Purnell and paulanka model of cultural competence

As new scientific information becomes available through basic and clinical research, recom- mended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no war- ranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regard- ing dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell, Betty J. Paulanka. — 3rd ed.

p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1865-7 ISBN-10: 0-8036-1865-4

1. Transcultural medical care—United States. 2. Transcultural medical care—Canada. I. Purnell, Larry D. II. Paulanka, Betty J.

[DNLM: 1. Delivery of Health Care—North America. 2. Cross-Cultural Comparison—North America. 3. Ethnic Groups—North America. W 84 DA2 T7 2008]

RA418.5.T73T73 2008 362.1089--dc22 2007043727

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 ! $.10.

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v

The rise in concern for cultural competence has become one of the most important developments in American health care over the past decade. Medicine and health more generally have moved beyond their traditional equanimous approach of application of scientific rational- ity to clinical problems to one that promotes an easier inte- gration of clinical science with empathy. This development has occurred with a rising tide of the diversity of the popu- lation of the United States. Some of this is driven by actual numbers of immigrants, but other dimensions of this awareness come from the visibility of the “new” ethnics and the waning of the social ideology of the melting pot. Beyond all of this is a younger generation that is much more attuned to diversity as part of their cultural landscape and their comfort with the globalization of perspectives resulting from technological and economic change.

From within health care, the advocacy for culturally competent approaches is driven in part by the dawning recognition of the danger to patient safety and overall inadequacy in the quality of outcomes in what we do. The literature around the disparities of outcomes across ethnic, social, and economic groups provides a com- pelling case to ensure that health care is attentive to these differences. But there is also attention to the costs that are driven up by health care that is not culturally competent and discourages compliance. The excess expenditures are associated with poor communication, the failure to use culturally responsive methods, and ineffective attempts to transfer treatment modalities to make the system cost efficient. Finally, as the health system makes its glacial move to more consumer and individual responsiveness, the system is recognizing that a cultural perspective is essential to provide services that earn high levels of con- sumer satisfaction.

Much of the activity aimed at advancing cultural com- petence has been centered on regulations and mandates. However, a generational change that begins with the edu- cation of each new practitioner is needed to bring about a culturally informed and competent professional commu- nity.

This edition of Transcultural Health Care provides the critical lessons to introduce students and practitioners to

how different cultures construct the social world and the dramatic impact that culture has on how health care, medicine, community, and family interact. These insights into the rich variety of human culture are only small steps toward developing real wisdom regarding culture compe- tence.

The first step in such a transformation is awareness of the other. Most young students and many seasoned prac- titioners simply do not have an appreciation of the vari- ety of backgrounds and perspectives that people bring to an encounter with the health-care system. They have the expectation that the patient or consumer will “fit” into their clinic or admission process. Moreover, much of what is done in health care follows a “procedure,” which implies that there are predetermined steps by which any one receiving the care or service must fit. For an increas- ingly large part of the population, nothing could be fur- ther from the truth. The care-seeking behavior, the atti- tude toward authority, the comfort with middle-class America culture that makes up so much of the health-care social world, and the relationship between genders are just a few of the literally hundreds of places at which a disconnect between the individual and the system can occur. When disconnects occur, the efforts by the system to maintain or return health may fail.

The second step after awareness is knowledge. What is it that we must know as practitioners in a system of care to reach the other person and overcome the cultural barri- ers? And it is essential that this knowledge pass both ways. What do they need to know about us in order to be an equal part of a team-focused plan to address a prob- lem? Knowledge also speaks to the need for every practi- tioner to be aware of his/her own attitudes, bias, and pre- judices. Everyone has such prejudices; they are not the issue. Awareness of them and the wisdom and insight to adjust care to provide nonjudgmental and supportive interventions is the challenge.

A culturally competent practitioner must also have a sense of comfort with the experiential process of engaging others from different cultures. This is perhaps the most difficult of all skills to teach and may only be learned through the practice of engaging others and being able to

Preface

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reflect critically on the experience and its impact on the patient as well as on the provider. This process is a famil- iar one, of course, as it is the core of clinical education. But students must come to value the variety of life and learn how to adapt their clinical expertise to different cul- tures and the individual unique development in a multi- cultural context.

As we focus on cultural competence, one fear is that we will make the knowledge more transactional than transfor- mational. It needs to be the latter. For the patient or con- sumer, health care presented in a culturally competent way must blend the traditions of the older culture with the promise and resources of modern health care. For the prac- titioner or health-care institution, new patterns of service and organization of care must be transformed using the experience with the new culture. Such a critical perspec- tive of cultural humility is essential for all practitioners in all dimensions of health care and is a vital part of devel- oping into a truly culturally competent provider.

This will be greatly assisted as care delivery moves from profession-specific models of care to more interpro- fessional and team-based approaches. This has long been a hope of many involved in efforts to reform health care. If one is truly committed in becoming culturally compe- tent, then one important lesson to learn is how to expand competence and the facility from the culture of nursing to an interdisciplinary culture that includes pharmacy, medicine, and the allied health professions. This seems obvious, but without these skills of closer adaptation and accommodation among all health profes- sions, how can you imagine practitioners adapting to cultures that are more alien than those we encounter on a routine basis?

Synthesizing cultural adaptations within the health pro- fessional perspectives and offering adapted care to patients may not be sufficient to guarantee individual cultural com- petence. Practitioners who achieve such skill will need to change their orientation from one that is focused on the profession and its clinical world to one that is patient-centric. This is easy to affirm but very difficult to deliver because of the power and cultural hegemony of the clinical world. This cultural blindness serves neither the patient nor the practi- tioner. It is also a source of much of the dysfunction of the current system of care, both in terms of costs and quality.

The final stage in cultural competency is the ability to balance self-awareness with other-awareness. Such a balance is the hallmark of an outstanding clinician and is also the basis of all true cultural competence. This value allows for a response ability that transcends the simple knowledge of all practitioners knowing every detail about particular cul- tures and allows a different relationship to emerge between the provider of service and the recipient. In this way, the work toward developing the skills of a culturally compe- tent practitioner assists in the broader goal of becoming an outstanding clinician in any setting. This edition of Transcultural Health Care provides an outstanding guide to the journey of becoming just such a practitioner.

EDWARD O’NEIL, MPA, PHD, FAAN Professor

Departments of Family and Community Medicine, Preventive and Restorative Dental Sciences and

Social and Behavioral Sciences, and Director of the Center for the Health Professions

University of California, San Francisco San Francisco, California

vi • PREFACE

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The editors would like to thank all those who helped in the preparation of the third edition of this book. We espe- cially thank acquisitions editor, Jonathan D. Joyce, and associate acquisitions editor, Thomas A. Ciavarella, at F. A. Davis for their support and enthusiasm for the project; and Julie Catagnus, developmental editor, for her atten- tion to detail, timeliness, and patience during the editing

process. We thank the copyeditors at F. A. Davis for their assistance in bringing the book to completion. Most importantly, we want to thank the many multicultural populations and health professionals who are the impe- tus for this book. Finally, we thank our families, friends, and colleagues for their patience and support during the preparation of the book.

