Cultural Competency: Current Practice

You are driving down a beautiful country road in Germany. You have always wanted to see this country and are enjoying the time with your family. Suddenly, you are upside down in the car. You hear sirens and strange voices. As you become more alert, you realize you have been in an accident. You frantically start looking for your family only to learn you cannot move. You try to call out, but your voice is very weak. The voices are louder now outside the car. They are talking in German. You can catch a few words here and there but are not sure what they are saying. As the paramedics reach you, you start asking about your family. However, they can not understand you, and you can not understand what they are saying. Imagine yourself in this scenario. How frightened are you? What are you thinking as this is all going on? How will you communicate your needs with the paramedics? This situation may seem unreal, but some patients feel just like this. What can be done to help this person?

There are seven billion people worldwide who speak a staggering 6,000+ languages. The world's population is becoming increasingly mobile with the resultant blurring of traditional language and racial and ethnic lines. Up to one-third of the United States population was identified as a racial or ethnic minority in the 2000 census. This population is not unique to the United States; more than 50 countries have reported that greater than 15% of their population is accounted for by immigrants (Stanton, 2016).

Healthcare facilities have a responsibility to provide staff that reflects their service area. They also have a responsibility to ensure staff are educated on cultural issues relevant to their service area.

Culture is focused on how groups of people understand their history, share their values, and engage in similar behaviors while sharing a similar worldview. Culture is not necessarily equivalent to racial and ethnic groups. It may reflect a similar socioeconomic background, religious background, sexual orientation, or even occupation, such as the military culture or nursing culture. People who share a cultural belief are organized into groups such as a family or could be grouped by other identifiers such as gender, age, or common interests.

Cultural competency is the ability of the healthcare provider to comprehend the beliefs and values of specific religious, racial, ethnic, and other social groups. Healthcare in the 21st century should and must be practiced in a culturally competent manner. Health-related cultural beliefs can be seamlessly integrated into the care of patients (Stanton, 2016). The National Quality Forum defines cultural competency as "the ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient and family-centered, evidence-based, and equitable.

A cultural assessment needs to be done for each individual. Skills in assessment and interventions are also important in caring for culturally diverse patients. Do not depend on standard knowledge of the cultural norms of the group the patient seems to fit. Inadequate cultural assessment can erode the patient's trust in the healthcare provider's credibility, leading to poor health outcomes and noncompliance (Stanton, 2016).

Evaluate cultural information that is relevant to the care of the patient. This assessment includes asking open-ended questions and allowing for the expression of the situation. Asking the patient what they think about the illness or injury and how it will impact their lives can reveal cultural perceptions. The healthcare provider can alleviate fears and partner with the patient, enhancing the outcome.

Most facilities have a standard tool. Many tools are based on Madeleine Leininger’s theory of Cultural Care. Leininger’s theory is founded on the idea that cultural heritage and customs are important to each group. Leininger’s Cultural Care Diversity and Universality Theory and the Sunrise model, which arose from the theory, started the revolution of defining cultural care and using cultural care concepts in the nursing assessment process. The Sunrise model uses Leininger’s Culture Care Diversity and Universality Theory components that focus on patient care in a global environment and is multifaceted to include the culture’s characteristics in an interdependent relationship (Leininger, 2002).

It is imperative that healthcare providers understand these customs and can care for each patient individually to preserve the cultural atmosphere. This level of care translated into transcultural patient care, and several models of care were developed, including Giger and Davidhizar, and Purnell.

Giger and Davidhizar's Transcultural Assessment Model is based on six data collection areas (Giger, 2014). The model centers on the idea that although cultures have different characteristics, they share fundamental factors.

