, Illini Campus, forty-seven (n = 47) nurses participated. The data from the completed questionnaires were reviewed and entered into Websurveyor, a data entry program provided by the University of Iowa, then exported into an Excel file for analysis. Each questionnaire was scored according to the scoring key. Possible scores range from and indicate whether a healthcare professional is operating at a level of cultural proficiency, cultural competence, cultural awareness or cultural incompetence. Higher scores depict a higher level of cultural competence (Campinha-Bacote, 2002). Analysis The analysis of the IAPCC-R questionnaire began with descriptive statistics, particularly measures of central tendency and frequency. Likert responses were summed and scored

38 26 according to the IAPCC-R scoring key Attitude was measured, where answers are given on a scale ranging from complete agreement on one side to complete disagreement on the other side, with no opinion in the middle. Responses to a single Likert item are normally treated as ordinal data, because, especially when using only four levels, there is no assumption that respondents perceive the difference between adjacent levels as equidistant. When treated as ordinal data, Likert responses can be analyzed using non-parametric tests, such as the Wilcoxon signed-rank test. Likert scale data can, in principle, be used as a basis for obtaining interval level estimates by applying the polytomous Rasch model, which permits testing of the hypothesis that the statements reflect increasing levels of an attitude or traits, as intended (Answers.com, 2009). This analysis will use a level of significance α =.05. Results Demographic Flysheet Each medical center was analyzed individually. Seven questions were included in the demographic flysheet (Appendix A). Trinity Regional Health System had 45 nursing participants (n = 45), with 38 (n = 38) returning the demographic flysheet with the questionnaire. Genesis Medical Center, Illini Campus had 47 nursing participants (n = 47) and all participants returned the demographics flysheet with the IAPCC-R questionnaire. This demographic flysheet was used as a proxy to describe characteristics of my sample population. The demographics reflected the composition of the sample nursing participants/workforce in Rock Island County, Illinois. The majority of respondents age range was 46 65, indicating the population of nurses treating Black cardiovascular patients in Rock Island County is aging along with the patients The 2007 Illinois Nursing Workforce Survey (National Research Corporation [NRC], 2007) finds the most common age

39 27 category for their research participants was between 46 and 65 years of age, which represented the most common category for LPNs (53.5%), RNs (57.6%), and NPs (73.0%). The second most common age range was 36 to 45 years of age who participated in the 2007 Illinois Nursing Workforce survey (NRC, 2007). The least common age range for all three nursing categories was 18 to 25 years of age, which accounted for, 3.0% of LPNs, 3.0% of RNs, and less than 1.0% of NPs (NRC, 2007). The percentages for the age range of over 65 were 5.3% of LPNs, and 15.5% of RNs. There were no reported NPs over the age of 65. Ninety-four percent (n = 80) of the respondents were White, which is indicative of the disparity in the racial composition of health care workforce in Rock Island County, Illinois (Tables 2.4 and 2.5). Moreover, a culturally diverse nursing population in both locations did not treat any patients in Rock Island County. This is a permutation of the health disparities and cultural competence facing an underserved and under-represented patient population. Compared to Rock Island County population statistics provided by the U. S. Census Bureau (2008), the sampled nursing workforce is not reflective of the area s racial and cultural diversity. Registered Nurses (RNs) were the largest healthcare occupation in 2003, with 2.4 million jobs, with women comprising 92.1 percent of RNs nationally in According to the Bureau of Labor Statistics (BLS), in 2003 nationally, 81.9 percent of RN's were white, 9.9 percent were black, 7.0 percent were Asian, and 3.9 percent were Hispanic. Compared with total employment figures in 2003, blacks and Hispanics were underrepresented as registered nurses. Hispanics represented 12.6 percent of total employment, while blacks represented 10.7 percent. The 2007 Nursing Workforce survey (NRC, 2007) reports that in Rock Island County, the prevailing age range for all nursing participants was 46 to 55 years, 29.4% for LPNs, 31,6% for RNs, and 50.0% for NPs. The second most common age range was 36 to 45 years for all levels of nursing.

40 28 The percentage years as a licensed nursing professional are similar for participants of Rock Island County as compared to the state of Illinois statistics. Statewide, the percentage of LPNs who had more than 20 years of practice been 40.9%, RNs had 62.7% longevity, and of NPs, 83.1% had more than 20 years of practice (Tables 2.7, 2.8).

