needs of those who have a culture that we are not familiar with and speak a different language


Defining a Culturally Competent Organization Culturally competent health care, broadly defined as services that are respectful of and responsive to the cultural and linguistic needs of patients, is increasingly viewed as essential in reducing racial and ethnic disparities, improving health care quality, and controlling costs. The U.S. government considers cultural competence as a method of increasing access to quality care for all patients. The aim should be to develop systems more responsive to diverse populations. Managed care organizations view cultural competence as driving both quality and business. By embedding cultural competence strategies into quality improvement initiatives to make care more efficient and effective, clinical outcomes are improved while costs are controlled. Those in academic settings agree that cultural competency education is crucial for preparing future health care workers, although appropriate education on the topic is provided in only half of the medical schools in the United States (Betancourt, Green, Carrillo, & Park, 2005). According to the Office of Minority Health, cultural competence refers to the ability of health care providers and organizations to understand and respond effectively to the cultural and linguistic needs of patients (Office of Minority Health, 2001). Cultural competence encompasses a wide range of activities and considerations. It includes providing respectful care that is consistent with cultural health beliefs of the clients and family members. Competent interpreter services and programs to promote staff diversity are other ways in which health care organizations can increase cultural competence (Clancy & Stryer, 2001). Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands. Effective communication allows patients to participate more fully in their care. Communicating effectively with patients is also critical to the informed consent process and helps practitioners and hospitals give the best possible care. For communication to be effective, the information provided must be complete, accurate, timely, unambiguous, and understood by the patient. Many patients of varying circumstances require alternative communication methods: patients who speak and/or read languages other than English; patients who have limited literacy in any language; patients who have visual or hearing impairments; patients on ventilators; patients with cognitive impairments; and children. The hospital has many options available to assist in communication with these individuals, such as interpreters, translated written materials, pen and paper, communication boards, and speech therapy. It is up to the hospital to determine which method is the best for each patient. Various laws, regulations, and guidelines are relevant to the use of interpreters. These include Title VI of the Civil Rights Act, 1964; Executive Order 13166; policy guidance from the Office of Civil Rights regarding compliance with Title VI, 2004; Title III of the Americans with Disabilities Act, 1990; state laws; and the American Medical Association Office Guide to Limited English Proficiency (LEP) Patient Care (Joint Commission Resources, 2010). In the United States, a variety of organizations have addressed the need for culturally competent organizations. For example, The Joint Commission has set standards, outlined in Box 9-2, to ensure that patients receive care that respects their cultural, psychosocial, and spiritual values (Joint Commission Resources, 2010). As outlined in Box 9-3, the American Nurses Association (2001) and American Nurses Credentialing Center (2008) have also addressed the need for culturally competent care. The United States government has also addressed culturally appropriate health care systems. For example, the Institute of Medicine (IOM) report “Health Professions Education: A Bridge to Quality” (Greiner & Knebel, 2003) identifies five core competencies for all health professionals: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics. Providing patient-centered care includes sharing power and responsibility with patients and caregivers; communicating with patients in a shared and fully open manner; taking into account patients’ individuality, emotional needs, values, and life issues; implementing strategies for reaching those who do not present for care on their own, including care strategies that support the broader community; and enhancing prevention and health promotion. In order to accomplish the goal of meeting patients’ individuality, emotional needs, values and life issues, the IOM report further indicates that clinicians must provide care in the context of the culture, heath status, and health needs of the patient.

Joint Commission Standards That Address Culture 2010 Leadership Standards

Overview Leaders shape the hospital’s culture, and the culture affects how the hospital accomplishes its work. A healthy, thriving culture is built around the hospital’s mission and vision, which reflect the core values and principles that the hospital finds important. Leaders ask some basic questions to provide this focus: How does the hospital plan to meet the needs of its population(s)? By what ethical standards will the hospital operate? What does the hospital want to accomplish through its work? Once leaders answer these questions, the culture of the hospital will begin to take shape. Leaders also have an obligation to set an example of how to work together to fulfill the hospital’s mission. By dedicating themselves to upholding the values and principles of the hospital’s mission, leaders model to others how to collaborate, communicate, solve problems, manage conflict, and maintain ethical standards, essential practices that contribute to safe health care. Specific Standards LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital 2010 Rights and Responsibilities of the Individual Overview When the hospital recognizes and respects patient rights, it is providing an important aspect of care that has been shown to encourage patients to become more informed and involved in their care. The hospital shows its support of patient rights through its interactions with patients and by involving them in decisions about their care, treatment, and services. Recognizing and respecting patient rights directly affects the provision of care. Care, treatment, and services should be provided in a way that respects and fosters the patient’s dignity, autonomy, positive self-regard, civil rights, and involvement in his or her care. Care, treatment, and services should also be carefully planned and provided with regard to the patient’s personal values, beliefs, and preferences.