Acknowledgments

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Diane Alain, Med, RN Teacher La Cité Collégiale University of Ottawa Ottawa, Ontario, Canada

Josepha Campinha-Bacote, PhD, MAR, APRN, BC, CNS, CTN, FAAN

Clinical Assistant Professor Case Western Reserve University Cleveland, Ohio President, Transcultural C.A.R.E. Associates Cincinnati, Ohio

Marga Simon Coler, EdD, APRN-C, FAAN Professor Emeritus University of Connecticut Storrs, Connecticut Adjunct Professor University of Massachusetts Amherst, Massachusetts Collaborating Professor Federal University of Paraíba Paraíba, Brazil

Jessie M. Colin, PhD, RN Professor Barry University School of Nursing Miami Shores, Florida

Ginette Coutu-Wakulczyk, RN, MSc, PhD Associate Professor School of Nursing Faculty of Health Sciences University of Ottawa Ottawa, Ontario, Canada

Tina A. Ellis, RN, MSN, CTN Nursing Instructor Florida Gulf Coast University Fort Myers, Florida

Rauda Gelazis, RN, PhD, CS, CTN Associate Professor Ursuline College Pepper Pike, Ohio

Divina Grossman, PhD, RN, FAAN Dean College of Nursing and Health Sciences Florida International University Miami, Florida

Homeyra Hafizi, RN, MS, LHRM Occupational Health Dynamac Corporation Kennedy Space Center, Florida

Sandra M. Hillman, PhD, MS, BSN Professor Nelson Mandela Metropolitan University Port Elizabeth, South Africa

David Hodgins, MSN, RN, CEN Indian Health Service Shiprock, New Mexico

Olivia Hodgins, RN, PhD, MSA, BSN Map Instructor and Nurse Executive Indian Health Service San Fidel, New Mexico

Kathleen W. Huttlinger, PhD, RN Associate Director for Research and Interim Director of Graduate Programs School of Nursing New Mexico State University Las Cruces, New Mexico

Eun-Ok Im, PhD, MPH, FAAN Professor The University of Texas at Austin Austin, Texas

ix

Contributors

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Misae Ito, MSN, RN, NMW Associate Professor, Fundamental Nursing Department of Nursing, Faculty of Health Sciences Yamaguchi University School of Medicine Yamaguchi-Ken, Japan

Anahid Dervartanian Kulwicki, RN, DNS, FAAN Deputy Director Wayne County Health and Human Services Detroit, Michigan Professor Oakland University Rochester, Michigan

Juliene G. Lipson, RN, PhD, FAAN Professor Emerita University of California, San Francisco School of

Nursing Mill Valley, California

Afaf Ibrahim Meleis, PhD, DrPS(hon), FAAN Margaret Bond Simon Dean of Nursing Professor of Nursing and Sociology University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Mahmoud Hanafi Meleis, PhD, PE Retired Nuclear Engineer Philadelphia, Pennsylvania

Denise Moreau, PhD, MSc, RN Assistant Professor and Lecturer University of Ottawa Ottawa, Ontario, Canada

Dula F. Pacquiao, EdD, RN, CTN Associate Professor and Director Bergen Center for Multicultural Education,

Research and Practice School of Nursing University of Medicine and Dentistry of New Jersey Newark, New Jersey

Irena Papadopoulos, PhD, MA, RN, RM, DipNEd, NDN Cert

Professor of Transcultural Health and Nursing Middlesex University, United Kingdom Highgate Hill, London

Ghislaine Paperwalla, BSN, RN Research Nurse in Immunology Veterans Administration Medical Center Miami, Florida

Henry M. Plawecki, RN, PhD Professor of Nursing Purdue University Calumet School of Nursing Hammond, Indiana

Judith A. Plawecki, RN, PhD Professor University of South Florida Tampa, Florida

Lawrence H. Plawecki, RN, JD, LLM Health Law Consultant Plawecki Consultants, LLC Highland, Indiana

Martin H. Plawecki, PhD, MD Faculty Indiana University School of Medicine Indianapolis, Indiana

Jeffrey Ross, BFA, MA, MAT Graphic Designer and Language Arts Teacher Archbishop Hoban High School Akron, Ohio

Ratchneewan Ross, PhD, MSc, RN, Certificate in Midwifery

Assistant Professor College of Nursing Kent State University Kent, Ohio

Maryam Sayyedi, PhD Adjunct Professor Department of Counseling California State University, Fullerton Fullerton, California

Janice Selekman, DNSc, RN Professor University of Delaware Newark, Delaware

Linda S. Smith, MS, DSN, RN, CLNC Associate Professor and Director Idaho State University Pocatello, Idaho

Jessica A. Steckler, MS, RNBC National Program Manager Employee Education System, VHA Erie, Pennsylvania

Gulbu Tortumluoglu, PhD Assistant Professor Nursing Department Chief Yuksekokulu, Canakkale, Turkey

Susan Turale, DEd, MNStud, BN, DApSci(AdvPsychNurs), RN, RPN, FRCNA, FANZCMHN

Professor of International Nursing Department of Nursing, Faculty of Health Sciences Yamaguchi University School of Medicine Yamaguchi-Ken, Japan

Yan Wang, MSN, RN-BC Nursing Informatics System Specialist III Duke University Health System Duke Health Technology Solutions Durham, North Carolina

x • CONTRIBUTORS

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Anna Frances Z. Wenger, PhD, RN, CTN, FAAN Professor and Director of Nursing Emerita Goshen College Goshen, Indiana Senior Scholar Interfaith Health Program School of Public Health Emory University Program Consultant Ethiopia Public Health Training Initiative The Carter Center Atlanta, Georgia

Marion R. Wenger, PhD Retired Professor of Foreign Languages and Linguistics Emory University Atlanta, Georgia

Sarah A. Wilson, PhD, RN Associate Professor Director, Institute for End of Life Care Education Marquette University College of Nursing Milwaukee, Wisconsin

Cecilia A. Zamarripa, RN, CWON Wound, Ostomy, and Continence Nurse University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Rick Zoucha, APRN, BC, DNSc, CTN Associate Professor Duquesne University School of Nursing Pittsburgh, Pennsylvania

CONTRIBUTORS • xi

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Introduction ........................................................................................................ xvii

Chapter 1 Transcultural Diversity and Health Care ........................................ 1 LARRY D. PURNELL

Chapter 2 The Purnell Model for Cultural Competence .............................. 19 LARRY D. PURNELL

Chapter 3 People of African American Heritage ............................................ 56 JOSEPHA CAMPINHA-BACOTE

Chapter 4 The Amish ........................................................................................ 75 ANNA FRANCES Z. WENGER and MARION R. WENGER

Chapter 5 People of Appalachian Heritage .................................................... 95 KATHLEEN W. HUTTLINGER and LARRY D. PURNELL

Chapter 6 People of Arab Heritage ................................................................ 113 ANAHID DERVARTANIAN KULWICKI

Chapter 7 People of Chinese Heritage .......................................................... 129 YAN WANG and LARRY D. PURNELL

Chapter 8 People of Guatemalan Heritage .................................................... 145 TINA A. ELLIS and LARRY D. PURNELL

Chapter 9 People of Egyptian Heritage.......................................................... 157 AFAF IBRAHIM MELEIS and MAHMOUD HANAFI MELEIS

Chapter 10 People of Filipino Heritage .......................................................... 175 DULA F. PACQUIAO

Chapter 11 People of French Canadian Heritage............................................ 196 GINETTE COUTU-WAKULCZYK, DENISE MOREAU, and DIANE ALAIN

Chapter 12 People of German Heritage .......................................................... 213 JESSICA A. STECKLER

Chapter 13 People of Haitian Heritage ............................................................ 231 JESSIE M. COLIN and GHISLAINE PAPERWALLA

Chapter 14 People of Iranian Heritage ............................................................ 248 HOMEYRA HAFIZI, MARYAM SAYYEDI, and JULIENE G. LIPSON

Contents

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Chapter 15 People of Japanese Heritage .......................................................... 260 SUSAN TURALE and MISAE ITO

Chapter 16 People of Jewish Heritage ............................................................ 278 LARRY D. PURNELL and JANICE SELEKMAN

Chapter 17 People of Korean Heritage ............................................................ 293 EUN-OK IM

Chapter 18 People of Mexican Heritage .......................................................... 309 RICK ZOUCHA and CECILIA A. ZAMARRIPA

Chapter 19 People of Russian Heritage ............................................................ 325 LINDA S. SMITH

Chapter 20 People of Polish Heritage .............................................................. 337 HENRY M. PLAWECKI, LAWRENCE H. PLAWECKI, JUDITH A. PLAWECKI, and MARTIN H. PLAWECKI

Chapter 21 People of Thai Heritage ................................................................ 355 RATCHNEEWAN ROSS and JEFFREY ROSS

Appendix Cultural, Ethnic, and Racial Diseases and Illnesses.................... 373

Abstracts People of Baltic Heritage: Estonians, Latvians, and Lithuanians ............................................................................ 381 RAUDA GELAZIS

People of Brazilian Heritage.......................................................... 383 MARGA SIMON COLER

People of Greek Ancestry ..............................................................385 IRENA PAPADOPOULOS and LARRY D. PURNELL