41 29 Table 2.1. Trinity Demographic Age. Frequency N Percent Cumulative Percent Valid Total Table 2.2. Scoring Key for Demographics Age = 1pt = 2pts = 3pts = 4pts. 65+ = 5pts. The most common age category for respondents to this survey was between 46 and 65 years of age. The second most common age range was 36 to 45 years of age. The valid percent represent an accurate picture of the distribution of the valid cases since these "valid" percentages are not deflated by the inclusion of the missing cases in the denominator. In the state of Illinois, the most common age category for respondents to this survey was between 46 and 55 years of age (National Research Corporation, 2007).

42 Figure 2.1 Trinity Demographic Age Range. 30

43 31 Table 2.3. Illini Demographic Age Range. Valid years years years years Frequency N Percent Cumulative Percent Total Total Table 2.4. Scoring Key for Demographics Age. Scoring Key for Demographics Age = 1pt = 2pts = 3pts = 4pts. 65+ = 5pts. The most common age category for respondents to this survey was between 36 and 45 years of age. The second most common age range was 46 to 65 years of age. The valid percent represent an accurate picture of the distribution of the valid cases since these "valid" percentages are not deflated by the inclusion of the missing cases in the denominator.

44 Figure 2.2. Illini Demographic Age Range. 32

45 33 Table 2.5. Illini and Trinity Race/Ethnicity of Nursing Workforce vs. Race/Ethnicity of Rock Island County Hospital Nurses. Race/Ethnicity Response N Percentage Race/Ethnicity of Rock Island County Hospital Nurses Black/African American 2 2.4% 55 Hispanic/Non-White 3 3.5% 9 White % 491 Asian/Pacific Islander 0 0.0% 18 Native American/American Indian 0 0.0% 2 Multiracial 0 0.0% 0 a. Calculated from grouped data. b. Percentiles are calculated from grouped data The racial identification question in the survey allowed respondents to indicate one or more racial categories and for study purposes, the term race/ethnicity is used to clarify racial identification. As shown in Table 2.4, almost all nurses (94.1%) identified White as their racial group, followed by 2.4% who indicated Black or African American. There was not any racial identification of nurses who were Native American/American Indian, Multiracial, or Asian/Pacific Islander. As compared to the state of Illinois statistical data, the diversity of nurses remains consistent.

46 34 Table 2.6. Racial Demographics of Rock Island County Population. Rock Island County, Illinois Estimate Margin of Error Total: 146,800 ***** White alone 122,211 +/-1,112 Black or African American alone 11,771 +/-379 American Indian and Alaska Native alone 359 +/-150 Asian alone 2,862 +/-193 Native Hawaiian and Other Pacific Islander alone 33 +/-38 Some other race alone 6,376 +/-1,024 Two or more races: 3,188 +/-663 Two races including Some other race 1,123 +/-430 Two races excluding Some other race, and three or more races 2,065 +/-494 Source: U.S. Census Bureau, American Community Survey. According to the completed demographic flysheets for each location (Tables 2.4 and 2.5), the composite of the sample population did not accurately reflect the racial composite and cultural diversity of Rock Island County. Ninety-four percent (n = 80) of the respondents were White, which is indicative of the disparity in the racial composition of health care workforce in Rock Island County, Illinois. Moreover, a culturally diverse nursing population in both locations did not treat any patients in Rock Island County. This is a permutation of the health disparities and cultural competence facing an underserved and under-represented patient population.

47 35 Table 2.7. Study Participants Job Title/Level of Nursing. Response Count Percentage Nurse Practitioner % RN % LPN 4 4.7% Table 2.8. Study Participants Years of Training (Schooling). Response Count Percentage 1 year 2 2.4% 2 years % 3 years % Graduate % Most of the LPNs, RNs, and NPs who participated in this survey indicated their years of education at Associate s degree (2 years) followed by a Graduate degree. This pattern was consistent with the findings of The 2007 Illinois Nursing Workforce Survey (NRC, 2007), RNs were employed at a higher rate, with 67.8% of responding nurses completing 3 or more years of college.