2010 Provision of Care, Treatment, and Services Overview

The provision of care, treatment, and services is composed of four core elements: assessing patient needs; planning care, treatment, and services; providing the care, treatment, and services; and coordinating care, treatment and services. The complexity of providing care, treatment, and services often requires an interdisciplinary collaborative approach. The activities are performed by a wide variety of staff and licensed independent practitioners. Communication, collaboration, and coordination are essential so that care, treatment, and services are provided at the highest level.

The Need for Culturally Competent Organizations

Disparities in health have long been acknowledged. The National Institutes of Health (2010) define disparities in health as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” At the most basic level, disparities are evident in life expectancies. For example, the Centers for Disease Control and Prevention National Vital Statistics System (2009) reports the U.S. life expectancy is 77.9 years. However, life expectancy varies by race, with White males (75.8 years) and White females (80.7 years) higher than African American males (70.2 years) and African American females (77.0 years). Annually, the Agency for Healthcare Research and Quality (AHRQ) tracks disparities in health care delivery as it relates to racial and socioeconomic factors (AHRQ, 2008a). Three themes emerged from the National Healthcare Disparities Report, 2008 (AHRQ, 2008b): 1. Disparities persist in health care quality and access 2. Some disparities exist across multiple populations 3. The magnitude and patterns of disparities are different within subpopulations Access (getting into the health care system) and quality care (receiving appropriate, safe and effective health care in a timely manner) are key factors in achieving good health outcomes. Access to primary care is a key aspect of health care in the United States; research suggests that having a usual source of care increases the chances that people will receive adequate preventive care and other important health services. Yet evidence suggests that access disparities persist for all minority populations. Between 2000–2001 and 2005–2006, 20% to 80% of the access measures stayed the same or worsened for Black, Asian, American Indian/Alaskan Native, Hispanic, and the poor. Barriers include lack of health insurance and trouble getting appointments. For example, both Blacks and Hispanics are more likely than Whites to be unable to receive care or to delay care. In addition, between 2000–2001 and 2005–2006, 70% of quality of care measures stayed the same or worsened for Black, Asian, American Indian/Alaskan Native, Hispanic, and the poor.

Some disparities exist across multiple populations.

For example, core measures for cancer screening (colonoscopy, sigmoidoscopy, or fecal occult blood test) have worsened for Black, Asian, American Indian/Alaskan Native, and Hispanic populations. Blacks and Asians are more likely to report poor provider–patient communication and are less likely to have received a pneumococal vaccination if age 65 or older. Blacks and Hispanics are less likely to have received treatment for a major depressive episode. In addition, the magnitude and patterns of disparities are different within subpopulations. The three largest disparities are summarized in Box 9-5. Box 9-5 Three Largest Disparities in Quality of Care for Select Groups

* Poor is defined as people living in families whose household income falls below specific poverty thresholds, established annually by the U.S. Bureau of the Census based on family size and composition. The number of people living in poverty increased from 31.6 million in 2000 to 36.5 million in 2006. Poverty rates vary by race and ethnicity, with 24% of Blacks, 21% of Hispanics, 10% of Asians, and 8% of Whites classified as poor in 2006. Source: AHRQ (Agency for Healthcare Research and Quality). (2008b). Disparities in health care quality among racial and ethnic minority groups.

Findings from the National Healthcare Disparities Report, 2008. In Canada, with its National Health Insurance Model, many individuals experience similar disparities in access to preventative services. This implies that other factors may account for health disparities. Although these factors have not yet been identified, potential barriers that contribute to the disparities may be related to demographics, culture, and the health care system itself. Potential barriers are summarized in Box 9-6. Although identifying disparities in care is important, it is not sufficient. To reduce health disparities, individuals must deliver culturally competent health care that focuses on risk reduction, vulnerability reduction, and promotion and protection of human rights (Flaskerud, 2007). A variety of projects are underway to develop tools to help eliminate racial and ethnic disparities. Organizational culture is one area that may influence both cultural competence and health disparities. A culturally competent organization is extremely complex. Within the health care setting, practitioners must be aware of the effects of culture on individual behaviors. A culturally competent organization, however, goes beyond this awareness and calls for an understanding of the interplay among organizational culture, professional culture, and community culture.

