Culturally Competent Care is Patient Centered Care. Larry D. Purnell PhD, RN, FAAN

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1 Culturally Competent Care is Patient Centered Care Larry D. Purnell PhD, RN, FAAN

2 Faculty Larry D. Purnell PhD, RN, FAAN Professor Emeritus University of Delaware Newark, DE

3 Learning Objectives 1. Assess whether or not culturally competent care is being delivered in your organization 2. Recognize and understand the cultural and clinical dynamics that impact patient encounters in your organization 3. Analyze demographic data and propose standards for delivering culturally competent care to cancer patients and caregivers in your organization 4. Identify key components of staff education programs in cultural competence

4 Introduction Cultural competence in health care describes the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring health and nursing care delivery to meet patients social, cultural, and linguistic needs Cultural competence training does not guarantee cultural competence: Only provides the knowledge, skills, and abilities to become culturally competent. Currently no tool that measures staff cultural competence. Would need to do initial and ongoing observation of caregivers assessment and find evidence in the medical record. Purnell (2016)

5 Organizational Assessment: Why Culturally Competent Care Increases trust Increases community participation and involvement in health issues Assists patients and families in their care Promotes patient and family responsibilities for health Improves patient data collection Increases preventive care by patients American Hospital Association

6 Organizational Assessment: Why Culturally Competent Care Reduces care disparities in the patient population Increases cost savings from a reduction in medical errors, number of treatments, and legal costs Reduces the number of missed medical visits Improves health outcomes, increases respect, and increases participation from the local community Organizations that are culturally competent may have lower costs and fewer care disparities American Hospital Association

7 Organization s Responsibility Mission and philosophy reflects respect and values related to diversity and inclusivity Need a managerial taskforce to oversee diversity and cultural competence Provide staff with adequate resources to deliver culturally competent care Include cultural competence in job descriptions Translation should be that of the local TV/radio stations Lewin Group, 2002

8 Organization s Responsibility Signage is in different languages Pictures and décor consistent with ethnicity of the client population Toys reflective of ethnicity: Dolls for example Organization conducts fairs: distributes literature, and conducts health screenings Partner with hospice and palliative care

9 Organization s Responsibility Seeks advice from individuals and groups in the communities they serve: can help healthcare systems to develop educational materials, increase patient access to services, and improve health literacy. Board of Trustees should have members who are representatives of the community. Satisfaction surveys in different languages: Back translate by at least one native speaker of the language.

10 Cultural and Clinical Dynamics Recognize we all possess biases and stereotypes, some of which we may not be fully aware Patient has the right to know their condition and the right not to know - beneficence is seen differently Becoming culturally competent involves developing and acquiring the skills needed to identify and assist patients from diverse cultures. Starts with critical reflection cultural self-awareness

11 Cultural and Clinical Dynamics Do staff make derogatory comments, slurs, about certain ethnicities or vulnerable populations, includes LGBT. Establish a no tolerance policy. Are we open to different approaches to the same problem? Accepting of complementary and alternative medicine? Be aware of and accepting of cultural differences but not illegal ones such as female circumcision. Power dynamics: power is bestowed upon us by our titles, white coats, education, etc.

12 Cultural and Clinical Dynamics If we believe in a particular treatment for a patient and the patient does not agree based on cultural differences, because of our power we may not respect and work with that difference Sometimes we work the patient to fit into what we think is best for them especially with allopathic medicine The curing versus caring paradigm and the concept of disease versus illness contribute to the development of attitudes that influence empathic behavior in clinical encounters.

13 Cultural and Clinical Dynamics Interpersonal dynamics operate in clinician patient encounters, to comply with the orders of authority figures to uncritically accept authority figures may be too polite to disagree and just nod their head which does not mean yes or no but I hear you a nod of the head does not necessarily mean agreement but that I hear you.

