Cultural Competency and Implicit Bias (4 Hour)

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 cannot understand you, and you cannot 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? The situation may seem unreal, but some patients feel just like this. What can be done to help this person?

Seven billion people in the world today 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 (US) population identified as a racial or ethnic minority in the 2000 census. This population is not unique to the US; more than 50 countries have reported that more than 15% of their population is accounted for by immigrants (Kaljee & Stanton, 2011).

Culture, bias, age, gender, background, sexuality, and much more help to define our identity and beliefs. We are all unique and deserve appreciation and respect for who we are. Healthcare facilities are responsible for employing staff that reflect their service area and the people they serve. They are also responsible for ensuring staff are educated on cultural issues relevant to their service area and beyond.

Before defining culture and cultural competency, it is important to provide definitions for common words used when discussing culture.

Race- this is a social construct and term that has been used to group or classify individuals. These classifications have been used to identify and often marginalize people across the globe. Our physical appearance, cultural backgrounds, and social factors help classify our race (National Human Genome Research Institute, 2023). According to the US Census Bureau (2022), there are five major races, and they include:

• White- those with origins in Europe, North Africa, or the Middle East.
• Black or African American- those with origins in Africa.
• American Indian or Alaskan Native- those with origins in North, Central, and South America with community attachment and/or tribal affiliation.
• Asian- those with origins in the Far East, Southeast Asia, and the Indian Continent, including China, Japan, India, Cambodia, Korea, Vietnam, Pakistan, Thailand, and the Philippines.
• Native Hawaiian or Other Pacific Islander- those with origins in the Pacific Islands, such as Hawaii, Guam, and Samoa.

Unfortunately, prejudice and racism are often tied in with racial identity (Charmaraman & Grossman, 2010).

Ethnicity- this term refers to the social group that an individual identifies with or belongs to and is often made of factors that include a proper name that expresses the community, common ancestry, shared memories that are often historical, elements of a common culture, including language and religion, a sense of solidarity, and a link to a homeland (Hutchinson & Smith, 1996).

Both race and ethnicity are social constructs tied to an individual's self-concept and lived experience (Charmaraman & Grossman, 2010).

Diversity- this term encompasses the inclusion of individuals from various races, ethnic and social backgrounds, sexual orientations, genders, ages, experiences, opinions, etc. (Oxford University Press, 2021; Servaes et al., 2022). It is often used to describe or encompass individual and unique differences (The George Washington University, n.d.).

Equity- this refers to justice and fairness. Equity, different from equality, means acknowledging and adjusting to imbalances (National Association of Colleges and Employers, n.d.). With equity, resources, and opportunities are made available to promote equality. Differences and divergences are included and should be celebrated (Jurado de Los Santos et al., 2020).

Inclusion- this describes an active intent to engage with diversity (The George Washington University, n.d.).

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- Many definitions of cultural competency exist, and it has evolved over the years. Generally, it means a set of values, behaviors, attitudes, and beliefs allowing effective cross-cultural communication. It represents the ability to:

• Value similarities and differences
• Have an awareness of differences and respond appropriately to them
• Conduct a cultural self-assessment
• Institutionalize cultural knowledge
• Adapt to cultural diversity

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 (Kaljee & Stanton, 2011). The National Quality Forum (2008) defines cultural competency as "the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse patient populations high-quality care that is safe, patient and family-centered, evidence-based, and equitable.

Cultural humility- this is a tool that can be used to embrace self-reflection to learn about one's internal beliefs and thoughts that may influence cultural identity. Cultural humility also involves self-awareness and self-critique (Yeager & Bauer-Wu, 2013).

When discussing culture, it is important to highlight and define types of bias, as it is often seen, felt, or experienced by many.

Implicit bias (IB), the human tendency to make decisions outside of conscious awareness and based on inherent factors rather than evidence, may influence the provided health care. Also known as unconscious bias, IB establishes itself through attitudes or behaviors developed early in life that are prejudiced against or in favor of one person or group compared to another (FitzGerald & Hurst, 2017). As identified in the literature across professional health disciplines, IB is associated with negative health disparities, health inequities, and substandard care among diverse populations. Likewise, IB may affect all persons' health by unconsciously influencing how providers perceive and act toward clients and, conversely, how clients may view provider interactions (National Center for Cultural Competency [NCC], 2021; Institute of Medicine [IOM], 2003).