Potential Demographic, Cultural, and Health System Barriers

Demographic Barriers

· Age

· Gender

· Ethnicity

· Primary language

· Religion Educational level and literacy level Occupation, income, and health insurance

· Area of residence Transportation

· Time and/or generation in the United States

Cultural Barriers

· Age

· Gender, class, and family dynamics

· Worldview/perceptions of life

· Time orientation

· Primary language spoken

· Religious beliefs and practices

· Social customs, values, and norms

· Traditional health beliefs and practices

· Dietary preferences and practices

· Communication patterns and customs

Health System Barriers

· Differential access to high-quality care

· Insurance and other financial resources

· Orientation to preventive health services

· Perception of need for health care services

· Lack of knowledge and/or distrust of Western medical practices and procedures

· Cultural insensitivity and incompetence in providers, including bias, stereotyping, and prejudice Lack of diversity in providers Western versus folk health beliefs and practices

· Poor provider–patient communication

· Lack of bilingual and bicultural staff

· Unfriendly and cold environment

· Fragmentation of care Physical barriers (such as excessive distances)

· Information barriers

Organizational Culture

Organizational culture has emerged as an important variable for behavior, performance, and outcome in the workplace. Nurses, while familiar with the concept of culture, may be less familiar with the area of organizational culture. Organizational culture is not consistently described in the literature, and multiple definitions exist. Many definitions center on enduring attributes of culture such as values, assumptions, and beliefs (Scott-Findlay & Estabrooks, 2006). Leininger (1996) defines organizational culture as the goals, norms, values, and practices of an organization in which people have goals and try to achieve them in beneficial ways. Organizations are complex, with multiple and competing subcultures. For example, nurse specialties result in subcultures within hospitals that impact nurse and patient outcomes (Mallidou, 2004). Organizations are subcultural systems with inherent values and beliefs, folklore, and language; these systems are organized in a hierarchy of authority, responsibilities, obligations, and functional tasks that are understood by members of the organization. Organizational culture has been studied as it relates to accountability (O’Hagan & Persaud, 2009); change (Seren & Baykul, 2007); emotional intelligence (Momeni, 2009); effectiveness (Casida, 2008); implementation of best practices and research (Marchionni & Ritchie, 2007; Scott-Findlay, 2006); leadership and management (Carney, 2006; Casida & Pinto-Zipp, 2008; Kane-Urrabazo, 2006); mentoring (Bally, 2007); and patient safety (Dekker, 2007; Khatri, Brown, & Hicks, 2009; Singer et al., 2009; Sorra, Famolaro, Dyer, Nelson, & Khanna, 2008). However, organizational culture affects not only people working in the institution, such as employees, physicians, and volunteers, but also those who access the institution’s services, such as patients, families, and community members. The social organization of hospitals and other health care facilities has a profound effect on patients, both directly through the care provided and indirectly through organizational policies and philosophy. Organizational culture has not been directly linked to patient or provider outcomes, or to the provision of culturally competent care.

Theories of Organizational

Culture A variety of definitions, methods of measurement, and theories for organizational culture exist. However, there is reasonable consensus on the following (Strasser, Smits, Falconer, Herrin, & Bowen, 2002):

• an organization’s culture consists of shared beliefs, assumptions, perceptions, and norms leading to specific patterns of behaviors;

• an organization’s culture results from an interaction among many variables, including mission, strategy, structure, leadership, and human resource practices;

• culture is self-reinforcing; once in place, it provides stability and changes are resisted by organizational members.