48 36 Table 2.9. Study Participants Years in the Nursing Profession. Response Count Percentage 1-5 years % 6-10 years % years % years 6 7.1% More than 20 years % Health Resources and Services Administration (HRSA, 2004) The majority of nurses were employed in the same setting in 2004 as they were in Eighty-nine percent (88.8 percent) of registered nurses who were working in a hospital in 2004 were also working in a hospital in In order to get more data on job market conditions for RNs, the NSSRN asked the nurses whether they had changed employers or positions between 2003 and Results show that 62.4 percent of those in the RN population in March 2004 were employed both years in the same position. Sixteen percent of nurses (16.1 percent or 467,566) were employed both years but changed employers and/or positions. Of all RNs who reported making an employer or position change within the past year, a large proportion, 82.7 percent, cited a workplace issue as a reason for the change (Health Resources and Services Administration HRSA, 2004), indicating a problem with retaining trained nursing staff.

49 37 Table Number and Percentage of Black Patients Treated in Rock Island County. Response (both locations) Count Percentage Less than 10% % 10%- 25% % 26%-40% % 41%-55% 5 6.1% 56%-70% 2 2.4% More than 71% 1 1.2% Blacks and Hispanics had 13 percent fewer follow-up consultations than whites. Forty percent of Black patients were less likely to be referred for angioplasty or by-pass surgery. Blacks had fewer follow-up consultations and received lower cardiac performance measures over five years (Bozzette, S., Ake, C., Tam, H., Chang, S., Louis, T., (2003). The percentage of Black patients treated is related to the quality and number of cultural encounters of each nurse. This percentage reflects the amount of intercultural learning each nurse participant has experienced (Table 2.9). In comparison to the racial distribution of the county, the nursing workforce in Rock Island County is primarily White. The representation of other ethnic/racial groups is minimal to nonexistent.

50 38 Figure 2.3. Percentage of Black Patents Treated. Key 1.00 = <10% 2.00 = 10% - 25% 3.00 = 26% - 40% 4.00 = 41% - 55% 5.00 = 56% - 70% 6.00 = > 71%

51 39 Questionnaire Results All answers to the questionnaire were categorized into sets to score each level/degree of responses according to the scoring key (Campinha-Bacote, 2002). The sets of responses to the questions were scored using the Likert Scale in Table 2.10 to convert into numbers. Each scored response was categorized to represent each of the constructs of cultural competency. levels: The final cultural competency scores were compiled and categorized into the following 1) Culturally Proficient points 2) Culturally Competent points 3) Culturally Aware points 4) Culturally Unaware points

52 40 The scoring key can be found in the book The Process of Cultural Competence in the Delivery of Health Care Services 2002), available through most libraries.

53 41 I hypothesized that cardiovascular health care providers in Rock Island County perceive themselves as culturally competent. This perception of cultural competence is self-reported since it was not directly observed and only an assessment at the institutional level and not an actual measurement. The self-reported cultural competence levels as measured by the questionnaire are not as high as perceived. The findings were consistent with this hypothesis; the cardiovascular health care providers sampled at both locations using self-reporting on the questionnaire are primarily culturally aware, but not culturally competent or proficient. The results of cultural competency scores for Trinity Regional Health System are; 1) Culturally Proficient 0 2) Culturally Competent 7 3) Culturally Aware 37 4) Culturally Incompetent 1 Total 45 The results of cultural competency scores for Genesis Medical Center, Illini Campus are; 1) Culturally Proficient 0 2) Culturally Competent 7 3) Culturally Aware 39 4) Culturally Incompetent 1 Total 47

54 42 Table Cultural Competency Scores for Trinity Regional Health System. N Mean Median 67.50(a) Mode Skewness 0.09 Std. Error of Skewness 0.35 Range Minimum Maximum Percentiles (b) a. Calculated from grouped data. b. Percentiles are calculated from grouped data

55 43 Figure 2.4. Cultural Competency Scores for Trinity Regional Health System. Key 1) Culturally Proficient points 2) Culturally Competent points 3) Culturally Aware points 4) Culturally Unaware points

56 44 Table Cultural Competency Scores for Genesis Medical Center, Illini Campus. N Mean Median 66.00(a) Mode Variance Skewness 0.03 Std. Error of Skewness 0.35 Range Minimum Maximum Percentiles (b) a. Calculated from grouped data. b. Percentiles are calculated from grouped data.