Facts and Bias

IB is unintentional and attributed to the reflexive neurological system that drives the brain's automatic processing function. As such, an individual's feelings, attitudes, and decisions are involuntary, and their subsequent actions may conflict with their stated views (NCC, 2021). Consequently, the effects of IB can be difficult to identify and measure, and actions resulting from it often are challenging to recognize and control. Healthcare literature describes ongoing IB mitigation efforts, including the promotion of provider awareness, participation in continuing education, advancement of policy development, legislation, and institutional changes, and the contribution of research (FitzGerald & Hurst, 2017; NCC, 2021; Brecher et al., 2019; The Joint Commission, 2020). Learning about IB (later in the course) and how it differs from explicit bias, recognizing types of IB and how provider-client interactions are affected, and embracing strategies to address its impact on practice are approaches toward reducing barriers to equitable care, closing the gap in health disparities between diverse populations, and achieving patient-centered care.

IB presents challenges in health care when it manifests itself inappropriately and unconsciously contributes to health disparities. Health disparities are the differences in the burden of illness, injury, disability, or mortality outcomes between groups distinguished by characteristics such as age, gender, race, and ethnicity, leading to unfair and avoidable differences in health outcomes and are considered preventable (Centers for Disease Control and Prevention [CDC], 2020b). For example, the CDC reports that from 2007 to 2016, nearly 700 women died in the US annually from pregnancy-related complications (Petersen et al., 2019). Maternal mortality in the US is alarming, as are its significant racial and ethnic disparities. American Indians, Alaska Natives, and African Americans are two to three times more likely to die of pregnancy-related causes than Caucasians. It is understood that social determinants of health have historically prevented many people from diverse minority groups from "accessing fair opportunities for economic, physical, and emotional health, factors understood to impact health equity" (Howell, 2018). Although targeted efforts to isolate causes and develop successful mitigation strategies to combat US maternal mortality are ongoing, further innovative research and creative strategies are warranted. Suggestions for provider-targeted IB research on this topic may include providers' IB influencing their decision not to refer a patient because they believe that patient to be non-compliant.

In 2003, the IOM's formative report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, laid a foundation for exploration into healthcare disparities in the US, including bias toward patients of diverse racial, ethnic, or cultural populations. The report concluded that "bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care" (IOM, 2003). More recently, FitzGerald and Hurst's (2017) systematic review of 42 articles discussed robust documentation of IB among nurses and physicians and reinforced the negative effects of professional caregivers' IB on vulnerable populations, including "minority ethnic populations, immigrants, socioeconomically challenged individuals, persons with low health literacy, sexual minorities, children, women, elderly, mentally ill, overweight and the disabled." These reports and studies contribute to the evolving body of knowledge about IB in health care through research and provoke thoughts about the effects of IB on health outcomes.

Multidisciplinary health literature indicates that many factors contribute to health disparities, including "quality of healthcare, underlying chronic conditions, structural racism, and IB" (Petersen et al., 2019). Narayan (2019) cites literature that indicates health care providers' IB is associated with "inequitable care and negative effects on patient care including inadequate patient assessments, inappropriate diagnoses and treatment decisions, less time involved in patient care, and patient discharges with insufficient follow-up." Additionally, Saluja and Bryant (2021), suggest that IB can affect provider-patient communication among people of color. The effects may include "subtle racial biases expressed by providers, such as approaching patients with a condescending tone that decreases the likelihood that patients will feel heard and valued by their providers" (Saluja and Bryant, 2021). Variations in therapy options may also occur based on assumptions about clients' treatment adherence capabilities or presumed health issues.