14 Demographic Data and Standards Develop a data collection system to monitor demographics (culture, ethnicity) served by the organization Obtain state and local census tract information and include income and employment What are the elementary school enrollments? What are their ethnicities, languages, and cultural backgrounds? The older population: how many long-term care facilities are in the catchment area

15 Demographic Data and Standards Ethnicity as a variable of cancer and other biological illnesses i.e. which groups have increased incidences of specific cancers: breast, colon, prostate, etc. Track data from patient satisfaction scores Track data from healthcare disparities data: much of it comes from local hospitals and outpatient clinics as well as national data from the Centers for Disease Control and Prevention

16 Educational Components Begins with some definitions: enculturation, ethnocentrism, acculturation, assimilation, cultural awareness, culture sensitivity, cultural competence, cultural congruence, generalization versus stereotype, cultural imperialism, cultural imposition, cultural relativism, ethnic group, and subculture. Objective culture includes things that people make such as art, music, and styles of clothing and dress. Subjective culture is a way of perceiving the social environment that includes ideas, beliefs, and values, including those related to health and health care

17 Educational Components Levels of subjective culture A primary level that represents the deepest level in which rules are known by all, observed by all, implicit, and taken for granted. A secondary level, in which only members know the rules of behavior and can articulate them. The healthcare provider must make a conscious effort to uncover them. A tertiary level visible to outsiders: things that can be seen, worn, or otherwise observed: the objective culture

18 Educational Components Nurses (all healthcare providers) need specific knowledge about the major groups of culturally diverse individuals, families, and communities they serve Start with individual versus collectivistic cultures as a framework.

19 Educational Components Provide in-service classes on the basic terminology of culture and anthropology. Could be as simple as a handout with definitions and a quiz that could include case studies and be online Institute a Train the Trainer program for staff to bring cultural related information on a 24 hour basis. Develop an internal website where staff can access culturally general and culturally specific information. Attend formal courses and conference concentrating on culture. Douglas et al. (2014)

20 Educational Components Use a comprehensive cultural assessment tool that can be added to as time and circumstances permit. Specific content of the groups should include the overview and heritage of the group, communication practices, family roles and organization, workforce issues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and the child-bearing family, death rituals, spirituality and religion, healthcare practices, and healthcare practitioners Purnell (2013); Purnell (2014)

21 Variant Characteristics of Culture Nationality Race Color Age Religious affiliation Educational status Socioeconomic status Occupation Language spoken Literacy level Military experience Political beliefs Purnell (2013); Purnell (2014).

22 Variant Characteristics of Culture Educational status Urban versus rural residence Enclave identity Marital status Parental status Sexual orientation Gender issues Physical characteristics Immigration status (sojourner, immigrant, or undocumented status) Length of time away from home country Purnell (2013); Purnell (2014)

23 Educational Components Provide orientation and annual in-service training in cultural competence for all levels of staff, including management, professionals, and auxiliary staff in any department with patient contact. Establish journal clubs to review current literature about the most common cultural groups served to ensure evidencebased practice. Simulation labs network with local college/medical center Online courses and webinars

24 Educational Components Invite ethnic individuals to workshops Include lunch and learn where staff addresses cultural and ethnic issues and practices Have diverse staff talk about their culture Health screenings at fire stations and local libraries combine with book/video sales Douglas, et al. (2014)

25 References/Resources American Hospital Association. Health Research & Educational Trust. (2013). Becoming a culturally competent health care organization. Available at American Nurses Association. Cultural self-assessment. Your-Practice/Diversity-Awareness/Self-Assessment.html American Association of Colleges Nursing. Tool kit for cult competent education. Available at Campinha-Bacote. J. (2015). The Process Of Cultural Competence In The Delivery Of Healthcare Services. Available at Has tools for measuring cultural competence. However, there is a charge for each time you administer the tool Department Health and Human Services, Office of Minority Health (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care. Available at