People of Cuban Heritage.............................................................. 387 DIVINA GROSSMAN and LARRY D. PURNELL

People of Hindu Heritage .............................................................. 389 LARRY D. PURNELL

People of Irish Heritage ................................................................ 391 SARAH A. WILSON

People of Italian Heritage.............................................................. 393 SANDRA M. HILLMAN

People of Puerto Rican Heritage .................................................. 395 LARRY D. PURNELL

Navajo Indians ................................................................................397 OLIVIA HODGINS and DAVID HODGINS

People of Turkish Heritage ............................................................399 GULBU TORTUMLUOGLU

People of Vietnamese Heritage .................................................... 401 LARRY D. PURNELL

Glossary................................................................................................................ 403

Index .................................................................................................................... 411

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People of Baltic Heritage: Estonians, Latvians, and Lithuanians RAUDA GELAZIS

People of Brazilian Heritage MARGA SIMON COLER and MARIA ADRIANA FELIX COLER

People of Greek Heritage IRENA PAPADOPOULOS and LARRY D. PURNELL

People of Cuban Heritage DIVINA GROSSMAN and LARRY D. PURNELL

People of Hindu Heritage LARRY D. PURNELL

People of Irish Heritage SARAH A. WILSON

People of Italian Heritage SANDRA M. HILLMAN

People of Puerto Rican Heritage LARRY D. PURNELL

Navajo Indians OLIVIA HODGINS and DAVID HODGINS

People of Turkish Heritage GULBU TORTUMLUOGLU

People of Vietnamese Heritage LARRY D. PURNELL

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Contents – DavisPlus

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The Purnell Model for Cultural Competence and its accompanying organizing framework has been used in education, clinical practice, administration, and research, giving credence to its usefulness for healthcare providers. They have been translated into Spanish, French, Flemish, Portuguese, Turkish, and Korean. Healthcare organiza- tions have adapted the organizing framework as a cultural assessment tool and numerous students have used the Model to guide research for theses and dissertations in the United States and overseas. The Model’s usefulness has been established in the global arena, recognizing and including the client’s culture in assessment, healthcare planning, interventions, and evaluation. The Model is now being used more with organizational cultural com- petence as well.

The third edition of Transcultural Health Care: A Culturally Competent Approach has been revised based upon response from students and practicing healthcare professionals such as nurses, physicians, physical thera- pists, emergency medical technicians, and nutritionists to name a few as well as educators from associate degree, baccalaureate, masters, and doctoral programs in nursing. We appreciate their review and suggestions.

Chapter 1 has three important changes: (a) a more extensive section on health disparities, (b) a more exten- sive section on organizational cultural competence, and (c) a section on evidence-based practice as it relates to cul- ture care. We have made a concerted effort to use non- stereotypical language when describing cultural attributes of specific cultures, recognizing that there are exceptions to every description provided and that the differences within a cultural group may be greater than the diversity between and among different cultural groups. We have also tried to include both the sociological and anthropo- logical perspectives of culture.

Chapter 2 expands the description of the Purnell Model for Cultural Competence to include application of the domains and concepts of culture to the dominant American Culture in a cross-cultural fashion. Chapters 1 and 2 have critical thinking questions dispersed throughout each chapter. The glossary remains as it did in the second

edition because users have noted its importance. Cultural specific chapters have changes based on users’ suggestions. Instead of one large case study at the end of each chapter, shorter vignettes covering several domains with study questions are dispersed throughout each chapter.

Given the world diversity and the diversity within cul- tural groups, it is impossible to cover each group more extensively. Space and cost concerns limit the number of chapters that are included in the book; therefore, additional cultural groups, PowerPoint slides, test banks, useful web sites, and additional case studies are include on DavisPlus.

Specific criteria were used for identifying the groups represented in the book and those included in electronic format. Groups included in the book were selected based on any of the six criteria that follow.

• The group has a large population in North America, such as people of Appalachian, Mexican, German, and African American heritage.

• The group is relatively new in its migration status, such as people of Haitian, Cuban, and Arab her- itage.

• The group is widely dispersed throughout North America, such as people of Iranian, Korean, and Filipino heritage.

• The group has little written about it in the health- care literature, such as people of Guatemalan, Russian, and Thai heritage.

• The group holds significant disenfranchised sta- tus, such as people of Navajo heritage, a large American Indian group.

• The group was of particular interest to readers in the second edition, such as people from Amish heritage.

Again, we have strived to portray each culture posi- tively and without stereotyping. We hope you enjoy our book and are as excited about the content as we are.

Larry D. Purnell Betty J. Paulanka

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1

Transcultural Diversity and Health Care

Chapter 1

LARRY D. PURNELL

The Need for Culturally Competent Health Care Cultural competence in multicultural societies continues as a major initiative for business, health-care, and educational organizations in the United States and throughout most of the world. The mass media, health-care policy makers, the Office of Minority Health, and other Governmental organi- zations, professional organizations, the workplace, and health insurance payers are addressing the need for individ- uals to understand and become culturally competent as one strategy to improve quality and eliminate racial, ethnic, and gender disparities in health care. Educational institutions from elementary schools to colleges and universities also address cultural diversity and cultural competency as they relate to disparities and health promotion and wellness.

Many countries are now recognizing the need for addressing the diversity of their society, including the client base, the provider base, and the organization. Societies that used to be rather homogeneous, such as Portugal, Norway, Sweden, Korea, and selected areas in the United States and the United Kingdom, are now facing sig- nificant internal and external migration, resulting in eth- nocultural diversity that did not previously exist, at least not to the degree it does now. As commissioned by the U.K. Presidency of the European Union, several European countries—such as Denmark, Italy, Poland, the Czech Republic, Latvia, the United Kingdom, Sweden, Norway, Finland, Italy, Spain, Portugal, Hungary, Belgium, Greece, Germany, the Netherlands, and France—either have in place or are developing national programs to address the value of cultural competence in reducing health dispari- ties (Health Inequities: A Challenge for Europe, 2005).

Whether people are internal migrants, immigrants, or vacationers, they have the right to expect the health-care system to respect their personal beliefs, values, and health-care practices. Culturally competent health care from providers and the system, regardless of the setting in which care is delivered, is becoming a concern and expec- tation among consumers. Diversity also includes having a diverse workforce that more closely represents the popu- lation the organization serves.

Health-care personnel provide care to people of diverse cultures in long-term-care facilities, acute-care facilities, clinics, communities, and clients’ homes. All health-care providers—physicians, nurses, nutritionists, therapists, technicians, home health aides, and other caregivers— need similar culturally specific information. For example, all health-care providers engage in verbal and nonverbal communication; therefore, all health-care professionals and ancillary staff need to have similar information and skill development to communicate appropriately with diverse populations. The manner in which the informa- tion is used may differ significantly based on the disci- pline, individual experiences, and specific circumstances of the client and provider.

Culturally competent staff and organizations are essen- tial ingredients in increasing clients’ satisfaction with health care and reducing multifactor reasons for gender, racial, and ethnic disparities and complications in health care. If providers and the system are competent, most clients will access the health-care system when problems are first recognized, thereby reducing the length of stay, decreasing complications, and reducing overall costs.

A lack of knowledge of clients’ language abilities and cultural beliefs and values can result in serious threats to life and quality of care for all individuals. Organizations

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and individuals who understand their clients’ cultural values, beliefs, and practices are in a better position to be coparticipants with their clients in providing culturally acceptable care. Having ethnocultural specific knowledge, understanding, and assessment skills to work with cultur- ally diverse clients assures that the health-care provider knows what questions to ask. Providers who know ethno- culturally specific knowledge are less likely to demon- strate negative attitudes, behaviors, ethnocentrism, stereotyping, and racism. Accordingly, there will be improved opportunities for health promotion and well- ness; illness, disease, and injury prevention; and health maintenance and restoration. The onus for cultural com- petence is on the health-care provider and the delivery system in which care is provided. To this end, health-care providers need both general and specific cultural knowl- edge to help reduce gender and ethnic and racial dispari- ties in health care.