Additionally, IB may negatively impact clinical outcomes and violate patient trust. Penner et al. (2016) found in a study of oncology patients who were African American and their physicians that patients perceived providers high in IB as less supportive of and spent less time with their patients than providers low in implicit bias. In turn, patients recognized those attitudes and viewed physicians with high IP as less patient-centered than physicians low in this bias. "The patients also had more difficulty remembering what their physicians told them, had less confidence in their treatment plans, and thought it would be more difficult to follow recommended treatments." These findings on providers' implicit racial bias underscore patients' perceptions of their experiences with providers' IB. However, its overall effects on healthcare quality and health outcomes for diverse populations invite further exploration (Penner et al., 2016).

A cultural assessment needs to be done for each individual to bring forth knowledge and prevent IB. 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 (Kaljee & Stanton, 2011).

Culture

Evaluate cultural information that is relevant to the care of the patient. An 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 form a partnership with the patient, which will enhance the outcome.

Besides a cultural assessment, healthcare providers should participate in IB testing. Surprising to many providers, the level of IB demonstrated by healthcare professionals is understood to be comparable to the general population (FitzGerald & Hurst, 2017). Given the unconscious nature of IB, directly asking providers about their IB through a self-report survey is not recommended. However, two common methods used to assess IB are Implicit Association Testing (IAT) and Assumption Method (AM).

IAT is a computer-generated online testing method that "measures implicit associations between participants' concepts and attitudes across a wide range of domains: race and ethnicity, disability, sexuality, age, gender, religion, and weight." For over 20 years, web-based IAT data has been collected through Project Implicit, a consortium of researchers from Harvard University, the University of Virginia, and the University of Washington to study and promote the understanding of attitudes, stereotypes, and other hidden biases that influence perception, judgment, and action (Project Implicit, 2021).

AM is a clinical vignette-based testing method that measures differences across participants' responses. The vignettes are designed to be the same except for one variable, such as gender. Inferences are made based on statistically significant responses correlated with the selected feature, such as the patient's gender. An inference is made that "the response is partly due to the result of implicit processes in the subject's decision-making" (FitzGerald & Hurst, 2017).

Priming is another way to measure reactions related to inherent and subconscious attitudes. The Priming Test is designed to measure the strength of the association between two stimuli, or targets and particular attributes, or primes. The targets are comparable categories, and the primes are associated with those categories. The Semantic Priming Test uses words, and the Visual Priming Test uses images. With these tests, a prime (word or image) is produced on a screen for a specific period before the target is shown. The participant is told to focus on separating the targets. The participant will react faster if the target is more associated with the prime (Ocejo, 2020).

Affect Misattribution Procedure (AMP) is another test used to measure and evaluate IB. The AMP presents multiple images that are assigned to two categories. Examples of categories include products, ethnic groups, or people. The second category may be neutral, such as a gray image. Then, an icon is displayed with a character, which is judged as positive or negative. According to the logic of the measurement, the effect associated with the image is transferred to the character (Payne et al., 2005).

These are just some examples of common tests used to measure and evaluate IB. There are others; however, they may not be commonly used, and their validity has not been verified.

Because culture, cultural competency, racism, and IB are evident in care, most facilities use a standard tool or model of care to help provide equitable care to all. 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 the use of 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. The level of care translates into transcultural patient care, and several models of care were developed, including Giger and Davidhizar, and Purnell.

Giger and Davidhizar's Transcultural Assessment Model (2013) is based on six data collection areas. 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 structures.
• Cultural uniqueness- place of birth, race, length of time in the 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, 2002). 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. Twelve domains in the Purnell Model are used as guides in the assessment. These are (Purnell, 2002):

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 use
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.

Another model frequently used is The Process of Cultural Competence in the Delivery of Healthcare Services by Campinha-Bacote (2002). There are five assumptions with this model, including the following:

1. Cultural competence is not a singular event but an ongoing process.
2. There are five constructs related to cultural competence- cultural awareness, knowledge, desire, skill, and encounters.
3. Intra-ethnic variation exists.
4. Healthcare providers' competence levels and their ability to provide care to ethnically and culturally diverse individuals are directly related.
5. Cultural competence is essential when effectively caring for patients.

Our multicultural world is continuously evolving, and this model encompasses the ever-changing and multidirectional roles of culture in our everyday society.

Now that culture has been defined, it is time to review specific cultural and personal variables that may be important to patients.