Strasser et al. (2002) describe four types of hospital culture: personal, dynamic, formal, and production oriented. A personal hospital is like an extended family. People share information about themselves. A dynamic hospital is entrepreneurial. People are willing to take risks. A formal hospital is structured. Bureaucratic procedures govern actions. A production-oriented hospital is concerned primarily with getting the job done. People are not personally involved. Studies suggest that teams in cultures perceived as personal and dynamic have higher ratings of team functioning (Strasser et al., 2002). Bolman and Deal (1997) describe four organizational culture perspectives or “frames” that affect the way in which an organization resolves conflicts. The human resource frame strives to facilitate the fit between person and organization. When conflict arises, the solution considers the needs of the individual or group as well as the needs of the organization. The political frame emphasizes power and politics. Problems are viewed as “turf” issues and are resolved by developing networks to increase the power base. The structural frame focuses on following an organization’s rules or protocols. This culture relies on its policies and procedures to resolve conflict. The symbolic frame relies on rituals, ceremony, and myths in determining appropriate behaviors. To understand how these four perspectives will result in different outcomes, consider typical responses to the following situation. Hospital A is located on the border of two communities. One community is primarily African American. The other community is primarily Hispanic. The hospital has traditionally provided care to African Americans and is well regarded by that community. The hospital has noted, however, that few members of the Hispanic community use its services. The hospital’s board of directors realizes that, to survive, the hospital must expand its patient base. The approach to this challenge will vary based on the organization’s culture. Hospital leaders in a human resource perspective culture are likely to approach the situation by assessing the needs of both communities and the staff. For example, a hospital with a human resource perspective culture may convene focus groups with members of the Hispanic community to identify why the hospital’s services are not used by that community. At the same time, the hospital will assess the African American community’s perspective on the hospital’s expanding its services and becoming a more inclusive organization. The hospital will also provide opportunities for staff members to provide input and to express their feelings about the goals of the organization. In the end, the hospital with a human resource perspective culture will reach a decision that balances the needs of all of these groups while enhancing the goal of expanding the patient base. Hospital leaders in a political perspective culture will take a different approach. They will identify key “power” leaders in the Hispanic community. Perhaps they will invite a Hispanic leader to join their board of directors or serve in another advisory capacity, or ask a priest from a Hispanic congregation to serve as a hospital chaplain. In addition, they will actively recruit Hispanic physicians and other clinician leaders. They will build a Hispanic power base within the hospital and use it to reach out to the larger Hispanic community and expand the patient base. Hospital leaders in a structural perspective culture will develop policies and procedures to attract more Hispanic patients. For example, they may make certain that all signage appears in both English and Spanish, or develop a policy that requires all patient educational materials to be available in both Spanish and English. They may require all staff to attend a session on Hispanic culture, and may strongly encourage or mandate Spanish-language training for key personnel. Finally, hospital leaders in a symbolic perspective culture will use ceremony to meet their goal. They will make physical changes to the environment to attract more Hispanics. For example, they may create or alter a chapel, inviting a priest from a Hispanic congregation to say mass.

They may display other religious symbols, such as a crucifix or a statue of Our Lady of Guadalupe, or alter their artwork to be more culturally inclusive. They may also include Hispanic stories and rituals in their internal communications. These leaders will draw on symbols and rituals that will make persons of Hispanic culture more comfortable in the hospital environment and that will attract a larger Hispanic patient base. None of these organizational cultures are inherently good or bad, just different. Each presents both strengths and weaknesses, and more than one culture may exist in an organization. For example, an organization may be guided primarily by both human resource and symbolic perspectives.

Schein (2004) describes organizational culture at three levels:

(1) observable artifacts,

(2) values, and

(3) basic underlying assumptions.

Artifacts are visible manifestations of values. Artifacts may include signage, statues and other decorations, pictures, décor, dress code, traffic flow, medical equipment, and visible interactions. Values are explicitly stated norms and social principles, and are manifestations of assumptions. Underlying assumptions are shared beliefs and expectations that influence perceptions, thoughts, and feelings about the organization; they are the core of the organization’s culture. Assumptions define the culture of the organization, but because they are invisible, they may not be recognized. At times, the assumptions of an institution are ambiguous and selfcontradictory, especially when an institutional merger or acquisition has occurred. The basic premises of an organization, reflected in its mission statement, provide insight into the presence or absence of a commitment to providing culturally competent care. Organizations are well aware of the need to identify a consistent vision and a set of values to guide their organizational culture.

As seen in Table 9-1, the mission, vision, and values may also include specific behaviors demonstrated toward both customers and colleagues.

Organizational Culture and Employees

There is a significant relationship between race/ethnicity and beliefs about the quality of workplace relationships and career opportunities. For example, research suggests that African American nurses experience stressors such as racism and lack of teamwork and supervisory support that causes them to contemplate leaving the workplace or the profession (Gibson-Jones, 2009). Health care organization leaders are called upon to implement strategies to make diversity work in health care organizations. Many organizations are aware of the impact of organizational culture on its employees. When filling positions, recruiters consider the “fit” between the organization and the potential employee, because a good “fit” results in better retention and satisfied employees. Nurses and other health care professionals also learn how to determine whether an organization will match their personal values. For example, a nurse who wants to provide care in a culturally competent manner to lesbians and homosexuals will not be happy in a critical care unit that restricts visitors to nuclear family members.