57 45 Figure 2.5. Cultural Competency Scores for Genesis Medical Center, Illini Campus. Key 1) Culturally Proficient points 2) Culturally Competent points 3) Culturally Aware points 4) Culturally Unaware points

58 46 Table Illini and Trinity Cultural Competency Scores. N Mean Median 66.50(a) Mode Std. Deviation 7.48 Variance Skewness 0.06 Std. Error of Skewness 0.25 Range Minimum Maximum Percentiles (b) a. Calculated from grouped data. b. Percentiles are calculated from grouped data.

59 47 Figure 2.6. Illini and Trinity Cultural Competency Scores. Key 1) Culturally Proficient points 2) Culturally Competent points 3) Culturally Aware points 4) Culturally Unaware points.

60 48 CHAPTER IV CONCLUSION The purpose of this study was to examine the level of cultural competence of the health care providers treating Black patients with cardiovascular disease and the resulting comorbid conditions, based on The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised [(IAPCC-R ), ]. This chapter will discuss the results based on the analysis of the questionnaire for each of the constructs of cultural competency, cultural mistrust and racism, and perception of these barriers to quality health care services for treatment and management of cardiovascular disease affecting the Black/African American patient population in Rock Island County, Illinois. Recommendations will be included in the discussion that nursing departments can implement to potentially increase cultural understanding and competency to address the needs of a rapidly changing diversity within their patient population. Discussion In comparing this study results to several similar research studies, Teresa Seright (2007) describes a similar population of nurses, who had indicated that they were culturally competent. The nurses were evaluated using the Campinha-Bacote method; results were a mean score of Noble, Noble and Hand (2009) report their findings of one hundred twenty eight (n=128) surveyed healthcare professionals, twenty-nine (n=29) of the nurses achieved a score of cultural competence (75-90 points). The combined mean score of Trinity and Genesis nurses was 66.98, which correlates to the Campinha-Bacote category of merely culturally aware (range score of points), not culturally competent (range score of points).

61 49 This study found that nurses at both locations, who had fewer years of nursing experience and graduate level of nursing education did not score at the cultural proficient ( points), which supports the hypothesis. Compared with Cooper Braithwaite s (2006) research study, regression analysis showed that nurses with fewer years of nursing experience and higher level of education had a weak association with increased cultural knowledge and cultural competence. Nurses' personal and professional characteristics influenced their response to an educational intervention to improve their cultural knowledge and cultural competence. This study results found that although age and years of nursing experience were a factor in nurses being culturally aware, none achieved the level of cultural proficiency (91 100). According to this study, the majority of responding nurses reported that 10%-25% of total patients treated for cardiovascular conditions were Black. The Center for Disease Control and Prevention (CDC, 2010) reports that from , 39% percent of Black men 20 years and over were diagnosed with hypertension. In the same period, 43% of Black women 20 years and over were reported to have hypertension. This indicates that the Black population is not seeking treatment for cardiovascular conditions, or that more interventions of outreach and education are needed for this target population in Rock Island County, Illinois. This is also indicated for the entire Quad Cities area which is composed of Rock Island, Moline, East Moline, and Silvis in Illinois; Davenport and Bettendorf in Iowa Scott County. When comparing the cultural competency scores with the percentage of Black patients treated, there is the overall recognition and understanding that Black (minorities) do not always receive an equal level of health care compared to White patients. According to a report by Michele Late (2003), 65 percent of Blacks recognize this statistical fact, while only 30 percent of Whites admit the problem. Racism is incompatible with democratic ideals, yet both are deeply