Religion

Religion is an organization that shares beliefs and practices. Spirituality is a person's sense of connection to something bigger than themselves. Individuals within the same religion may have different beliefs and practices.

It is important to recognize the many different religions that are practiced today. The following list is not all-encompassing, as many other religions and practices exist.

Buddhism- originating in South Asia, this is one of the world's largest religions. In Buddhism, individuals believe that life cycles through a period of suffering and rebirth. The goal is to achieve a state of nirvana, or total enlightenment. Buddhists do not believe in a god or type of deity but believe in supernatural beings that can aid or hinder them on their paths to nirvana (National Geographic Society, 2023). Buddhists also believe in four noble truths, which include the following (Aich, 2013):

1. Life is full of suffering (Duhkha)- examples of suffering include disease, death, old age, sorrow, and despair.
2. The cause of suffering (Duhkha-samudaya)- attachment is the cause of suffering. Attachment, derived from the word trishna, is associated with or translated from craving, thirst, clinging, desire, and lust. Attachment is also associated with dvesha, or hate and avoidance, as well as avidya, or ignorance.
3. Stopping suffering (Duhkha-nirodha)- this is where nirvana comes in; working through life without attachment can help Buddhists achieve nirvana.
4. Extinguishing suffering (Duhkha-nirodha-marga)- this represents another path, often referred to as marga, that Buddha called the Eightfold Path to liberation. This path can allow a Buddhist to be misery-free.

Christianity- with over two billion practicing this faith, it is the most widely practiced religion. At the center of this religion is Jesus Christ and His birth, death, and resurrection. Christians, followers of Christianity, are considered monotheistic, believing in only one God. Christians who believe God sent Jesus to save the world also believe Jesus will return for the Second Coming. This religion is outlined in the Holy Bible (History, 2021).

The three elements of God include the following:

1. The Father
2. The Son
3. The Holy Spirit

These three exist as one God and are termed the Holy or Blessed Trinity (Stanford Encyclopedia of Philosophy, 2020).

Hinduism- this has been identified as the oldest religion and is sometimes referred to as Sanatana Dharma. Hinduism, considered a natural religion, is practiced by Hindus. It is a natural and indigenous religion with diverse traditions and philosophies. All beings, including organisms, are Divine manifestations and have equal worth. The Divine can do the following:

1. Manifest in different ways
2. Be worshipped in many ways
3. Speak and relate to individuals in different ways

Hindus also believe in pluralism, which allows for diversity. Those both alike and unlike can connect through unique and varying characteristics with the Divine and on their own. Pluralism allows for increased religious and social freedom (Hindu American Foundation, 2022).

Islam- the second largest religion is Islam. Like Christianity, this is considered a monotheistic faith, only believing in one God named Allah. Followers of Islam, also known as Muslims, try to live in complete submission to Allah. Muslims follow the Koran, believing there will be a judgment day and that life exists after death (History, 2023a).

There are five pillars to the Islam faith, and they include the following:

1. Shahada- this means the profession of faith.
2. Salat- this means prayer, which occurs five times throughout the day and is performed while facing Mecca. Prayer is often performed in a certain way, such as on a rug or mat.
3. Zakat- this involves the donation of income to those who are in need.
4. Sawm- this centers around fasting. During Ramadan, which occurs in the ninth month of the Islamic calendar, Muslims fast during the daylight.
5. Hajj- this means pilgrimage. If Muslims are able, which is dependent on financial and health status, they should at least once travel to Saudi Arabia to the holy city (Canby, 2019). 

Jehovah's Witness- this religion is newer, starting in the 19th century. Jehovah's Witnesses do not believe in the Trinity; they believe Jesus is a separate entity and that the Holy Spirit refers to the power of God. Kingdom Halls serve as a gathering center for Jehovah's Witnesses (Schmalz, 2023). While some of their beliefs are similar to those of Christians, such as living morally by the Bible and aiming to live honestly, they hold unique beliefs and perspectives. For example, Jehovah's Witnesses do not celebrate Christmas or non-religious holidays like birthdays. Jehovah's Witnesses' beliefs also prevent them from receiving blood transfusions (Pavlikova & van Dijk, 2021).