World Diversity and Migration The world’s population reached 6.5 billion people in the year 2005 and is expected to approach 7.6 billion by 2020 and 9.3 billion by 2050. The estimated population growth rate is 1.14 percent, with 20.05 births per 1000 popula- tion, 8.6 deaths per 1000 population, and an infant mor- tality rate of 48.87 per 1000 population. Worldwide, life expectancy at birth is currently 64.77 years, with males at 63.17 years and females at 66.47 years (CIA, 2007).

As a first language, Mandarin Chinese is the most popu- lar, spoken by 13.59 percent of the world’s population, fol- lowed by Spanish at 5.05 percent, English at 4.8 percent, Hindi at 2.82 percent, Portuguese at 2.77 percent, Bengali at 2.68 percent, Russian at 2.27 percent, Japanese at 1.99 percent, German at 1.49 percent, and Wu Chinese at 1.21 percent. Only 82 percent of the world population is liter- ate. When technology is examined, more people now have a cell phone than a landline: 1.72 billion versus 1.2 billion. Slightly over 1 billion people are Internet users (CIA, 2007).

We currently live in a global society, a trend that is expected to continue into the future. According to the United Nations High Commissioner for Refugees, there is a global population of 9.2 million refugees, the lowest num- ber in 25 years, and as many as 25 million internally dis- placed persons. Migrants represent 2.9 percent or approxi- mately 190 million people of the world population, up from 175 million in the year 2000. Moreover, international migration is decreasing while internal migration is increas- ing, especially in Asian countries. Only two countries in the world are seeing an increase in their migrant stock— North America and the former USSR (CIA, 2007).

The International Organization for Migration com- pleted the first-ever comprehensive study looking at the costs and benefits of international migration. According to the report, ample evidence exists that migration brings both costs and benefits for sending and receiving coun- tries, although these are not shared equally. Trends sug- gest a greater movement toward circular migration with substantial benefits to both home and host countries. The perception that migrants are more of a burden on, than a benefit to, the host country is not substantiated by

research. For example, in the Home Office Study (2002) in the United Kingdom, migrants contributed U.S. $4 billion more in taxes than they received in benefits. In the United States, the National Research Council (1998) esti- mated that national income had expanded by U.S. $8 bil- lion because of immigration. Thus, because migrants pay taxes, they are not likely to put a greater burden on health and welfare services than the host population. However, undocumented migrants run the highest health risks because they are less likely to seek health care. This not only poses risks for migrants but also fuels sentiments of xenophobia and discrimination against all migrants.

2 • CHAPTER 1

What evidence do you see in your community that migrants have added to the economic base of the community? Who would be doing their work if they were not available?

UNITED STATES POPULATION AND CENSUS DATA

As of 2006, the U.S. population was over 300 million, an increase of 16 million since the 2000 census. The most recent census data estimates that 74.7 percent are white, 14.5 percent are Hispanic/Latino (of any race), 12.1 per- cent are black or African American, 0.8 percent are American Indian or Alaskan Native, 4.3 percent are Asian, 0.1 percent are Native Hawaiian or other Pacific Islander, 6 percent are some other race, and only 1.9 percent are of two or more races. Please note: These figures total more than 100 percent because the federal government consid- ers race and Hispanic origin to be two separate and dis- tinct categories. The categories as used in Census 2000 are

1. White refers to people having origins in any of the original peoples of Europe, the Near East, and the Middle East, and North Africa. This cate- gory includes Irish, German, Italian, Lebanese, Turkish, Arab, and Polish.

2. Black or African American refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any per- son who self-designates this category regardless of origin.

3. American Indian and Alaskan Native refer to people having origins in any of the original peoples of North, South, or Central America and who main- tain tribal affiliation or community attachment.

4. Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This category includes the terms Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, and Thai.

5. Native Hawaiian and other Pacific Islander refer to people having origins in any of the original peo- ples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands, and Chuuk.

6. Some other race was included for people who are unable to identify with the other categories.

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7. In addition, the respondent could identify, as a write-in, with two races (U.S. Bureau of the Census, 2006).

The Hispanic/Latino and Asian populations continue to rise in numbers and in percentage of the overall popula- tion; although the black/African American, Native Hawaiian and Pacific Islanders, Native American and Alaskan Natives groups continue to increase in overall numbers, their percentage of the population has decreased. Of the Hispanic/Latino population, most are Mexicans, followed by Puerto Ricans, Cubans, Central Americans, South Americans, and lastly, Dominicans. Salvadorans are the largest group from Central America. Three-quarters of Hispanics live in the West or South, with 50 percent of the Hispanics living in just two states, California and Texas. The median age for the entire U.S. population is 35.3 years, and the median age for Hispanics is 25.9 years (U.S. Bureau of the Census, 2006). The young age of Hispanics in the United States makes them ideal candidates for recruitment into the health professions, an area with crisis-level shortages of person- nel, especially of minority representation.

Before 1940, most immigrants to the United States came from Europe, especially Germany, the United Kingdom, Ireland, the former Union of Soviet Socialist Republics, Latvia, Austria, and Hungary. Since 1940, immigration patterns to the United States have changed: Most are from Mexico, the Philippines, China, India, Brazil, Russia, Pakistan, Japan, Turkey, Egypt, and Thailand. People from each of these countries bring their own culture with them and increase the cultural mosaic of the United States. Many of these groups have strong ethnic identities and maintain their values, beliefs, prac- tices, and languages long after their arrival. Individuals who speak only their indigenous language are more likely to adhere to traditional practices and live in ethnic enclaves and are less likely to assimilate into their new society. The inability of immigrants to speak the language of their new country creates additional challenges for health-care providers working with these populations. Other countries in the world face similar immigration challenges and opportunities for diversity enrichment. However, space does not permit a comprehensive analysis of migration patterns.

the Secretary’s Task Force’s report on Black and Minority Health (Perspectives on Disease Prevention and Health Promotion, 1985). Two goals from Healthy People 2010 are to increase quality and years of healthy life and eliminate health disparities (Healthy People 2010, 2005). In 2005, the Agency for Healthcare Research and Quality (AHRQ) released the Third National Healthcare Disparities Report (Agency for Healthcare Research and Quality [AHRQ], 2005) that provides a comprehensive overview of health disparities in ethnic, racial, and socioeconomic groups in the United States. This report is a companion document to the National Healthcare Quality Report (NHQR) that is an overview of quality health care in the United States. These two documents highlight four themes: (1) Disparities still exist, (2) some disparities are diminishing, (3) opportunities for improvement still exist, and (4) information about disparities is improving. These docu- ments address the importance of clinicians, administra- tors, educators, and policymakers in cultural competence. Disparities are observed in almost all aspects of health- care, including

1. Effectiveness, patient safety, timeliness, and patient centeredness.

2. Facilitators and barriers to care and health-care utilization.

3. Preventive care, treatment of acute conditions, and management of chronic disease.

4. Clinical conditions such as cancer, diabetes, end- stage renal disease, heart disease, HIV disease, mental health and substance abuse, and respira- tory diseases.

5. Women, children, elderly, rural residency, and individuals with disabilities and other special health-care needs.

6. Minorities and the financially poor receive a lower quality of care (AHRQ, 2005).

When ethnocultural specific populations are exam- ined, although some disparities have shown improve- ment, many have not improved and some have wors- ened. With whites as the comparison group, the report shows:

1. Blacks were 10 times more likely to be diagnosed with AIDS, 59 percent less likely to be given antibiotics for the common cold, 9 percent more likely to receive poorer quality care, 17 percent more likely to lack health insurance, 7 percent less likely to report difficulties in getting care, and 10 percent more likely to have worse access to care.

2. Non-white Hispanics/Latinos were 3.7 times more likely to be diagnosed with AIDS, 16 per- cent more likely to receive poorer quality care, 2.9 times for under age 65 to lack health insur- ance, 18 percent less likely to report difficulties or delays getting care, and 87 percent more likely to have worse access. However, they were 40 per- cent less likely to die of breast cancer.

3. Asians were 57 percent more likely to report com- munication problems with the child’s provider,

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 3

What changes in ethnic and cultural diversity have you seen in your community over the last 5 years? Over the last 10 years? Have you had the opportu- nity to interact with newer groups?

