The United States is often referred to as a melting pot. Cultural diversity is an inevitable reality in today’s society. We are faced with an increasingly diverse patient population and a diverse group of health care providers. Culture is a dynamic and complex phenomena that most understand as something that describes a particular ethnic group (Mitchell, Fioravanti, Founds, Hoffmann, & Liebman, 2010). Culture influences a person’s behaviors, practices, norms, customs, and beliefs on health, illness, and health care. According to Freidman, Bowden, and Jones (2003), people view culture as a model for our way of behaving, living, and feeling. There is an existence associated between culture and health practices. As the world becomes more diverse with migration, it is important that nurses and other health care workers understand and recognize the various cultures they encounter.
The current U.S. population exhibits unparalleled ethnic and sociocultural diversity, yet the nursing workforce fails to reflect the current state of the nation’s diversity. According to the U.S. Department of Health and Human Services, the U.S. nursing workforce is predominantly White/Non-Hispanic and female (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010). Nurses face the challenge to meet the health care needs of a culturally diverse population while promoting diversity in the workforce. Nurses promote diversity in the workforce through educating nurses on cultural sensitivity and competence.
Cultural competence in nursing is evolving as a standard of care. It is essential that nurses and other health care providers employ knowledge of various social and cultural influences in the care setting to promote patient-centered care (Mitchell, Fioravanti, Founds, Hoffmann, & Libman, 2010). It is necessary to appreciate and recognize the relevance of diversity in the acute care setting to set standards of culturally competent nursing care, and to improve delivery of care through improving and meeting these standards.
It is important that health care providers not only embrace cultural diversity, but also strive for cultural competence in order to ensure that all patients receive the best possible care. It is imperative that health care professionals integrate a patient’s cultural beliefs and practices into his or her treatment and recovery plan. Health care is rapidly changing. Patients and families are more receptive to these changes in modern medicine if their traditions and practices are integrated (Chater, 2008).
Cultural competence not only pertains to race, sex, age, and ethnicity, but also encompasses “other inseparable factors of culture such as economic, political, religious, psychosocial, and biological conditions” (Stein, 2010). Delivery of culturally competent care entails promotion of the principles of social justice. According to the American Nurses Association (2001), “respect for the inherent worth, dignity, and human rights of every individual is a fundamental principle that underlies all nursing practice” (American Nurses Association, 2001). These principles model the standards in providing culturally competent care. They also guide nurses’ decisions pertaining to patient care. It is crucial that nurses and other health care providers examine their own beliefs and values. They must determine how their beliefs and values influence their interactions with patients, families, and colleagues.
The concepts of cultural aspiration, cultural skill, cultural appreciation, cultural knowledge, and cultural acquaintances all produce cultural competency. Motivation of the nurse to become culturally proficient leads to acceptance of cultural diversity. Cultural awareness is the profound self-exploration of an individual’s personal cultural background. This includes identifying one’s cultural assumptions, biases, and prejudices of different cultures. The capability of assessing and assembling relevantly cultural facts that are significant to the patient’s presenting problem refers to cultural skill. Cultural knowledge includes both seeking for and acquiring a strong educational foundation of the existing multicultural population that includes health beliefs and practices. And, lastly, the process that encourages nurses to interact face-to-face with diverse cultures is cultural encounter. Culturally competent care is reached by incorporating these concepts. By doing so, there is a decrease in health disparities and an increase in the potential for better outcomes and relevant care (Campinha-Bacote, 2003).
The HHS Disparities Action Plan was initiated by the Department of Health and Human Services. This plan coordinates with other agencies to reach its goal of promoting health equality by using provisions set forth from Healthy People 2020 and the Affordable Care Act (HHS, 2011). According to HHS (2011), ethnic groups such as Hispanics, Asian Americans, American Indians, and African Americans experience higher mortality rates than other ethnic groups. The HHS Disparities Action Plan identifies factors such as poverty, socioeconomic status, lack of access to health care and racially driven disparities to promote safe patient outcomes and health equality.
Several critical components establish standards of practice contribute to an organization’s capacity to provide culturally competent care. These components include: critical reflection, transcultural nursing knowledge, social justice, cross-cultural practice and communication, patient advocacy, health care systems, multicultural workforce education, policy development, training, and evidenced-based practice and research (Brady, 2010).
Health care facilities need to ensure that tools such as multilingual teaching materials and interpreters are in place to effectively provide care. The use of cultural knowledge in composing a patient’s plan of care is a way to value diversity. Cultural competency is a continuous learning experience. Health care facilities may collaborate with professional organizations to establish best evidence-based practice in order to develop policies and standardized culturally competent care and reduce disparities (Brady, 2010).