Vision and Values

Culturally caring organizations are needed for nurses and other staff members, and humans need care to survive, thrive, and grow. Historically, however, organizations have made few attempts to nurture and nourish the human spirit. According to Leininger (1996), organizations need to incorporate universal care constructs, including respect and genuine concern for clients and staff. An inclusive workplace is characteristic of a caring organization. Such a workplace, however, is not satisfied simply by a diverse workforce. Instead, such an organization focuses on capitalizing on the unique perspectives of a diverse workforce, in essence “managing for diversity” rather than “managing diversity” (Chavez & Weisinger, 2008).

An inclusive workplace also reaches out beyond the organization by encouraging members of the workforce to become active in the community and participate in state and federal programs, working with the poor and with diverse cultural groups. Rather than espousing the golden rule (treat others as you wish to be treated), an inclusive workplace treats others as they wish to be treated, in what is sometimes called the platinum rule (Alessandra, 2010).

Organizations with inclusive workplaces draw staff members who are committed to cultural competence and who value diversity and mutual respect for differences. Although the impact of organizational culture on employees has been acknowledged, the impact of organizational culture on the community being served has received less attention. For years, hospitals and other health care organizations have espoused the view that “If we build it, they will come” (i.e., all that is needed is to offer the services). Now, there is a growing recognition that health care services should be structured in ways to appeal to and meet the needs of various members of the community. Health care leaders recognize that cultural competence in organizations is essential if organizations are to survive, grow, satisfy customers, and achieve their goals. Image is critically important for an organization’s survival. A variety of factors are needed to move an organization toward cultural competence.

Assessing the Organizational Culture

Organizational culture may be assessed in numerous ways. Various instruments have been summarized by Scott-Findlay and Estabrooks (2006). In addition, Dansky, Weech-Maldonado, De Souza, and Dreachslin (2003) describe a 64-item tool that measures the breadth and degree of diversity management practices. The Magnet Hospital Recognition Program for Excellence in Nursing Services also evaluates organizational climate or culture (American Nurses Credentialing Center, 2008) and is used by many organizations as a blueprint for achieving excellence (Schaffner & Ludwig-Beymer, 2003).

Leininger’s (1991) Theory of Culture Care Diversity and Universality is also helpful in assessing the culture of an institution. Leininger’s Culture Care Model may be used to conduct a cultural assessment of the organization, with dominant segments of the sunrise model identified. Other cultural care assessment tools are available to assess the culture of an institution. This assessment is then compared with the values and beliefs of the groups who use the health care organization.

Barriers to Creating Culturally Competent Health Care Organizations

Standards for providing culturally and linguistically appropriate health care services have been clearly articulated. Regulatory bodies, such as The Joint Commission, and certification groups, such as Magnet designation, require adherence to several mandates related to culturally competent health care organizations. Regardless, a variety of barriers exist. Prejudice, racism, stereotyping, and ethnocentrism are present in all health care settings. The dominant subgroup is often ignorant of its own privilege. For example, services may be organized for the convenience of providers, and providers may be completely oblivious to the fact that inconvenient hours or locations are affecting the community members who seek services. The identity of a group or organization is based on phenotype, culture, or any other characteristic that a group shares that sets it apart from others. The professional values espoused by nurses, for example, set us apart from other health care providers. Numerous boundaries exist in the health care professions; they may be based on gender, ethnic differences, class and hierarchy, licensure and certification, history, and tradition (Dreachslin, 1999).

Institutional racism may also exist in health care. The MacPherson Report (2001) defines institutional racism as “the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture or ethnic origin.” In contrast with individual behaviors, institutional racism occurs when systematic policies and practices disadvantage certain racial or ethnic groups. Institutions may be overtly racist, as when they specifically exclude certain groups from service. More often, institutions are unintentionally racist. For example, a dress code that requires everyone to wear the same hat would institutionally discriminate against Sikh men, who are expected to wear turbans, and Muslim women, who wear the hijab or veil. Institutions don’t necessarily adopt such policies with the intention of discriminating, and often revise their practice once the discrimination is pointed out. This is an international concern.