Racial and Ethnic Disparities in Health Care A number of organizations have developed documents addressing the need for cultural competence as one strat- egy for eliminating racial and ethnic disparities. In 1985, the Department of Health and Human Services released

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40 percent less likely to report difficulties or delays in getting care, and 20 percent more likely to have worse access to care.

4. American Indians and Alaskan Natives were twice as likely to lack early prenatal care, 67 per- cent less likely to develop late-stage breast can- cer, 8 percent more likely to receive poorer qual- ity care, twice as likely for the under-age-65 group to not have health insurance, 23 percent more likely to lack a primary-care provider, and 4 percent more likely to have worse access to care.

5. Data for Native Hawaiians and other Pacific Islanders were not available for this report but will be in future reports (AHRQ, 2005).

The health of the lesbian, gay, bisexual, and transgen- der populations has not been addressed in the Healthy People 2010 document or in other government publica- tions. However, the Gay and Lesbian Medical Association (www.glma.org) in 2001 developed Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. Salient disparities are noted in this publication. Gays and lesbians are more likely than their heterosexual cohort groups to have higher rates of tobacco, alcohol, and recreational drug use. Sexually transmitted infections, HIV (especially for men), suicide and suicide ideation, depression, being a victim of street violence (especially for men) and home violence (espe- cially for women), sexual abuse among men, hate crimes, and psychological and emotional disorders are higher among these groups. They are also more likely to be dis- criminated against by health-care providers owing to homophobia. Because of the stigma that alternative iden- tity gender discrimination brings, especially among racially and ethnically diverse populations (Purnell, 2003), these populations were less likely to disclose their sexual orientations. They are also less likely to have health insurance, have a primary-care provider, or take part in prevention programs; in fact, 57 percent of trans- gender people do not have health insurance (Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, Transgender Health, 2001; Purnell, 2003). To help combat violence and crimes against lesbians, gays, and transgender people, several cities such as Washington, D.C.; Fargo, North Dakota; and Missoula, Montana, in the United States have initiated Gay and Lesbian Crime Units (Police Unit Reaches Out to Gay Community, Inspires Others, 2006).

ethnic disparities in other countries. However, documents that include other countries, conditions, and policies are listed as a resource herein. Additional information on the role of cultural competence on eliminating racial and ethnic disparities includes:

1. Transcultural Nursing Society, International (www.tcns.org)

2. U.S. Department of Health and Human Services Office of Minority Health: Physician’s Toolkit and Curriculum (http://www.omhrc.gov/assets/ pdf/checked/toolkit.pdf)

3. Institute of Medicine’s Unequal Treatment study (http://www.iom.edu/?id=4475)

4. The Commonwealth Fund Report on Health Care Quality (http://www.cmwf.org/)

5. Delivering Race Equality: A Framework for Action (http://www.londondevelopmentcentre. org/silo/files/577.pdf)

6. Protecting Vulnerable Populations (www.wcc- assembly.info/en/news-media/news/english)

7. Canadian Institutes of Health Research: Reducing Health Disparities and Promoting Equity for Vulnerable Populations (www.cihr-irsc. gc.ca/e/19739.html)

8. American Physical Therapy Association’s docu- ment and monographs on cultural competence (www.apta.org)

9. Health Inequalities: A Challenge for Europe that includes health policies for the Czech Republic, England, Denmark, Finland, Greece, Germany, Hungary, Ireland, Latvia, the Netherlands, Northern Ireland, Poland Portugal, Scotland, Spain, Sweden, and Wales (www.fco.gov.uk/ Files/kfile/HI_EU_Challenge,0.pdf)

10. American Academy of Family Physicians docu- ments on health disparities and cultural com- petence (http://www.aafp.org)

11. American Academy of Physician Assistants doc- ument The Four Layers of Diversity (http:// www.aapa.org/)

12. Health Resources and Services Administration publication “Indicators of Cultural Competence in Health Care Delivery Organizations” and Cultural Competence Works (www.hrsa.gov)

13. American Student Medical Association Culture and Diversity Curriculum (http://www.amsa.org/ programs/diversitycurriculum.cfm)

14. American Academy of Nursing Standards of Cultural Competence (in press).

15. Diversity Rx (www.diversityRx.org)

Self-Awareness and Health Professionals Culture has a powerful unconscious impact on health professionals. Each health-care provider adds a new and

4 • CHAPTER 1

What health disparities have you observed in your community? To what do you attribute these dispar- ities? What can you do as a professional to help decrease these disparities?

Only broad categories of health disparities are addressed in this chapter. More specific data are included in individual chapters on cultural groups. As can be seen by the overwhelming data, much more work needs to be accomplished to improve the health of the nation. Space does not permit an extensive discourse on racial and

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unique dimension to the complexity of providing cultur- ally competent care. The way health-care providers per- ceive themselves as competent providers is often reflected in the way they communicate with clients. Thus, it is essential for health professionals to think about their cul- tures, their behaviors, and their communication styles in relation to their perceptions of cultural differences. They should also examine the impact their beliefs have on oth- ers, including clients and coworkers, who are culturally diverse. Before addressing the multicultural backgrounds and unique individual perspectives of each client, health- care professionals must first address their own personal and professional knowledge, values, beliefs, ethics, and life experiences in a manner that optimizes interactions and assessment of culturally diverse individuals.

Self-knowledge and understanding promote strong professional perceptions that free health-care profession- als from prejudice and allow them to interact with others in a manner that preserves personal integrity and respects uniqueness and differences among individual clients. The process of professional development and diversity com- petence begins with self-awareness, sometimes referred to as self-exploration. Although the literature provides numerous definitions of self-awareness, discussion of research integrating the concept of self-awareness with multicultural competence is minimal. Many theorists and diversity trainers imply that self-examination or aware- ness of personal prejudices and biases is an important step in the cognitive process of developing cultural compe- tence (Andrews & Boyle, 2005; Campinha-Bacote, 2006; Giger & Davidhizar, 2008). However, discussions of emo- tional feelings elicited by this cognitive awareness are somewhat limited, given the potential impact of emo- tions and conscious feelings on behavioral outcomes.

Culture and Essential Terminology CULTURE DEFINED

Anthropologists and sociologists have proposed many definitions of culture. For the purposes of this book, cul- ture is defined as the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life- ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making. Health and health-care beliefs and values are assumed in this definition. These patterns may be explicit or implicit, are primarily learned and transmitted within the family, are shared by most (but not all) members of the culture, and are emergent phenomena that change in response to global phenom- ena. Culture, a combined anthropological and social con- struct, can be seen as having three levels: (1) a tertiary level that is visible to outsiders, such as things that can be seen, worn, or otherwise observed; (2) a secondary level, in which only members know the rules of behavior and can articulate them; and (3) a primary level that repre- sents the deepest level in which rules are known by all, observed by all, implicit, and taken for granted (Koffman, 2006). Culture is largely unconscious and has powerful influences on health and illness. Health-care providers must recognize, respect, and integrate clients’ cultural beliefs and practices into health prescriptions.

An important concept to understand is that cultural beliefs, values, and practices are learned from birth: first at home, then in the church and other places where people congregate, and then in educational settings. Therefore, a 3-month-old male child from Korea adopted by an African American family and reared in an African American environment will have an African American worldview. However, that child’s “race” would be Asian, and if that child had a tendency toward genetic/hereditary conditions, they would come from his Korean ancestry, not from African American genetics.

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 5

In your opinion, why is there conflict about work- ing with culturally diverse clients? What attitudes are necessary to deliver quality care to clients whose culture is different from yours?

Self-awareness in cultural competence is a deliberate and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional knowledge standards, your ethics, and the impact of these factors on the various roles you play when interacting with individuals different from yourself. The ability to understand oneself sets the stage for integrating new knowledge related to cultural differ- ences into the professional’s knowledge base and percep- tions of health interventions.

What have you done in the last 5 to 10 years to increase your self-awareness? Has increasing your self-awareness resulted in an increased apprecia- tion for cultural diversity? How might you increase your knowledge about the diversity in your community? In your school?

Who in your family had the most influence in teaching you cultural values and practices? Outside the family, where else did you learn about your cultural values and beliefs? What cultural practices did you learn in your family that you no longer practice?