So, how does one become culturally competent? The initial step to becoming culturally competent is self-awareness. We must be aware of and value our own culture in order to identify with and recognize the value of the culture of others. We do this by critically reflecting on ourselves. “Examining and reflecting on one’s own ethnicity, belief structure, and values” determine the impact on our ability to “deliver culturally competent care” (Brady, 2010). A Nurses who understand themselves are able to understand and appreciate cultural differences. By doing so, the nurse can establish ideal ways to render effective health care services. An example would be that of a patient from the Far East. A nurse caring for a Chinese patient must appreciate that the Chinese adhere to traditional healing practices such as acupuncture, meditation, and homeopathy.
Knowing this, the nurse will attempt to integrate these traditional practices into the patient’s treatment plan. The nurse can integrate acupuncture as an alternative treatment for pain management. A nurse who appreciates cultural diversity will strive to understand the cultural practices and beliefs of that patient and integrate applicable elements of the patient’s culture in the plan of care. Explanation of the plan of care and identifying the needs and expectations of the patient and family will aide in reducing tension, hence, develop a trust between the nurse, patient, and family.
Nursing is making advances in promoting and implementing culturally competent care. Transcultural Nursing Society is a professional nursing organization involved in ensuring cultural competence is being included in the curriculum of nursing schools throughout the nation. The Transcultural Nursing Society is also involved in ensuring that curriculums are providing nurses with the necessary knowledge base to ensure cultural competence in their practice (Transcultural Nursing Society, 2013).
Another organization, the Agency for Healthcare Research and Quality (AHRQ), provides guidelines to enhance culturally competent care in health care facilities. This organization recognizes the disparities in health care delivery due to linguistic differences. They also recognize that there is prevalence in racial and ethnic disparities in health care delivery in the United States. The AHRQ points out that culturally and linguistically diverse groups, as well as individuals with limited proficiency in English are disadvantaged in the health care system. These groups often experience poor health status and outcomes by accessing inadequate medical care in regards to quality despite consistent insurance status and income.
Policy makers, civil rights groups, and health care facilities are responsible to understand the reasons behind persistent disparities and implement effective strategies to eliminate them. One way to do this is to improve cultural and linguistic competence of health care providers (Wilby, 2009). Linguistic competence is the ability of health care facilities to provide individuals with limited English proficiency appropriate oral and written language services. Health care facilities can hire bilingual/bicultural staff, train health care providers, or hire translators to assist during communication.
The National Standards for Culturally and Linguistically Appropriate Services, (CLAS), standards are “intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations” (OMH, 2013). There are four categories under which these standards fall: principle standard; governance, leadership, and workforce; communication and language assistance; and engagement, continuous improvement, and accountability. Health care professionals can make the production of positive health outcomes for distinct populations possible by customizing services to a person’s verbal communication preference and way of life.
Pursuing health integrity must remain at the forefront of healthcare’s efforts, with continuous identification of dignity, respect, and quality of care as rights of all, and not the civil liberties of some. According to OHM (2013), culture defines how individuals receive health care information, and how individuals exercise their rights and protections. It is what individuals consider a health dilemma, and how individuals express their indications and anxieties regarding the crisis.
Holistic care involves designing care to meet the individual needs of the patients, to care for the whole. This includes considering cultural differences when planning care. Barriers to culturally competent interactions entail verbal communication, communication approach, individuality, and sometimes a lack of respect for the patient’s preferences and needs. Language is a method by which a patient approaches the health care system, becomes aware of services, and formulates determination in relation to his or her health performance (Woloshin, Schwartz, Katz, & Welch, 1997). Communication endorses the opportunity for people of various backgrounds to learn from each other. Put the patients’ desire to understand first and make certain that they receive a chance to describe, in their own words, the information regarding their health care concerns and plans are fundamental initial measures in eliminating descrepancies and enhancing quality of care.
Cultural competence requires people to develop an awareness of the differences of other people and their cultural personality groups. One is not capable of being culturally competent without considering the differences. Cultural competence does not involve giving up one’s own beliefs, values, or practices (Elliott, 2011). According to Elliott (2011), we can crack the cultural competency code by asking questions, listening, and aligning our attitude.
The late Madeleine Leininger was a pioneer in the influence of culture on health care. Leininger was a Transcultural Nurse. She advocated two leading standards that nurses can employ in caring for patients from various diverse cultures. First, preserve an extensive, independent, and open attitude in regards to each patient. Secondly, evade the perception that all patients are alike. Leininger believed that by pursuing these principles, we can free ourselves to discovering the way others envision health and illness, and develop relationships that are therapeutic. She viewed every clinical experience as cross-cultural (Leininger, 2002).