In Australia, for example, a government report in the 1990s identified that the exclusionary culture of the health care system was a major impediment to equity and access for people of non–English-speaking background. Health care providers tend to use their own cultural frameworks as the normative reference point and may view people of culturally and linguistically diverse backgrounds as a problem. Blackford (2003) found that a Melbourne, Australia, hospital was designed to deliver care to an Anglo-Saxon population rather than meeting the needs of the surrounding multicultural population. Blackford suggests that the interactions that occur between health professionals and non– English-speaking patients may result in systems of exclusions and repressions. For example, Blackford found that families were defined from an Anglo-Saxon perspective. This resulted in a physical environment that could not accommodate large family groups, policies that limited visitors to two at any time, and parental expectations that were culturally incongruent with non–Anglo-Saxon cultures. In some cases, organizations may fail to correctly collect race and ethnicity data.

Research conducted in California (Gomez, Le, West, Santariano, & O’Connor, 2003) suggests that while 85% reported consistently collecting data on race, approximately half of the hospitals obtained data on race by observing a patient’s physical appearance. In addition, only 12% of the hospitals reported having a procedure for recording the race and/or ethnicity of a patient with mixed ancestry, and 55% reported never collecting ethnicity data. According to a report from the Commonwealth Fund and the American Hospital Association’s Health and Research Educational Trust (Hasnain-Wynia et al., 2004), fewer than 80% of hospitals collect data on race and ethnicity. Most often, data are collected because of a law or regulatory requirement. However, the information that is collected may not always accurate or valid. Frequently, the admitting clerk collects the data by asking questions of the patient and/or by observing patients. The report recommends that hospitals standardize who provides the information, when it is collected, which racial and ethnic categories should be used, and how the data are stored. Regenstein and Sickler (2006) also found that 78.4% of hospitals collect race information, 50.4% collect data on patient ethnicity, and 50.2% collect data on language preference. However, only 20% have formal data collection policies and fewer than 20% use the data to assess and compare care quality, health services utilization, health outcomes, or patient satisfaction.

The Institute of Medicine (2002) reports that 51% of providers believe that patients do not adhere to treatment because of culture or language. At the same time, nurses and other health care report having received no language or cultural competency training (Baldonado et al., 1998; Park et al., 2005). Many medical residents feel unprepared to treat patients who have religious beliefs that may affect treatment (20%), have LEP (22%), are new immigrants (25%), use complementary medicine (26%), or distrust the U.S. health system (28%) (Weissman et al., 2005). Similarly, while both nurses and baccalaureate nursing students perceive an overwhelming need for transcultural nursing, they report only 61% confidence in their ability to provide care to culturally diverse patients (Baldonado et al., 1998). Providing care to non-English-speaking patients is especially problematic. Large health care organizations may have resources to secure trained professional interpreters and bilingual providers. Regardless of setting, however, Youdelman and Perkins (2005) suggest the following eight-step process for developing appropriate language services: 1. Designate responsibility 2. Conduct an analysis of language needs 3. Identify resources in the community 4. Determine what language services will be provided 5. Determine how to respond to LEP (limited English proficient) patients 6. Train staff 7. Notify LEP patients of available language services 8. Update activities after periodic review

The Physical Environment of Care Organizational leaders must assess the physical environment of care to determine barriers and potentially negative messages. A flow chart is a helpful tool for determining such barriers. For example, in an effort to provide comprehensive women’s health programs in a caring fashion, organizational leaders may examine the steps for admission to a particular hospital for the delivery of a baby. To determine this, staff members may walk through this care process at their site, and then create a flow chart that outlines the steps. Staff members may be alert, in particular, for possible sources of confusion for parents at this highly stressful time. The flow chart can then be used to design changes in the environment that can be implemented to decrease barriers and improve services. The physical environment should also be assessed. Approaching this assessment as a potential client is helpful, and a variety of factors should be considered. What message does the organization send through its physical surroundings? How is the facility organized physically? How does the entryway present the culture of the organization to the public? Is the entrance warm and inviting? Is the signage prominent? What languages are presented on signs? Is the patient at a loss for where to go to give or receive information? Are amenities available to patients and their family members? Are the doors open or closed? Do people talk with one another, and what language(s) are spoken? What is the traffic pattern, and what is the general flow of traffic? Does the environment appear calm or turbulent? Are the staff members attentive and courteous? A physical environment may send unintentional messages. Several years ago, I visited a birthing unit in a city hospital. The hospital’s service area was undergoing tremendous changes, with a large influx from African American, Hispanic, Indian, and Polish American communities. The birthing unit was beautifully and tastefully decorated with oak furniture and pastel prints. Every picture on the walls, however, showed a Caucasian family. This clearly sent a message of exclusivity rather inclusiveness. When I brought this to the attention of the nurse manager, she was completely dumbfounded and quickly took steps to rectify the situation. Ethnocentrism and stereotyping were in play here, but it took an outsider to identify this and bring it to recognition and resolution.