When individuals of dissimilar cultural orientations meet in a work or a therapeutic environment, the likeli- hood for developing a mutually satisfying relationship is improved if both parties attempt to learn about each other’s culture. Moreover, race and culture are not syn- onymous and should not be confused. For example, most people who self-identify as African American have vary- ing degrees of dark skin, but some may have white skin. However, as a cultural term, African American means that the person takes pride in having ancestry from both Africa and the United States; thus, a person with white skin could self-identify as African American.

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IMPORTANT TERMS RELATED TO CULTURE

Attitude is a state of mind or feeling about some matter of a culture. Attitudes are learned; for example, some peo- ple think that one culture is better than another. One cul- ture is not better than another; the two are just different, although many patterns are shared among cultures. A belief is something that is accepted as true, especially as a tenet or a body of tenets accepted by people in an eth- nocultural group. A belief among some cultures is that if a pregnant woman craves a particular food substance, strawberries, for example, and does not satisfy the crav- ing, the baby will be born with a birthmark in the shape of the craving. Attitudes and beliefs do not have to be proven; they are unconsciously accepted as truths. Ideology consists of the thoughts and beliefs that reflect the social needs and aspirations of an individual or an ethnocultural group. For example, some people believe that health care is a right of all people, whereas others see health care as a privilege.

The literature reports many definitions for the terms cultural awareness, cultural sensitivity, and cultural com- petence. Sometimes, these definitions are used inter- changeably. However, cultural awareness has more to do with an appreciation of the external signs of diversity, such as arts, music, dress, and physical characteristics. Cultural sensitivity has more to do with personal atti- tudes and not saying things that might be offensive to someone from a cultural or ethnic background different from the health-care provider’s. Cultural competence in health care is having the knowledge, abilities, and skills to deliver care congruent with the client’s cultural beliefs and practices. Increasing one’s consciousness of cultural diversity improves the possibilities for health-care practi- tioners to provide culturally competent care.

as the humanities. An understanding of one’s own culture and personal values and the ability to detach oneself from “excess baggage” associated with personal views are essential to cultural competence. Even then, traces of eth- nocentrism may unconsciously pervade one’s attitudes and behavior. Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, act- ing, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally com- petent care. Ethnocentrism, a concept that most people practice to some degree, perpetuates an attitude in which beliefs that differ greatly from one’s own are strange, bizarre, or unenlightened and, therefore, wrong. Values are principles and standards that are important and have meaning and worth to an individual, family, group, or community. For example, the dominant U.S. culture places high value on youth, technology, and money. The extent to which one’s cultural values are internalized influences the tendency toward ethnocentrism. The more one’s values are internalized, the more difficult it is to avoid the tendency toward ethnocentrism.

6 • CHAPTER 1

What activity have you done to increase your cul- tural awareness and competence? How do you demonstrate that you are culturally sensitive?

One progresses from unconscious incompetence (not being aware that one is lacking knowledge about another culture), to conscious incompetence (being aware that one is lacking knowledge about another culture), to con- scious competence (learning about the client’s culture, verifying generalizations about the client’s culture, and providing cultural specific interventions), and finally, to unconscious competence (automatically providing cul- turally congruent care to clients of diverse cultures). Unconscious competence is difficult to accomplish and potentially dangerous because individual differences exist within specific cultural groups. To be even minimally effective, culturally competent care must have the assur- ance of continuation after the original impetus is with- drawn; it must be integrated into, and valued by, the cul- ture that is to benefit from the interventions.

Developing mutually satisfying relationships with diverse cultural groups involves good interpersonal skills and the application of knowledge and techniques learned from the physical, biological, and social sciences as well

Given that everyone is ethnocentric to some degree, what do you do to become less ethnocen- tric? If you were to rate yourself on a scale of 1 to 10, with 1 being less ethnocentric and 10 being very ethnocentric, what score would you give yourself? What score would your friends give you? What score would you give your closest friends?

The Human Genome Project provides evidence that all human beings share a genetic code that is over 99 percent identical. However, the controversial term race must still be addressed when learning about culture. Race is genetic in origin and includes physical characteristics that are sim- ilar among members of the group, such as skin color, blood type, and hair and eye color. Although there is less than a 1 percent difference, this difference is significant when conducting physical assessments and prescribing medication, as outlined in culturally specific chapters that follow. People from a given racial group may, but do not necessarily, share a common culture. Race as a social con- cept is just as important, and sometimes more important, than race as a biological concept. Race has social meaning, assigns status, limits or increases opportunities, and influ- ences interactions between patients and clinicians. Racism has been described as prejudice combined with power (Abrums, 2004). The International Convention on the Elimination of All Forms of Racial Discrimination defines racism (1965) as “Any distinction, exclusion, restriction, or preference based on race, colour, descent, or national or ethnic origin which has the purpose or effect of nullifying or impairing the recognition, enjoyment, or exercise, on equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural, or any other field of public life.” Racism may be overt or covert. Recent antidiscrimination laws make racism illegal, but the laws do not eliminate racist attitudes; thus, people are just less likely to express racist attitudes openly. Moreover, one

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must remember that even though one might have a racist attitude, it is not always recognized because it is ingrained during socialization and leads to ethnocentrism.

culture. Some of these differences may include socioeco- nomic status, ethnic background, residence, religion, edu- cation, or other factors that functionally unify the group and act collectively on each member with a conscious awareness of these differences. Subcultures differ from the dominant ethnic group and share beliefs according to the primary and secondary characteristics of culture.

Primary and Secondary Characteristics of Culture Great diversity exists within a cultural group. Major influences that shape peoples’ worldview and the degree to which they identify with their cultural group of origin are called the primary and secondary characteristics of culture. The primary characteristics are things that a person cannot easily change, but if they do, a stigma may occur for themselves, their families, or the society in which they live. The primary characteristics of culture include nationality, race, color, gender, age, and religious affiliation. For example, consider two people with these primary characteristics: one is a 75-year-old devout Islamic female from Saudi Arabia; the other is a 19-year-old African American fundamentalist Baptist male from Louisiana. Obviously, the two do not look alike, and they probably have very different worldviews and beliefs, many of which come from their religious tenets and country of origin.

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 7

How do you define race? What other terms do you use besides race to describe people? In what cate- gory did you classify yourself on the last census? What categories would you add to the current census classifications?

Worldview is the way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them. Worldview includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics.

Any generalization—reducing numerous character- istics of an individual or group of people to a general form that renders them indistinguishable—made about the behaviors of any individual or large group of people is almost certain to be an oversimplification. When a gener- alization relates less to the actual observed behavior than to the motives thought to underlie the behavior (i.e., the why of the behavior), it is likely to be oversimplified. Thus, generalizations can lead to stereotyping, an over- simplified conception, opinion, or belief about some aspect of an individual or group. Generalization and stereotyping are similar, but functionally, they are very different. Stereotyping is an endpoint; generalization is a starting point. For example, knowing whether the person comes from an individualistic versus a collectivistic cul- ture is important. Remember, individualism and collec- tivism exist to some degree in all cultures, but one pattern tends to dominate. People identifying with a collectivist culture, such as most Asians, are more likely to place a higher value on the family than on the individual, harmony, and solidarity. However, people who identify with an individualistic culture, such as the dominant American and Scandinavian cultures, are more likely to place a higher value on the individual, independence, autonomy, and achievement. The health-care provider must specifically ask questions to determine these values and avoid stereotypical views of clients.

Everyone engages in stereotypical behavior to some degree. We could not function otherwise. If someone asked you to think of a nurse, what image do you have? Is the nurse male or female? How old is the nurse? How is the nurse dressed? Is the nurse wearing a hat? How do you distinguish a stereotype from a generalization?

Even in relatively homogeneous cultures, subcultures and ethnic groups exist that may not hold all the values of their dominant culture. Subcultures, ethnic groups, or ethnocultural populations are groups of people who have experiences different from those of the dominant

What are your primary characteristics of culture? How has each one influenced you and your world- view? How has your worldview changed as your primary characteristics have changed? How is each of these a subculture?