• Communication- what language is spoken? How is silence used? Notice the pronunciation of words. What non-verbal forms of communication are used?
• Space- what is personal space? Notice body movements during conversations.
• Social Organization- Note gender and sexual orientation, geography, socioeconomic status, ethnicity, family role, religion, age, and life cycle status.
• Time- How is time used, how important is time, and is there more focus on past, present, or future?
• Environmental controls- What are current health practices? What is the definition of health and illness?
• Biological variations- physical dimensions, genetic susceptibility to disease, nutritional preferences, social support, coping structure.
• Cultural uniqueness- Place of birth, race, length of time in this country

The Purnell Model for Cultural Competence is an assessment tool used in primary, secondary, and tertiary care. The model has its roots in biology, anthropology, sociology, economics, geography, political science, pharmacology, nutrition, communication, family development, and social support (Purnell, 2008). Concepts from each discipline are reflected in the domains used in the model. It is conceptualized as a circle, with society as the outer ring, community as the second ring, family as the third ring, and the inner ring as the person. There are 12 domains in the Purnell Model that are used as guides in the assessment. These are (Purnell, 2008):

1. Heritage- origin, residence, economics, topography, politics, education, occupation
2. Communication- language, dialects, time, names, touch, facial expression, body language, spatial distancing, volume, tone, eye contact
3. Family role and organization- structure, gender, roles, child-rearing, social status, roles of child and elderly
4. Workforce- language barriers, autonomy, dominant culture, secondary culture
5. Biocultural ecology- biological and physical characteristics
6. High-risk behaviors – safety, alcohol, and drug
7. Nutrition – common foods, rituals, limitations, health promotion
8. Pregnancy and child-rearing - fertility practices, view on pregnancy and child-rearing, birthing, postpartum
9. Death- rituals, bereavement
10. Spirituality – religion, the meaning of life, prayer, spirituality
11. Healthcare practices - traditions, responsibility for health, self-medication, rehabilitation, beliefs, barriers
12. Healthcare practitioner – perceptions, folk practices, gender healthcare status

The model is based on the assumption that all healthcare providers need the same information. The assessment is based on four factors of how the person functions: global society, family, personal practice, and health practices. Further, it is assumed that all cultures have similar core components, but each culture has specific variations that can change over time. The model also assumes that healthcare providers understand the importance of culture in assessing and caring for each patient.

Cultural differences can affect how patients view healthcare interventions purported by a perceived dominant cultural group. The Tuskegee experiment began in 1932 under the direction of the Public Health Service in conjunction with the Tuskegee Institute. The study's goal was to examine the natural history of syphilis in patients with hopes of justifying the treatment of syphilis among black patients (CDC, n.d.).

The study involved 600 black men who were enrolled in the study without obtaining informed consent. The patients were told they were being treated for a "bad blood" condition. The study was initially supposed to last six months but ended up running for 40 years. In the end, the patients enrolled did not receive adequate treatment for syphilis even when penicillin was established as the treatment of choice for syphilis. In 1972, the Assistant Secretary for Health and Scientific Affairs appointed a panel to review the study practices (CDC, n.d.).

The advisory panel eventually discovered that the study was ethically unjustified and that the knowledge gained was pale compared to the risks the participants incurred. This knowledge resulted in a class-action lawsuit and an out-of-court settlement. The federal government eventually established a program to provide healthcare benefits to the study participants, widows, and children. The Center for Disease Control and Prevention eventually became responsible for the federal program. The Tuskegee experiment led to creating of the National Research Act, which was signed into law in 1974. The National Commission for the protection of human subjects of biomedical and behavioral research was created. This commission eventually led to the creation of the National Bioethics Advisory Commission in 1995 (CDC, n.d.).

The Tuskegee experiment was evil and inexcusable. It left a bad taste for older African American patients who often choose to avoid preventative healthcare measures, especially when supported or purported by the federal government. However, with the advent of a more diverse healthcare workforce, the attitudes among minority groups are rapidly changing, although a lot of work remains to be done. The Tuskegee experiment led to groundbreaking laws on ethics in research and established an acute awareness of cultural competency.

The culture of medicine shifted from a more paternalistic view to one where patients are viewed as active participants in their care. Providers are encouraged to provide services tailored to the patient's values. At one time, stereotyping by healthcare providers was viewed as taboo in healthcare, but as the culture in healthcare continues to evolve, identifying patients by a cultural group they identify with has been associated with improved health outcomes.

Cultural competency has been identified as one of the main strategies deployed to dispel disparities in healthcare. Cultural competency has become a key aspect of healthcare policy and practice, which is now seen to enhance healthcare practices rather than detract from them.