Community Context Understanding what culturally competent health care means from the standpoint of patients is an important first step in building culturally competent organizations. Researchers (Napoles-Springer, Santoyo, Houston, Perez-Stable, & Stewart, 2005) conducted 19 community focus groups to determine the meaning of culture and what cultural factors influenced the quality of their medical visits. Culture was defined in terms of value systems, customs, self-identified ethnicity, and nationality. African Americans, Latinos, and non-Latino Whites all agreed that the quality of health care encounter was influenced by clinicians’ sensitivity to complementary/alternative medicine, health-insurance discrimination, social class discrimination, ethnic concordance between patient and provider, and age-based discrimination. Ethnicity-based discrimination was identified as a factor for Latinos and African Americans. Latinos also described language issues and immigration status factors. Overall, participants indicated greater satisfaction with clinicians who demonstrated cultural flexibility, defined as the ability to elicit, adapt, and respond to patients’ cultural characteristics. Health care institutions exist to provide care. A variety of factors, summarized in Box 9-8, contribute to mortality in the United States and Canada. Confronting these factors will require individual behavioral change, community change, social change, and economic change. Health care organizations cannot confront these complex factors in isolation but must partner with their communities to build trust in their institutions and meet the needs of their local communities. Community partnerships may be configured in a variety of ways. Hospitals and health care systems usually articulate their desire to improve the health of the communities they serve. Historically, hospitals have fulfilled this mission through charity care, health care provider education, research in health care, community education programming, and community outreach (Pelfrey & Theisen, 1993). Recognition is growing that true improvements in the health of a community require the focused efforts of the entire community. Such improvement may occur only in partnerships with community members and other community organizations.

Major Contributors to Mortality in the United States and Canada

· Tobacco use Alcohol

· Poor diet and physical inactivity

· Microbial agents Toxins

· Firearms

· Sexual behaviors

· Motor vehicle accidents

· Illicit drug use

· Poverty Lack of access to medical care

An ethnographic study of community (Davis, 1997) revealed five themes related to the experience of community caring. Of particular significance to this chapter are three themes:

(1) reciprocal relationships and teams working together are central to building healthy communities;

(2) education with a focus on prevention is key to enhancing health;

(3) understanding community needs is a primary catalyst for health care reform and change.

The healthy communities program, with partnerships between communities and hospitals, is one example of this trend in health care. In a healthy communities program, health care professionals collaborate with surrounding communities to conduct community health assessments. In community mapping, staff collect a variety of data, including demographics, health status, community resources, barriers, and enablers. Both strengths and needs are identified from the perspective of the community. All these data are then used collaboratively with communities to set priorities.

Data from these assessments are used to set priorities and guide the planning and implementation of key initiatives. These initiatives are most well accepted when they are sponsored by a variety of community organizations rather than by a single health care organization such as a hospital.

Focus groups may assist an organization in assessing how well they are meeting the needs of the populations they serve. For example, the Boston Pain Education Program worked collaboratively with community representatives to develop a culturally sensitive, linguistically appropriate cancer pain education booklet in 11 languages and for 11 ethnic groups. Focus groups were used to develop materials that would empower patients and families to more effectively partner with health care professionals and mange pain in culturally competent ways (Lasch et al., 2000). To ensure valid focus group results, the organization must understand racial identity development theory, models of communication style differences, cultural archetypes, and ethnic markers (Dreachslin, 1998). Box 9-9 Community Assessment Example By using the assessment of the communities served by Advocate Lutheran General Hospital and by analyzing data from clinical practice, staff members realized that Hispanics made up an increasing proportion of the population and were the most frequently underserved population. As a result, a family practice physician initiated the idea for a community center for health and empowerment. A coalition composed of individuals from social services, health care agencies, schools, police, churches, businesses, city government, and other community services also identified the Hispanic community as underserved. This group provided an etic, or outsider, view of the Hispanic community. To provide a local, or emic (insider), view, community members worked with health care personnel to design and conduct a door-to-door community assessment. As described elsewhere (Ludwig-Beymer, Blankemeier, Casas-Byots, & Suarez-Balcazar, 1996),

Leininger’s Theory of Cultural Diversity and Universality served to guide the assessment. The assessment process involved 2 focus groups, 15 community interviewers, and 220 door-to-door interviews. In addition, 5 meetings, attended by 180 community members, were held to report the findings to community members and solicit their input on how to maintain strengths and address needs. As a result, numerous task forces were formed to preserve strengths or mediate needs. Major strengths were identified as access to friends and families to socialize and get support, prenatal and postnatal care, and pediatric care. Major needs were identified as affordable housing, programs to help immigrants, Spanish-speaking dentists, and activities for youth.