62 50 characteristic of the US society (James and Arbor, 2003). Cooper Braithwaite s (2006) research study examined how nurses' personal and professional characteristics influenced their response to an educational intervention to improve their cultural knowledge and cultural competence (n=76). Regression analysis showed that fewer years of nursing experience and higher level of education had a weak association with increased cultural knowledge and cultural competence but learning style and age were not associated with the outcomes. A study by Wittwer and Herbold (2009) found eighty-nine percent (n = 85) of respondents knew fairly or very well the dietary choices/patterns of individuals they serve based on cultural preferences. More than 50% (n = 60) never or seldom asked about the use of traditional cultural practices, and 41% (n = 39) never or seldom asked about traditional remedies. Forty-eight percent (n = 43) regularly modified health education materials to meet the linguistic needs of individuals they serve, whereas 53% (n = 46) regularly modified materials to meet literacy needs. Survey research suggests that among White Americans, prejudicial attitudes toward minorities remain more common than not, as over half to three-quarters believe that relative to Whites, particularly African Americans, are less intelligent, more prone to violence, and prefer to live off of welfare. It is reasonable to assume, however, that the vast majority of healthcare providers find prejudice morally abhorrent and at odds with their professional values. But healthcare providers, like other members of society, may not recognize manifestations of prejudice in their own behavior. While there is no direct evidence that provider biases affect the quality of care for minority patients, research suggests that healthcare providers diagnostic and treatment

63 51 decisions, as well as their feelings about patients, are influenced by patients race or ethnicity. (Schulman, Berlin, Harless, Kerner, Sistrunk, Gersh et al., 1999). These findings suggest that while the relationship between race or ethnicity and treatment decisions is complex and may also be influenced by gender, providers perceptions and attitudes toward patients are influenced by patient race or ethnicity, often in subtle ways. Summary The concept of managing diversity is founded in recognizing diversity and difference as positive attributes of individuals and focuses on building the positives rather than seeking to eliminate or reduce the negatives (Cortis, 2003). The principals of the managing diversity approach are relevant to nursing because they offer less reliance on a legalistic approach, which can easily become tokenistic, mere gestures, and does not respect or accept racial or cultural differences, but address the issues at a level of organizational culture (Donald and Rattansi, 1992). This strategic approach is does more than tolerate differences and moves from the paradigm of understanding culture as belonging to a different group, but as an integral concept of individuality that is not static, not stereotypical. Three mechanisms might be operative in healthcare disparities from the provider s side of the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or health of minorities. Patients might also react to providers behavior associated with these practices in a way that also contributes to disparities. Research on how patient race or ethnicity may influence decision-making and the quality of care for minorities is still developing, and as yet there is no direct evidence to illustrate how prejudice, stereotypes, or bias may influence care.

64 52 In the absence of such research, the study committee drew upon a mix of theory and relevant research to understand how these processes might operate in the clinical encounter. Part of the problem is that health care professionals see some patients through a stereotypical lens that cloud their diagnosis and treatment. Another part of the problem is the collective memory among Blacks about their exploitation by the medical establishment (Gamble, 2002; Erlen, 2003). These memories cultivate fears of genocide and create barriers that impede the process of health promotion within the Black population and other racial/ethnic populations. One of the basic and essential roles of health promotion in public health is to address racial and ethnic disparities in a straight forward manner due to the demographic changes that are anticipated in the next decade (Campanelli, 2003; English and Videto, 1997). The success that is achieved in improving the quality of health and the delivery of health care services will significantly impact the future quality of health of the entire nation. Cultural awareness was described as self-examination and in-depth exploration of one s own cultural background (Campinha-Bacote, 2003). Without this awareness, health care providers may tend to engage in cultural imposition, which is described as imposing one s own cultural beliefs upon those from another culture (Campinha-Bacote) or cultural blindness. Cultural awareness does not go far enough toward achieving the level of cultural competence development that is required of health care providers and institutions to safely and effectively care for diverse populations. Some health care providers may believe that by treating others equally, regardless of cultural background that they are doing the right thing. Campinha-Bacote, (2003) described this as racism, however; racism is not easily talked about in health care. The American Nurses Association (2002) and the Institute of Medicine (2002) both described the