Self-awareness is the first step toward culturally competent care. This awareness starts with knowing one's values and beliefs as well as nursing values and beliefs. Self-awareness is helpful knowledge when assessing and understanding the cultural beliefs of patients. Being aware of your own biases and attitudes allows you to become more appreciative and sensitive to the needs of patients. The healthcare provider must introspect and reflect on their attitudes toward different ethnic backgrounds and how those beliefs may impede care when working with other cultures. Healthcare providers must be able to develop skills in delivering culturally competent care.

The perceived role of healthcare providers differs significantly between various cultures. Some cultures view the healthcare provider as a trusted confidant expected to provide valuable advice as needed. Other cultures may consider any advice provided as an intrusion. Thus, healthcare providers should adjust their practices based on the patient's background and expectations.

Empathy is integral to providing culturally competent healthcare, enabling providers to appreciate, perceive, and respond to a patient's verbal and nonverbal cues.

Several studies have shown that healthcare provider nonverbal communication remains the best predictor of patient satisfaction.

The Office of Minority Health of the US Department of Health and Human Services and the Agency for Healthcare Research and Quality established the National Standards on Culturally Linguistically Appropriate Services (CLAS). The CLAS standards are a collection of guidelines, recommendations, and mandates designed to eradicate ethnic and racial health disparities. The idea undergirding the CLAS standards is that better communication tailored to specific social, racial, and ethnic groups eventually leads to improved health status.

There are legal standpoints of equality and discrimination that have migrated into healthcare. Title VI Civil Rights Act of 1964 does not allow Federally funded programs to discriminate based on race, color, or nationality (Pakianathan & Hegazi, 2016). Therefore, federally funded healthcare programs must provide equal care to all patients. Furthermore, Title VI mandates equal care for patients with limited English-speaking skills. The Title also requires language assistance for any one part of a federally funded program, including a healthcare program (Pakianathan & Hegazi, 2016). This mandate includes Medicare, Medicaid, and state children's health programs.

Healthcare providers must create a safe environment for patients to feel comfortable providing their medical history and receiving necessary medical care. Electronic Medical Records that allow patients to identify themselves as LGBTQ can cue clinical providers to the patient's potential needs and challenges. Healthcare providers' cultural competency can ameliorate the quality of patient interactions.

There have been continued reports of negative experiences by the LGBTQ community, specifically related to unequal healthcare treatment and homophobia.

The Joint Commission and the Institute of Medicine have voiced that sexual orientation and gender identity should be included in the electronic medical record (Healthy People 2020, n.d.; TJC, n.d.). Having this information in the electronic medical record is imperative for tracking and analyzing health disparities in the LGBTQ community at the population level.

Education of the medical community to become competent in the care of the LGBTQ community has been identified as the way forward in helping bridge the gap in the healthcare disparities affecting the LGBTQ community. There has been a push to include competencies in the medical and nursing curriculum that address issues surrounding sex, gender, sexuality, and other related topics.

Continuing medical education to healthcare providers, physicians, and other clinical providers on LGBTQ issues has become the best recourse given the sparsity of LGBTQ issues in the curriculum.

The Healthcare Equality Index (HEI) is a benchmarking tool established in 2007. It is used to designate healthcare facilities in the United States that are leaders in LGBTQ healthcare equality (Healthcare Equality Index, n.d.).

Despite the increased awareness of the need for a diverse and culturally competent workforce, there remains a glaring lack of resources to train culturally competent providers. It has become apparent that cultural competency is an issue no longer relegated to the federal government, state governments, or even healthcare organizations but rather a central, fundamental issue necessary to provide appropriate healthcare in the 21st century. As the largest group in the healthcare workforce, healthcare providers should continue to champion as patient advocates (Healthcare Equality Index, n.d.).

The LGBTQ nomenclature is in flux constantly, and healthcare providers must make it a point to keep up with the newer terms even as the field continues to evolve. The following are definitions of terms (HRC, 2021).