Judaism- this is another older religion that follows monotheism, believing there is only one God. Abraham is the founder of Judaism. Followers of Judaism are referred to as Jews. Jews, along with rabbis (their spiritual leaders), worship in places called synagogues. Followers of Judaism also follow the sacred text called the Tanakh. The Torah, the first five books of the Tanakh, are more well-known and provide a guideline for Jews to follow (History, 2023b).

Age

There are clusters of people in a cultural group that have personal beliefs not shared with their group. These people have all the cultural beliefs of the group, plus individual differences. Age is one of those situations. Significant physical and developmental differences exist between infants, children, adolescents, adults, and aging adults.

Children have the added complications of the group's beliefs about the role of children, with limited cognition, communication, and judgment. Also, the caregiver's race, ethnicity, and religion may impact the child. The family unit may differ significantly, and culture helps determine the design, roles, and functions of the family dynamic (Committee on Family Caregiving for Older Adults et al., 2016).

The aging adult has the added complications of the group's culture and beliefs about the aged, with possible cognition, disability, and judgment limitations. The aging adult who is considered a minority will often have poorer health, such as an increase in chronic disease and higher rates of premature death (National Academies of Sciences, Engineering, and Medicine et al., 2017). This subset of the population faces barriers such as ageism, which is prejudice, bias, stereotyping, and discrimination based solely on someone's age (World Health Organization [WHO], 2021). Stereotypes include older adults being frail, dependent on others, or unable to contribute to society (Stubbe, 2021).

Disability

Individuals with disabilities have additional experiences and beliefs surrounding their disability, with added complications from the disability, like communication, cognition, and functional limitations (Van Herwaarden et al., 2020). Those with mental illness have different experiences and beliefs about mental illness (Snodgrass et al., 2017). Stigma and acceptance of mental treatment can be a significant obstacle to care planning.

With the shift towards diversity and equity, there come barriers to inclusion. Such barriers that patients with disabilities experience include attitudinal barriers, physical barriers, a lack of education, inappropriate education, or organizational and policy barriers.

Attitudinal- Attitudinal barriers are a common and basic type of barrier that can contribute to and lead to the formation of other barriers. Common attitudinal barriers include stereotyping, stigma, discrimination, and prejudice. For example, many individuals tend to assume those with disabilities have a poor quality of life. A disability should not be considered a deficit (CDC, 2020a). Attitudinal barriers further stigma and discrimination and deny others dignity and equal opportunity. Negative attitudes foster a disabling environment and intensify discrimination and other barriers to inclusion.

Physical- Physical barriers also pose a challenge to inclusion, including environmental and structural barriers that prevent access and mobility. Examples of physical barriers include not having a wheelchair ramp or accessible walkways (CDC, 2020a).

Communication- Communication barriers exist for many, including those with disabilities. Disabilities involving reading, writing, hearing, and speaking are more likely to experience communication barriers. Examples of barriers include the following (CDC, 2020a):

• No Braille or large print material available for those with vision impairments.
• Individuals with audio impairments may face communication barriers if there is no closed captioning on videos.
• No interpreter or someone fluent in American Sign Language is available.
• If someone has a cognitive impairment, using technical and over-medicalized language will result in a communication barrier. 

Financial- Financial barriers exist for disabled and non-disabled individuals. Financial barriers include a lack of insurance coverage, gaps in insurance coverage that may not cover rehabilitation services, lower income for those who are disabled, confusion, or a lack of information surrounding costs, payments, and insurance coverage. Not only is a lack of transportation a barrier, but so is the cost of transportation (Soltani et al., 2019).

Education can serve as a barrier to inclusion. If education is not inclusive, does not provide information on resources, or introduces bias, it is a barrier to inclusion.

Organizational barriers to inclusion encompass a variety of barriers on administrative, programmatic, and architectural levels. Examples include microaggressions, emotional barriers, jargon, and insensitive behaviors (Abbott & McConkey, 2006).

Policy can implement change. Unfortunately, it can also act as a barrier to inclusivity due to a lack of awareness of laws and regulations, a lack of the ability to enforce laws and regulations, or a lack of ability to make change. Policy barriers can also include a lack of funding (CDC, 2020a).