The secondary characteristics include educational status, socioeconomic status, occupation, military experi- ence, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented status), and length of time away from the country of ori- gin. For example, the secondary cultural characteristics of being a single transsexual urban business executive will most likely evolve into a different worldview from that of a married heterosexual rural secretary who has two teenagers. In another case, a migrant farm worker from the highlands of Guatemala, who has an undocumented status, has a different perspective than an immigrant from Mexico who has lived in New York City for 10 years. People who live in ethnic enclaves and get their work, shopping, and business needs met without learning the language and customs of their host country may be more traditional than people in their home country. Such was the case for a Japanese man who lived in a Japanese eth- nic enclave in San Francisco. When he returned to Japan after 20 years to visit relatives, he was criticized for being too traditional. Japanese society had changed, while he had not.

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Immigration status influences a person’s worldview. For example, people who voluntarily migrate generally acculturate more willingly; that is, they have given up most traits from the culture of origin as a result of contact with another culture. A number of acculturation scales exist; some are generic for any population, whereas others are specific to a particular culture such as Chinese, Korean, or Filipino. Yet, others are specific to an age group such as teenagers and older people. More traditional peo- ple adhere, and sometimes tenaciously, to most of the traits of their culture of origin. Similarly, assimilation is gradually adopting and incorporating the majority of the characteristics of the prevailing culture. Many people who migrate become bicultural; they are able to function equally well in their dominant and their host cultures. Marginalized people seem to have few traits from their dominant or host culture. People who voluntarily immi- grate assimilate and acculturate more easily than people who immigrate unwillingly or as sojourners. Sojourners, who immigrate with the intention of remaining in their new homeland only a short time, or refugees, who think they may return to their home country, may not identify a need to acculturate or assimilate. In addition, undocu- mented individuals (illegal aliens) may have a different worldview from those who have arrived legally with work visas or as “legal immigrants.”

The debate regarding the precise definition and differ- ences among the terms transcultural, cross-cultural, and intercultural continues. Many authors and texts define the terms differently. This book uses the terms interchange- ably to mean “crossing,” “spanning,” or “interacting” with a culture other than one’s own. When people interact with individuals whose cultures are different from their own, they are engaged in cultural diversity. Awareness of the differences and similarities among ethnocultural groups results in a broadened multicultural worldview.

Ethics Across Cultures As globalization grows and population diversity with nations increases, health-care providers are increasingly confronted with ethical issues related to cultural diversity. At the extremes stand those who favor multiculturalism and postmodernism versus those who favor humanism. Internationally, multiculturalism asserts that no com- mon moral principles are shared by all cultures; post- modernism asserts a similar claim against all universal standards, both moral and nonmoral. Postmodernism holds the stance that everything is social construction, which leads to the contention that context is all- important (Baker, 1998). The concern is that universal standards provide a disguise whereas dominant cultures destroy or eradicate traditional cultures.

Humanism asserts that all human beings are equal in worth, that they have common resources and problems, and that they are alike in fundamental ways (Macklin, 1999). Humanism does not put aside the many circum- stances that make individuals’ lives different around the world. Many similarities exist as to what people need to live well. Humanism says that there are human rights that should not be violated. Macklin (1998) asserts that uni- versal applicability of moral principles is required, not universal acceptability. Beaucamp (1998) concurs that fundamental principles of morality and human rights allow for cross-cultural judgments of immoral conduct. Of course, there is a middle ground.

Throughout the world, practices are claimed to be cul- tural, traditional, and beneficial, even when they are exploitive and harmful. For example, the practice of female circumcision, a traditional cultural practice, is seen by some as exploiting women. In many cases, the practice is harmful and can even lead to death. Whereas empirical anthropological research has shown that differ- ent cultures and historical eras contain different moral beliefs and practices, it is far from certain that what is right or wrong can be determined only by the beliefs and practices within a particular culture or subculture. Slavery and apartheid are examples of civil rights violations.

Accordingly, codes of ethics are open to interpretation and are not value-free. Furthermore, ethics belong to the society, not to professional groups. Ethics and ethical decision making are culturally bound. The Western ethical principles of patient autonomy, self-determina- tion, justice, do no harm, truth telling, and promise keeping are not interpreted or shared by some non- Western societies. In the dominant American culture, truth telling, promise keeping, and not cheating on examinations are highly valued. However, not all cultures place such high regard on these values. For example, in Russia, the truth is optional, people are expected to break their promise, and most students cheat on examinations. Cheating on a business deal is not necessarily dishonor- able (Birch, 2006).

In health organizations in the United States, advance directives give patients the opportunity to decide about their care, and staff members are required to ask patients about this upon admission to a health-care facility. Western ethics, with its stress on individualism, asks this question directly of the patient. However, in collectivist societies, such as among ethnic Chinese and Japanese, the preferred person to ask may be a family member. In most collectivist societies, a person does not stand alone, but rather is defined in relation to another unit, such as the family or work group. In addition, translating these forms into another language can be troublesome because a direct translation can be confusing. For example, “informed consent” may be translated to mean that the person relinquishes his or her right to decision making.

8 • CHAPTER 1

What are your secondary characteristics of cul- ture? How has each one influenced you and your worldview? How has your worldview changed as your secondary characteristics have changed? How is each of these a subculture?

How do you perceive truth telling? Do you always tell the truth? Do you always tell the whole truth? If a female colleague asks you how you like her new hairstyle, are you completely truthful or are

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Some cultural situations occur that raise legal issues. For instance, in Western societies, a competent person (or an alternative such as the spouse, if the person is married) is supposed to sign her or his own consent for medical procedures. However, in some cultures, the eldest son is expected to sign consent forms, not the spouse. In this case, both the organization and the fam- ily can be satisfied if both the spouse and the son sign the informed consent.

Instead of Western ethics prevailing, some authorities advocate for universal ethics. Each culture has its own def- inition of what is right or wrong and what is good or bad. Accordingly, some health-care providers encourage inter- national codes of ethics, such as those developed by the International Council of Nurses. These codes are intended to reflect the patient’s culture and whether the value is placed on individualism or collectivism. Most Western codes of ethics have interpretative statements based on the Western value of individualism. International codes of ethics do not contain interpretative statements, but rather let each society interpret them according to its culture. As our multicultural society increases its diversity, health-care providers need to rely upon ethics committees that include members from the cultures they serve.

As the globalization of health-care services increases, providers must also address very crucial issues such as cul- tural imperialism, cultural relativism, and cultural impo- sition. Cultural imperialism is the practice of extend- ing the policies and practices of one group (usually the dominant one) to disenfranchised and minority groups. An example is the U.S. government’s forced migration of Native American tribes to reservations with individual allotments of lands instead of group ownership as well as forced attendance of their children at white people’s boarding schools. Proponents of cultural imperialism appeal to universal human rights values and standards.

Cultural relativism is the belief that the behaviors and practices of people should be judged only from the context of their cultural system. Proponents of cultural relativism argue that issues such as abortion, euthanasia, female circumcision, and physical punishment in child rearing should be accepted as cultural values without judgment from the outside world. Opponents argue that cultural relativism may undermine condemnation of human rights violations, and family violence cannot be justified or excused on a cultural basis.

Cultural imposition is the intrusive application of the majority group’s cultural view upon individuals and families (Universal Declaration of Human Rights, 2001). Prescription of special diets without regard to clients’ cultures and limiting visitors to immediate family, a practice of many acute-care facilities, border on cultural imposition.

Health-care professionals must be cautious about forcefully imposing their values regarding genetic testing and counseling. No group is spared from genetic disease. Ashkenazi Jews have been tested for Tay-Sachs disease for many years. Advances in technology and genetics have found that many diseases such as Huntington’s chorea have a genetic basis. Some forms of breast and colon can- cers, adult-onset diabetes, Alzheimer’s disease, and hyper- tension are some of the newest additions. Currently, only the well-to-do can afford broad testing. Advances in tech- nology will provide the means for access to screening that will challenge genetic testing and counseling. The rela- tionship of genetics to disability, disabled individuals, and the potentially disabled will create moral dilemmas of new complexity and magnitude.