• Asexual: Can be called “ace" for short, asexual refers to a complete or partial lack of sexual attraction or lack of interest in sexual activity. Asexual people may experience no, little, or conditional sexual attraction.
• Bisexual: Someone who remains attracted to both genders.
• Cisgender: This person recognizes their gender as the same gender they had assigned at birth.
• Homosexual or Gay: Someone attracted to someone of the same gender.
• Intersex: Someone who is born with variations in sex characteristics that do not fall into the typical description of a male or female body. The bottom line is that this refers to someone whose anatomy is not exclusively female or male.
• Lesbian: This refers to a woman who is attracted to another woman.
• Pansexual: A person who is attracted to people of any gender or sexual orientation.
• Questioning: This refers to someone who is questioning their gender or sexual orientation.
• Transgender: This refers to someone whose gender is different from their gender at birth. This term may refer to people who are transgender, transsexual, or gender non-conforming.
• Transitioning: A series of processes that some transgender people may undergo in order to live more fully as their true gender. This typically includes social transition, such as names and pronouns, medical transition, which may include hormone therapy or gender affirming surgeries, and legal transition, which mainly includes changing legal name and sex on government identity documents. This individual may choose to undergo some or all of these processes.

LGBTQ usually refers to lesbian, gay, bisexual, transgender, and questioning/queer people. However, it is commonly used to represent all gender or sexual minorities, such as asexual or intersexual subgroups (Hegazi & Pakianathan, 2018). The Q in the LGBTQ community can mean "queer" or "questioning," and this refers to someone who is exploring their sexuality or gender identity (Hegazi & Pakianathan, 2018).

Several studies have documented the disparities in healthcare endeavors involving the lesbian, gay, bisexual, transgender, and queer communities. It has been established that lesbian and bisexual women are less likely to receive standard preventive cervical, breast, and colon cancer screenings (Hegazi & Pakianathan, 2018).

Lesbian, gay, bisexual, transsexual, and questioning communities have growing inequalities in healthcare delivery, including sexual health, mental health, and substance use. Clinical providers educated and competent in cultural awareness for LGBTQ communities have become necessary to bridge these communities' health inequalities (Hegazi & Pakianathan, 2018).

The World Health Organization defines sexual health as a state of physical, mental, and social well-being about sexuality. Sexual wellness necessitates an individual and positive approach to sexuality and sexual relationships and the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence (WHO, 2016).

There has been an increased prevalence of transgender diagnoses, with most studies observing a higher male to female than the female to male ratio (Ettner et al., 2016).

Sexual health is very intricate in the cultural, legal, socioeconomic, and political fabric of communities that provide a context to the lives of the LGBTQ community. Until 1992, homosexuality was considered a mental illness, at which time it was declassified by the World Health Organization (Pakianathan & Hegazi, 2016).

People in the LGBTQ community may experience fear in disclosing their sexual orientation, which can lead to higher rates of sexually transmitted diseases, including human immunodeficiency virus (HIV) in patients who are gay, bisexual, or men having sex with men, especially in countries where their sexual choices are criminalized (Pakianathan & Hegazi, 2016). Unfortunately, some people in the LGBTQ community still get attacked if they display affection publicly, even in countries where there is anti-discrimination legislation in place. Overall, there are increased reports of bullying and poor access to healthcare among the LGBTQ communities, especially in poorer countries (Pakianathan & Hegazi, 2016).

LGBTQ individuals report higher rates of suicide, anxiety, depression, and drug or alcohol dependence (Pakianathan & Hegazi, 2016). Men who only have sex with women are six times less likely to commit suicide than men who have sex with men (Pakianathan & Hegazi, 2016). The cause for the increased health disparities among the LGBTQ community is multifactorial and complex.

Gender dysphoria is a relatively new medical term that attempts to name and explain the dysphoric symptoms that people in this community may experience. As patients in the transgender community transition both socially and medically, they experience a unique set of challenges that clinical providers must remain aware of so they can provide appropriate support during their transition. There is a stark sparsity of research in transgender health and transgender communities.