Diversity at the Workplace
I work in a hospital in the small city of Tarpon Springs, FL. Tarpon Springs is located in Pinellas County. According to the 2010 census, the population was 23,484. Tarpon Springs has the highest percentage of Greek Americans than any other U.S. city. The city of Tarpon Springs has a total area of 16.9 square mile. 9.1 square miles being land, and 7.7 square miles being water. Tarpon Springs has a series of bayous which feed into the Gulf of Mexico, and was first settled around 1876 by white and black fishermen and farmers. It got its name because some visitors spotted tarpon jumping out of the waters. The first local sponge business was founded by John Cheyney.
In the 1890s, a few Greek immigrants arrived to work in the sponge industry. It was in 1905 that John Cocoris introduced sponge diving to Tarpon Springs and recruited divers and crew members from Greece. Tarpon Springs became the largest sponge dock industry in the world. Many restaurants serving traditional Greek cuisine line the streets of Tarpon Springs, as well as quaint boutiques. Nearby beaches are popular for swimming, picnics, boating and windsurfing. Viewing bottlenose dolphin are a favorite past-time of many.
Tarpon Springs is also known for its Greek Orthodox festivities, including the January 6 Epiphany celebration that includes youths diving for a cross and the blessing of the boats and waters. This celebration attracts Greek Americans from across the country.
The racial makeup of the city is 90.07% white, 6.15% African American, 0.29% Native American, 1.04% Asian, 0.06% Pacific Islander, 0.81% from other races. Hispanic or Latino is 4.33% of the population. 11.8% of the total population report their ancestry as Greek, which is included in the white statistic of 90.07%. 8.87% report speaking Greek at home, while 3.46% admit to speaking Spanish, and another 1.09% French. There are 91.8 males for every 100 females. The median income for a household is $38,251. About 7.7% of families and 9.8% of the population are below the poverty level.
The hospital which I work is the only hospital in Tarpon Springs. The hospital has 168 beds which comprise 150 acute care beds, 18 transitional care beds, 14 ER beds, 9 ORs, 2 C-Section rooms, and 2 cathlabs. Adventist Health Systems acquired the hospital from University Health approximately 4 years ago. As you can see from the above demographics, this hospital serves a diverse population and community. From a religious perspective AHS is of the Adventist religion, however, welcomes, serves, and does not discriminate against any religion.
The primary language is English, however, various languages such as Greek, Spanish, French and Italian are spoken as well. Unfortunately, there are some patients who only speak their native language, and do not speak, nor understand English. For the most part, the hospital experiences minimal difficulty in assisting the patients and families in translation. Recently, the hospital contracted with a translation service using the internet. The hospital does provide admission and treatment information sheets and consents in other languages, as well.
Our hospital is dedicated to serve the multicultural community of Tarpon Springs. Our food service caters to different cultures on a daily basis. Of course, Tuesday is Taco Tuesday. However, other ethnic foods are offered daily such as Greek, Italian, and Chinese cuisine as well as Soul Food and food that is in accordance with the beliefs of the Seventh Day Adventist religion, which excludes pork and shellfish from their diet.
Chaplains and different religious figures are available to visit and pray with patients and families. Every Friday at sunset, a prayer recognizing the beginning of the Sabbath is heard over the intercom. Every Saturday evening at sunset, another prayer is heard over the intercom to recognize the end of the Sabbath. All committees, meetings and gatherings are started with prayer. There is signage throughout the hospital to portray our mission:
Extending the healing ministry of Christ.
I feel confident in saying that this hospital does follow Culture Care Standards. Signage is posted in all patient care areas and public areas regarding the hospitals standards. Signage includes anything from Equal Opportunity Employer to EMTALA. Because the workforce is very multicultural, the hospital is at an advantage at meeting these standards. There is one thing that all employees know; we are family despite our cultural differences. I am very proud to say that I work for this hospital.
The United States is a melting pot, and is becoming more and more diverse every day. Recognizing that diverse cultures exist is the first step in decreasing health disparities, and providing the best possible care to individuals. Health care workers, including nurses, need to practice self-awareness. By becoming aware of self, they can then embrace other cultures and the needs of their patients. It is important for all health care professionals to understand the culture and beliefs of the patient population which they serve, in order to integrate these beliefs in his or her practice, whereby enhancing the quality of care provided to all patients.
Education and training is vital in ensuring that health care professionals attain clinical excellence and strong therapeutic relations with the patients they serve. We cannot dictate the communities that we serve. Cultural competence does not mean giving up one’s own beliefs or values. It means opening eyes to the beliefs and values of others. The need for health care professionals to integrate cultural competence will allow delivery of optimal care, treatment, satisfaction, and better patient outcomes.
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