65 53 existence of racism in healthcare and the detrimental effects on the health of patients (Seright, 2007). Cultural competence plays an important role when addressing racial/ethnic health disparities. Cultural competence is defined as a set of attitudes, skills, behaviors and policies that enable health professionals to work effectively in cross-cultural situations and take into account the health related beliefs, cultural values, disease prevalence, and treatment efficacy (Edwards and Erwin-Johnson, 2003; Richardson and Jacobs, 2002; Health Disparities, 2004; Kim, Clark, and Barton, 2001). Turnock (2001) identified several enabling steps, from an Institute of Medicine (IOM) report in 1988 that would guide the current health system to a more optimally functioning system. These steps include; improving the statutory base of public health; strengthening the structural and organizational framework; improving the capacity for action, including technical, political, management, programmatic, and fiscal competencies of public health professionals; and strengthening the linkages between academia and the practice of healthcare. Study Limitations The time of day was a major limitation because shift change was the optimal time to access the greatest number of nurses. The questionnaire was based on self-report of the nurse s personal beliefs and biases; there was no way to measure the effect of peer pressure in completing the answers. Recommendations The nursing profession will be required to develop culturally specific skills, attitudes, and beliefs in order to effectively promote the interventions that are necessary to begin the process of reducing the health disparities within this nation. The elimination of health disparities was a

66 54 bold step forward from the goal of Healthy People 2000 (Spector, 2000), which was to reduce disparities in health status, health risks, and use of preventative interventions within the population groups. The elimination of disparities by the year 2010 requires new knowledge of the cultural diversity within the nation starting with developing cultural competence of the workforce of Public Health. According to a report by Mail, Lachenmayr, Auld, and Roe (2004), a stronger organizational commitment from groups like Society for Public Health Education (SOPHE) and the American Public Health Association (APHA) is crucial to helping diverse practitioners eliminate the continuing practices among health care professionals of racism, stereotyping, bias, discrimination, and cultural and professional incompetence The ability to evolve and adapt to the emerging culturally diverse population is a challenge that is not just a necessity but also a requirement to address the goals of improving the quality of health and equal access to and the delivery of health care services of the minority populations of this nation. During the course of this research study, I have noted interaction between nurses and Black patients; I developed a list of common cultural courtesy rules that address some of the barriers when treating patients of another culture: 1. Unless they learn to become culturally sensitive, 90% to 95% of the current students will probably fail many attempts to develop and implement any type of interventions within a target population. 2. Do not assume you are familiar with the person/minority that you are addressing. Show respect and address the person with; Yes Sir, No Sir, Yes Ma am, and No Ma am. Age is not necessarily a proper guideline. 3. Do not assume anything about a particular culture, race, or ethnic group. Do the research. If you do not know, ask questions.

67 55 4. Remain nonjudgmental. The goal is to gain another perspective, not to express your opinion. You are now the one who has to gain acceptance. 5. Step out of your comfort zone. Do not be afraid to learn, experience something different or new, and what is accepted within the culture, race, or ethnic group. 6. Understand, what is accepted behavior by you, will possibly and can be perceived as offensive and discriminatory by another culture, race, or ethnic group. 7. Do not assume. The media is a very powerful provider of misinformation. Assumptions and stereotyping does not work or fit in reality. 8. Keep in mind that a goal you must obtain is trust. Without trust you will get absolutely nowhere. Be truthful and sincere. Do not promise anything you cannot do or give. You are the outsider and you must prove you can be trusted. 9. Do not dwell on cultural differences. Focus on similarities. Respect the cultural differences. 10. Actions speak louder than words. Whether conscious or unconscious, body language provides cues that send out powerful messages. 11. Capitalize on good listening skills. A large amount of information can be gained. 12. It would be wise to assess and identify your own personal prejudices and perceptions. In essence, know and understand yourself before you try to know and understand other cultures, races, or ethnic groups.

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74 62 APPENDIX A DEMOGRAPHICS SHEET

75 63 DEMOGRAPHICS Age Race/Ethnicity Black/African American Hispanic/NonWhite White Asian/Pacific Islander Native American/American Indian Multiracial College 1year 2 years 3 years Graduate Job Title Nurse Practitioner RN LPN Years in healthcare 1-5 years More than 20 years Job Location Illini Trinity What is the percentage of Black patients do you treat? Less than 10% 10% - 25% 26% - 40% 41% -55% 56% -70% More than 71%

76 64 APPENDIX B GENESIS INSTITUTIONAL REVIEW BOARD

77 65

78 66

79 67 APPENDIX C TRINITY INSTITUTIONAL REVIEW BOARD

80 68

81 69 APPENDIX D UNIVERSITY OF IOWA INSTITUTIONAL REVIEW BOARD

82 70

83 71 APPENDIX E POSTERS /FLYERS

84 72