26 References/Resources Douglas, M., Rosenketter, M., Pacquiao, D., Clark Callister, L., Hattar-Pollara, M., Lauderdale, L. Milsted, J., Nardi, D. & Purnell. L., & Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), End of Life Nursing Education Consortium. American Association of Colleges of Nursing. (2017). Available at Jeffreys, M. (2012). Self-Efficacy tools. Available at Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile (2002). Lewin Group, Inc. Available at Lewin Group. (2002). file:///d:/tx_oncology/lewen%20group.pdfindicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile. Available at

27 References/Resources Nursing Scope and Standards of Practice. (2016). American Nurses Association. Standard 8: Culturally Congruent Care. Oncology Nursing Society Multicultural Outcomes: Guidelines for Cultural Competence (2000). Oncology Nursing Press, Inc. Organizational Cultural Competence Assessment Profile. (2001). U.S. Bureau of the Census. Available at Purnell, L. (2013). Transcultural health care: A culturally competent approach (4 ed.). Philadelphia: F. A. Davis. For more information go to This site has basic Power Point Lectures, quizzes for students and faculty and additional resources

28 References/Resources National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: A Condensed Blueprint for Advancing and Sustaining CLAS Policy and Practice. (2014). New Jersey Department of Available at Purnell, L. (2014). Guide to culturally competent health care. Philadelphia: F.A. Davis Co. Being revised with Purnell & Fenkl sometime in late 2017?. For more information go to Purnell, L. (2016). Invited scholarly inquiry article: Are we really measuring cultural competence? Nursing Science Quarterly, 29(2), Think Cultural Health.org. Available at TCH-Suite-Clearinghouse.pdf This site has continuing education modules for physicians, nurse practitioners, registered nurses, and social workers. Transcultural Nursing Society: Theories and Models. (2013). Available at This site has over 100 Power Point Slides for all the major nurse cultural theories and models.

29 Individualistic Cultural Attributes Term used to describe a moral, political, or social outlook that stresses human independence and the importance of individual self-reliance, and freedom. All cultures and individuals fall on a continuum of 1 to 10. Frequently context dependent. Do not confuse individualism with individuality The individual is the most important element in society. Some languages do not have a word for individual as someone who stands alone.

30 Individualistic Cultural Attributes Has a controversial relationship with egotism selfishness. Should be able to choose your own lifestyle, occupation, partner, etc. Stresses doing your own work and taking care of yourself. Individualistic cultures: Scandinavian countries, European American, German, and Appalachian The USA was built on rugged individualism. Individualism tolerates individuality more than collectivism

31 Individualistic Cultural Attributes Low-context, explicit communication is valued over implicit communication. Communication is clearly stated or further explanation is expected. Communication is direct, linear, and precise Although interrupting someone who is talking is considered rude, it is common practice and forgiven. Sharing personal feelings is encouraged, even for sensitive issues because the stigma does not necessarily extend to the family.

32 Individualistic Cultural Attributes Direct explicit communication is expected with illnesses so plans for the future can be made. If a question is asked that can be answered with yes or no, the expectation is to tell the truth. Minimal touching unless very close family and friends and is reinforced by sexual harassment policies. One is expected to ask permission before touching another person.

33 Individualistic Cultural Attributes Conversants are expected to maintain eye contact regardless of class or social standing: lack of eye contact is usually interpreted as not listening, not caring, or not telling the truth Unless close family and friends, conversants stand 18 to 24 inches (45-60 cm) apart Punctuality is valued in both business and social settings Futuristic temporality dominates; want to know the possible ramifications of an illness in the future.

34 Individualistic Cultural Attributes Value on informality; commonly using first names in most situations. High value is placed on egalitarian spousal relationships with shared responsibilities and decision making. Ask the patient directly who has decision making authority if not cognitively impaired. Primary source of strength may not be family or religion but work and even material possessions.

35 Collectivistic Cultural Attributes Moral, political, or social outlook that stresses human interdependence. Important to be part of a collective. Individual is defined in terms of a reference group family, church, work, school, or some other group. Collectivism stifles individuality and diversity = common social identity. Most collectivist cultures are high-context.