Social barriers, often related to social determinants of health, are more likely in those who are disabled. The following are statistics related to social barriers for those who are disabled (CDC, 2020a):

• Those with disabilities are less likely to be employed.
• Those with disabilities are less likely to have completed high school.
• Children with disabilities are more likely to experience violence.

Barriers in healthcare exist that can make it more difficult for those with disabilities to get the care they deserve. Healthcare barriers include a lack of communication, inconvenient scheduling, insufficient time to care for the patient or explain necessary information, and poor attitudes of providers and staff (CDC, 2020a).

Military

Military members have different cultures and beliefs related to their training and warrior status. These may include hyper-masculine qualities like toughness, stoicism, aggressiveness and values like self-sacrifice (Shields et al., 2017).

Unfortunately, healthcare is often under-utilized by veterans because they believe that non-military healthcare members are unable to meet their needs due to a lack of understanding of the military experience.

There are many health conditions that military members and veterans are at greater risk of experiencing, such as suicide, infectious diseases, exposure to harmful chemicals, hearing loss, and traumatic brain injuries. They are also at an increased risk of experiencing mental illness, such as anxiety, depression, and post-traumatic stress disorder.

It is pertinent that healthcare providers aim to understand the various branches of the military and what they are likely to experience and move beyond seeing just the physical injuries but the emotional and psychological toll as well (National Academies of Sciences, Engineering, and Medicine et al., 2017).

Mental illness

Culture also influences aspects of mental health and illness. When there is a difference in culture and a healthcare provider does not possess knowledge or awareness of the differing culture, differences become obstacles, and the healthcare provider is less likely to meet the patient's needs (Nair & Adetayo, 2019). Members of racial and ethnic minorities who have a mental illness are:

• More likely to receive inadequate care.
• Less likely to have access to and receive needed mental health services.

Cultural barriers for patients with mental illness include the following (Fountain House, 2022; Stubbe, 2021):

• Mistrust of healthcare providers/care they receive
• Lack of diverse healthcare members
• Alternative idea of health and illness

Cultural Groups

Within each culture, there are often sub-cultural groups. For example, within cultures worldwide, there are pockets of health-conscious communities that are vigilant against vaccinations. Immunizations are often viewed with distrust. It is important to note that individuals within cultures may have differing beliefs due to unique experiences.

Previous nontraditional cultural groups are now increasing in popularity. For example, several nontraditional groups have now been recognized as cultural groups in healthcare, such as adolescents, deaf youth, street youth, and gay and lesbian youth. These groups have shared values and make similar but non-homogeneous healthcare decisions. Failure of the healthcare provider to recognize the individual patient's identification with a group can negatively impact health outcomes (Kaljee & Stanton, 2011).

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 lesbian, gay, bisexual, transgender, queer, and/or questioning (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 IOM have voiced that sexual orientation and gender identity should be included in the electronic medical record (Office of Disease Prevention and Health Promotion, 2022; The Joint Commission, 2011). Having this information in the electronic medical record is imperative for tracking and analyzing health disparities in the LGBTQ+ community.

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 resource, 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 US that are leaders in LGBTQ+ healthcare equality (Human Rights Campaign Foundation, n.d.). However, 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 obvious 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 (Human Rights Campaign Foundation, n.d.).

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 goal was to examine the natural history of syphilis in patients with hopes of justifying the treatment of syphilis among black patients (CDC, 2023).

The study involved 600 black men who were enrolled without obtaining informed consent. The patients were told they were being treated for a "bad blood" condition. The study was initially supposed to last for 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, 2023).

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 CDC eventually became responsible for the federal program. The Tuskegee experiment led to the creation 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 eventually led to the creation of the National Bioethics Advisory Commission in 1995 (CDC, 2023).

The Tuskegee experiment was evil and inexcusable. Patients who were African American often chose 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 has 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, where it is now seen to enhance healthcare practices rather than detract from them.