The community was involved in key decision making from the beginning, including selecting the site for the center, choosing the name for the center, and establishing a sliding scale for fees. The bilingual center provides primary health care services, a Women–Infant–Children program run by the county health department, and a community empowerment program. A salaried community outreach worker coordinates the community empowerment program. In collaboration with businesses, churches, and city services, community members have undergone training in group work and priority setting. Monthly dental services through a dental van were added at the center. Activities for youth were identified as concerns in the community assessment. As a result, community members and center personnel have actively partnered with the park district, schools, churches, and the police to provide recreational activities for youth. The community also uses this as an opportunity to celebrate their cultural heritage. Health promotion materials and activities are also provided through collaboration. Community-based participatory research or participatory action research is a research strategy for understanding a community and developing health improvement initiatives with community members. The method uses collaborative, participatory approaches to develop sustainable services (Koch & Kralik, 2006). Increasingly, such research is being funded. For example, the National Canter on Minority Health and Health Disparities (NCMHD), located within the National Institutes of Health, has funded disease intervention research in reducing and eliminating health disparities using community-based participation research that is jointly conducted by health disparity communities and researchers (NIH, 2010). Conducting community assessments requires cultural awareness and sensitivity. Interpreting the data requires knowledge of the cultural dimensions of health and illness. Using the data to develop and implement programs in conjunction with the community requires the ability to plan and implement culturally competent care. The skill of a transcultural nurse or other culturally competent health care professional is invaluable in these situations.

Developing Culturally Competent Initiatives

Once the elements, outlined above, are in place, it is possible to develop culturally competent initiatives. Many important factors must be considered in planning programs across cultural groups. Before a program is planned, a cultural assessment of the target population should be a routine component of the needs assessment process (Huff & Kline, 1999). In many cases, cultural competence must be demonstrated with multiple cultures simultaneously. For example, one hospital in the Chicago area provides care for individuals who speak 64 different languages. This calls for much effort and creativity on the part of patients, health care providers, and interpreters. Culturally competent initiatives must reach out to multiple cultural groups.

This case study focuses on one culturally competent program provided to a community. Additional programs, targeting the needs of other age groups, may also be envisioned. For example, adult immunizations are also an issue for many communities, so a program might be developed that focuses specifically on older adults and their immunization needs. Similarly, programs might be instituted to deal with other health issues of concern to community members. The case study demonstrates the importance of incorporating an understanding of culture in every aspect of an initiative. To design and implement an effective program, the cultural values of patients must be understood and addressed.

The Role of Individual Health Care Providers in Creating Culturally Competent Organizations

All of us play a role in creating culturally competent organizations. Individual health care providers are at the core of helping an institution attain cultural competence. If they listen and attend carefully, health care providers have a valuable window directly into the world of their patients. They can take what they learn and escalate it as needed to improve the cultural responsiveness of their organization. Speaking the language can also be an advantage. When health care providers fail to take the patient’s culture seriously, they misinterpret the patient’s value system and, by doing so, elevate their own value systems. This posture is culturally destructive because it minimizes the other person’s culture. A better approach is to take time to ask questions about what the patient prefers and to listen attentively. In the end, this will increase understanding, trust, collaboration, adherence, and satisfaction. Even when serving a diverse patient base, health care providers can make a difference. Individuals and groups of clinicians can develop special programs to meet the needs of the specific populations they serve. For example, in our interfaith chapel, prayer materials are available from many faith traditions.


As with individuals, the quest for organizational cultural competence is a lifetime journey. There is always room for improvement. To be truly effective in improving patient care for all, health care services and social services that take cultural diversity into account must make an organizational commitment to cultural competence. Cultural competence cannot live in one or two nurses; it must be systemic. It must involve all layers of the organization: the policy making level, the administrative level, the management level, and the provider level. In addition, an organization must have a mutually beneficial relationship with the community it serves to achieve cultural competence. As such, organizations must reach out to community members.