36 Collectivistic Cultural Attributes Do not reveal sensitive issues that may cause a stigma to the family or others unless agreed upon by the patient. Direct communication and discussing palliative care may mean giving up hope: approach these issues subtly. Many have difficulty with saying no because it is seen as disrespectful: Do not ask questions that have a yes or no answer.

37 Collectivistic Cultural Attributes Touching is common among same sex friends and new acquaintances but a high degree of modesty necessitates explaining the necessity of touching: ask permission before doing so. Time is more relaxed; punctuality is valued only in business and situation where it is essential such as in making transportation connections. Most value formality: always greet the patient and family members formally until told to do otherwise.

38 Collectivistic Cultural Attributes In most traditional cultures, but not all, men have decisionmaking authority. May be reluctant to appoint a family member for decision making for fear of isolating other family members and increase family conflict. Gender roles are less fluid; expectations upon immigration may cause significant family discord.

39 Cultural Imposition Cultural Imposition: Intrusively applies the majority cultural view to individuals and families. Prescribing a special diet without regard to the client s culture and limiting visitors to immediate family borders on cultural imposition. In this context, healthcare providers must be careful in expressing their cultural values too strongly until cultural issues are more fully understood. The practice of extending policies and procedures of one organization (usually the dominant one) to disenfranchised and minority groups.

40 Cultural Imposition Proponents appeal to universal human rights, values, and standards. Opponents posit that universal standards are a disguise for the dominant culture to destroy or eradicate traditional cultures through worldwide public policy.

41 Cultural Imperialism Cultural imperialism is the practice of extending the policies and practices of one group (usually the dominant one) to disenfranchised and minority groups. Proponents appeal to universal human rights values and standards. Opponents posit that universal standards are a disguise for the dominant culture to destroy or eradicate traditional cultures through worldwide public policy.

42 Cultural Relativism The belief that behaviors and practices of people should only be judged in the context of their cultural system. Proponents argue that issues such as abortion, euthanasia, female circumcision, and physical punishment in childrearing should be accepted as cultural values without judgment from the outside world. Opponents argue that cultural relativism may undermine condemnation of human rights violations and that family violence cannot be excused on any level.

43 Stereotype versus Generalization Stereotype: A simplified and standardized conception, opinion, or belief about a person or group. A healthcare provider who fails to recognize individuality within a group is jumping to conclusions about the individual or family. Generalization: Begins with assumptions about the individual or family within an ethnocultural group but leads to further information seeking about the individual or family. Uses aggregate data: a research principle.

44 Some Basic Definitions Acculturation: Gradually adopting and incorporating the characteristics of the prevailing culture. Assimilation: Modification of the culture of a group or individual as a result of contact with another individual or group. Enculturation: Enculturation is a natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one s culture through socialization.

45 Some Basic Definitions Cultural awareness has to do with an appreciation of the external signs of diversity, such as the arts, music, dress, foods, and physical characteristics. Cultural sensitivity has to do with personal attitudes and not saying things that might be offensive to someone from a cultural or ethnic background different from the healthcare provider s own. Cultural competence in health care is having the knowledge, abilities, and skills to become culturally competent.

46 Ethnocentrism Ethnocentrism the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways (which most people practice to some degree) can be a major barrier to providing culturally competent care. Ethnocentrism perpetuates an attitude in which beliefs that differ greatly from one s own are strange, bizarre, or unenlightened and, therefore, wrong.

47 Subculture Subculture: a group of people with a culture that differentiates them from the larger culture of which they are a part. Subcultures may be distinct or hidden (e.g., gay, lesbian, bisexual, and transgendered populations; bikers; Alcoholics Anonymous, etc.). A subculture can include members from the European American, Thai, Chinese, Hispanic, and other cultures. Counterculture: characterized by a systematic opposition to the dominant culture (examples are goths, punks, and stoners; although popular lay literature might call these groups cultures instead of subcultures). A counterculture would include cults.