Self-awareness is the first step toward culturally competent care. 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 engage in introspection and reflection on their own attitudes toward different ethnic backgrounds and how those beliefs may impede care when working with different cultures. It is essential 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 who is expected to provide valuable advice as needed. Other cultures may view 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 providers' nonverbal communication remains the best predictor of patient satisfaction.

The Office of Minority Health of the US Department of Health and Human Services (n.d.) 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.

Principal Standard

1) Provide effective, equitable, understandable, and respectful quality care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce

2) Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
3) Recruit, promote, and support culturally and linguistically diverse governance, leadership, and workforce responsive to the service area population.
4) Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

5) Offer language assistance to individuals with limited English proficiency and other communication needs at no cost to facilitate timely access to all healthcare and services.
6) Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7) Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and minors as interpreters should be avoided.
8) Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability

9) Establish culturally and linguistically appropriate goals, policies, and management accountability and infuse them throughout the organization's planning and operations.
10) Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
11) Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
12) Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
13) Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
14) Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
15) Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Health organizations that receive federal funding are required to keep standards 4 through 7. Several states have followed the Federal government's suit by enacting cultural competency legislation.

Now that steps to promote effective communication and appropriate services have been covered and we have learned the definition of IB, it is time to discuss how to mitigate IB while promoting culturally competent care.

Healthcare professionals typically intend to provide optimal patient care, but IB may negatively impact their aim. Strategies to disrupt IB, such as promoting self-awareness and participation in formal training, suggest that biases learned earlier in life may be mitigated (FitzGerald et al., 2019). Efforts to define consistent, evidence-based bias reduction strategies are advancing, and evaluation is ongoing. Meanwhile, learning about types of IB and how they may affect health care remains important. Likewise, supporting institutional changes is necessary to sustain meaningful, ongoing mitigation efforts. The literature is rich with resources to mitigate IB, including but not limited to the following topics:

1. Awareness of common types of IB
2. Legislation to institutionalize IB training across health professions and healthcare systems

Scenario/situation/patient description

A 66-year-old Hispanic male resides in a rural community. He contacted his primary care provider's office with the following complaints: temperature of 100.2 degrees for three days, headache, body ache, fatigue, and nasal congestion with a runny nose. They underwent a COVID-19 polymerase chain reaction (PCR) test at their local pharmacy yesterday, received their positive test result today, and are anxious to speak to their healthcare provider about treatment.

Intervention/strategies

A telehealth appointment is conducted with their healthcare provider. The patient's condition warrants community-based treatment, and strategies are discussed. The patient specifically asks about medication to cure Covid-19. They had heard about it from a friend and believed many people get it through their local livestock supply store. Their healthcare provider responds that they understand from speaking with other local healthcare professionals that some are recommending Ivermectin therapy, which coincidentally is available for livestock. The healthcare provider proceeds to write that prescription to be filled at the pharmacy.

Discussion of outcomes

The CDC reports that the US Food and Drug Administration has not authorized the use of Ivermectin to prevent or treat COVID-19 (CDC, 2021). Likewise, Ivermectin has not been recommended by the National Institutes of Health's COVID-19 Treatment Guidelines Panel for treating COVID-19. The healthcare provider's decision to prescribe this medication appears to be influenced by their IB to conform with their patient's request and some colleagues' anecdotal treatment recommendations. It is not an evidence-based treatment decision. Rather, the treatment decision is consistent with conformity bias, a type of IB.

Strengths and weaknesses of the approach used in the case

Typically, healthcare professionals intend to provide optimal care to all patients, but IB may negatively impact their aim. Conformity bias is an IB associated with the tendency to be influenced by other people's views (Brecher et al., 2019).

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

IB is the unconscious and, therefore, the unintentional human tendency to make decisions based on inherent factors rather than evidence. No one is immune, not even healthcare professionals. Recognizing common types of IB by building self-awareness and participating in voluntary or mandatory training are steps health professionals may take to minimize its impact on their care. Likewise, state governments' mandates specific to IB in healthcare are embedding training across health professions and care settings into law. More research is needed to measure how IB training may change health providers' short- and long-term beliefs, practices, and patients' perceptions. Ultimately, these steps are intended to minimize IB among healthcare providers, reduce barriers to equitable care, close the gap in health disparities between diverse populations, and meet patients' needs.

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