Most of the research among the transgender population has been on patients transitioning from male to female transgender. There is a great need for gender affirmation in these trans-men and trans-women due to the stigma and discrimination they often face. There are specific challenges faced by the transgender population that may make them more vulnerable to certain ails. For example, transgender men who receive testosterone therapy may experience increased vaginal atrophy, making them more susceptible to sexually transmitted diseases, including HIV.

Lesbian and bisexual women typically have fewer sexually transmitted diseases than heterosexual women. However, a diverse group of women identifies as lesbian, and a thorough and appropriate sexual history must always be performed. Note that bisexual women are more likely to report having an increased number of sexual partners and an increased rate of chronic pain and cervical cancer.

Multiple studies have shown bacterial vaginosis to be more common among bisexual and lesbian women. Although human papillomavirus (HPV) related cancers have been shown to occur in women participating in female-to-female transmission of genital HPV with occurrences of cervical neoplasia. Despite these facts, cervical cancer screening remains low among the lesbian and bisexual communities. Homosexual men have an increased rate of HPV-associated anal cancers compared to heterosexual men.

In conclusion, our Nation is a vessel for many ethnic nationalities, each with a subculture and healthcare ideas. Healthcare professionals are caregivers who have a responsibility to care for various individuals with different ethnic backgrounds and cultural beliefs. Cultural competence is important in healthcare and an ongoing learning, advocating, and understanding process. Conflicts and awareness of how one’s own ideas can impact care need to be identified. Healthcare professionals should seek resources to understand better how to care for a diverse patient population.

• Center for Disease Control and Prevention. Tuskegee Study and Health Benefit Program - CDC - NCHHSTP. Centers for Disease Control and Prevention. Updated 4/22/2021. Accessed 11/17/2021. Visit Source.
• Ettner, R., Monstrey, S., & Coleman, E. (2016) Principles of Transgender Medicine and Surgery. Taylor & Francis. Visit Source.
• Giger, J. N. (2014). Transcultural nursing: Assessment and intervention. Elsevier Health Sciences.
• Healthcare Equality Index Training. Human Rights Campaign web site. Visit Source.
• Healthy people 2020. Office of Disease Prevention and Health Promotion, Lesbian, Gay, Bisexual, and Transgender Health. Healthy People.gov. Visit Source.
• Hegazi, A., & Pakianathan, M. (2018). LGBT sexual health. Medicine. 2018;46(5):300-303. doi:10.1016/j.mpmed.2018.02.004.
• Human Rights Campaign (2021) Glossary of Terms. Hrc.org. Visit Source.
• Leininger, M. (2002). Culture care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of transcultural nursing13.3 (2002): 189-192.
• Office of Minority Health. Think Cultural Health. CLAS Standards. HHS.gov. Visit Source.
• Pakianathan, M., Daley, N., & Hegazi, A. (2016). Gay, bisexual, and other men who have sex with men: time to end the fixation with HIV. Bmj. 2016:i4739. doi:10.1136/bmj.i4739.
• Purnell, L. D.(2008). The Purnell model for cultural competence. In Purnell Larry.
• World Health Organization. (2016). Sexual health. Published February 12, 2016. Accessed February 2, 2019. Visit Source.
• Shields, D. M., Kuhl, D., & Westwood, M. J. (2017). Abject masculinity and the military: Articulating a fulcrum of struggle and change. Psychology of Men & Masculinity, 18(3), 215–225. Visit Source.
• Snodgrass, J. G., Lacy, M. G., & Upadhyay, C. (2017). "Developing culturally sensitive affect scales for global mental health research and practice: Emotional balance, not named syndromes, in Indian Adivasi subjective well-being." Social Science & Medicine, 187, 174–183. Visit Source.
• Stanton BF. (2016). Cultural Issues in Pediatric Care, Chapter 4. In: Nelson Textbook of Pediatrics. 20th ed. Elsevier, Inc.; 2016:33-37.
• The Joint Commission, (2011). Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Visit Source.
• Van Herwaarden, A., Rommes, E. W. M., & Peters-Scheffer, N. C. (2020). Providers' perspectives on factors complicating the culturally sensitive care of individuals with intellectual disabilities. Research in Developmental Disabilities, 96, 103543. Visit Source.