Many questions surround genetic testing. Should health-care providers encourage genetic testing? What is, or should be, done with the results? How do we approach testing for genes that lead to disease or disability? How do we maximize health and well-being without creating a eugenic devaluation of those who are disabled? Should employers and third-party payers be allowed to discrimi- nate based on genetic potential for illness? What is the purpose of prenatal screening and genetic testing? What are the assumptions for state-mandated testing programs? Should parents and individuals be allowed to “opt out” of testing? What if the individual does not want to know the results? What if the results could have a deleterious out- come to the infant or the mother? What if the results got into the hands of insurance companies that then denied payment or refused to provide coverage? Should public policy support genetic testing, which may improve health and health care for the masses of society? Should multiple births from fertility drugs be restricted because of the bur- den of cost, education, and health of the family? Should public policy encourage limiting family size in the con- texts of the mother’s health, religious and personal pref- erences, and the availability of sufficient natural resources (such as water and food) for future survival? What effect do these issues have on a nation with an aging popula- tion, a decrease in family size, and decreases in the num- bers and percentages of younger people? What effect will these issues have on the ability of countries to provide health care for their citizens? Health-care providers must understand these three concepts and the ethical issues involved because they will increasingly encounter situa- tions in which they must balance the client’s cultural practices and behaviors with health promotion and wellness as well as illness, disease, and injury prevention activities for the good of the client, the family, and society. Other international issues that may be less

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 9

you likely to be a little less than completely truth- ful and tell her what you think she wants to hear? If a patient asks you how he is doing and if he is going to get better, do you tell him that everything is okay, even if you know he is not?

What practices have you seen that might be considered a cultural imposition? What practices have you seen that might be considered cultural imperialism? What practices have you seen that might be con- sidered cultural relativism? What have you done to address them when you have seen them occurring?

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controversial include sustainable environments, pacifica- tion, and poverty (Purnell, 2001).

Individual Cultural Competence Much has been debated, especially since the early 1990s, about objectively measuring individual competence. Most tools for measuring cultural competence are self- reported and subjective in nature. A number of tools have been developed to assess individual and organizational cultural competence. Some have been validated and are specific to a discipline or area of practice, whereas others are more general in nature. To select one that more specif- ically meets your needs, go to the Internet search engine www.scholar.google.com and type “cultural competence measurement” or “cultural competence assessment tools” in the search field. The Office of Minority Health also has a document on Cultural Competence Standards (www.omhrc.gov). In general, cultural competence is a journey involving the willingness and ability of an indi- vidual to deliver culturally congruent and acceptable health and nursing care to the clients to whom one pro- vides care. To these authors, individual cultural compe- tence can be arbitrarily divided among cultural general approaches, the clinical encounter, and language.

11. Accepting responsibility for one’s own educa- tion in cultural competence by attending con- ferences, reading literature, and observing cul- tural practices.

12. Promoting respect for individuals by discourag- ing racial and ethnic slurs among coworkers.

13. Intervening with staff behavior that is insensi- tive, lacks cultural understanding, or reflects prejudice.

14. Having a cultural general framework for assess- ment as well as having cultural specific knowl- edge about the clients to whom care is provided.

THE CLINICAL ENCOUNTER

1. Adapting care to be congruent with the client’s culture.

2. Responding respectively to all clients and their families (includes addressing clients and family members as they prefer, formally or informally).

3. Collecting cultural data on assessments. 4. Forming generalizations as a method for formu-

lating questions rather than stereotyping. 5. Recognizing culturally based health-care beliefs

and practices. 6. Knowing the most common diseases and ill-

nesses affecting the unique population to whom care is provided.

7. Individualizing care plans to be consistent with the client’s cultural beliefs.

8. Having knowledge of the communication styles of clients to whom you provide care.

9. Accepting varied gender roles and childrearing practices from clients to whom you provide care.

10. Having a working knowledge of the religious and spirituality practices of clients to whom you provide care.

11. Having an understanding of the family dynam- ics of clients to whom you provide care.

12. Using faces and language pain scales in the eth- nicity and preferred languages of the clients.

13. Recognizing and accepting traditional, comple- mentary, and alternative practices of clients to whom you provide care.

14. Incorporating client’s cultural food choices and dietary practices into care plans.

15. Incorporating client’s health literacy into care plans and health education initiatives.

LANGUAGE

1. Developing skills and using interpreters (includes sign language) with clients and fami- lies who have limited English proficiency.

2. Providing clients with educational documents that are translated into their preferred language.

10 • CHAPTER 1

Whose values and beliefs should come first— yours, the organization’s, or the client’s?

CULTURAL GENERAL APPROACHES

1. Developing an awareness of one’s own exis- tence, sensations, thoughts, and environment without letting it have an undue influence on those from other backgrounds.

2. Continuing to learn cultures of clients to whom one provides care.

3. Demonstrating knowledge and understanding of the client’s culture, health-related needs, and meanings of health and illness.

4. Accepting and respecting cultural differences in a manner that facilitates the client’s and the family’s ability to make decisions to meet their needs and beliefs.

5. Recognizing that the health-care provider’s beliefs and values may not be the same as the client’s.

6. Resisting judgmental attitudes such as “differ- ent is not as good.”

7. Being open to new cultural encounters. 8. Recognizing that the primary and secondary

characteristics of culture determine the degree to which clients adhere to the beliefs, values, and practices of their dominant culture.

9. Having contact and experience with the com- munities from which clients come.

10. Being willing to work with clients of diverse cultures and subcultures.

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3. Providing discharge instructions at a level the client and the family understand and in the lan- guage the client and the family prefer.

4. Providing medication and treatment instruction in the language the client prefers.

5. Using pain scales in the preferred language of the client.

12. The organization is willing to support a men- toring program to entice recruitment into the health professions.

13. Data collected include race, ethnicity, culture, and language preferences of the staff and client base.

14. Patient rights documents are in the major lan- guages served by the community.

15. Cultural and Linguistic Appropriate Services (CLAS) Standards are adhered to.

16. Fiscal resources are available for interpretation. 17. The strategic plan reflects the needs of the com-

munity. 18. Input on research priorities is sought from con-

sumers. 19. Researchers are reflective of the staff, clients,

and community. 20. Human Resources recruitment and hiring activ-

ities reflect the diversity of the community. 21. The job analysis procedure includes scoring for

ethnocultural and language ability. 22. Position descriptions and evaluation practices

reflect cultural competence. 23. Conflict and grievance procedures reflect the

language of the staff. 24. The organization demonstrates active recruit-

ment of bilingual staff. 25. The staff is compensated for bilingual ability

and certification. 26. The ethics committee has members reflective of

the staff and clients. 27. Hours of operation of clinics are adjusted to

meet the needs of the community. 28. Pictures and posters are reflective of the client

base. 29. Food choices are reflective of the client and staff. 30. The holiday calendar represents the client pop-

ulation base. 31. Intake forms reflect cultural assessment. 32. Pain scales are in diverse languages of the pop-

ulation served. 33. Culturally appropriate toys are available

(Hispanic Santa, black dolls). 34. If staff is used or interpretation is available, a

plan is in effect to address their job duties while interpreting for patients and staff (also a Joint Commission on Accreditation of Healthcare Organizations [ JCAHO] requirement).

EDUCATION AND ORIENTATION

1. Diversity must be addressed as part of new em- ployees’ orientation, in-service, and continuing- education programs.

2. Nursing care delivery systems, the U.S. system of insurance reimbursement, and issues related to culture and autonomy are discussed.

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 11

Look at the list of activities that promote individ- ual cultural competence. Which of these activities have you used to increase your cultural compe- tence? Which ones can you easily add to increase your cultural competence? Which ones are the most difficult for you to incorporate?

Organizational Cultural Competence Individual cultural competence is not sufficient for cul- turally competent care. The organization in which the care is delivered must also demonstrate a commitment to cultural competence. Several things must be in place if an organization is to demonstrate cultural competence. A list of attributes of culturally competent organizations, orga- nized arbitrarily by governance and administration, edu- cation and orientation, and language follows:

GOVERNANCE AND ADMINISTRATION

1. The organization must have a mission state- ment and policies that address diversity.

2. The Board of Governance must include mem- bers of the ethnicity of the community it serves.

3. A committee for cultural competence exists and includes staff, managers, administrators, chap- lains, and members representative of the com- munity.

4. The organization engages in community diver- sity fairs.

5. The organization seeks resources from federal, state, and private agencies to continually upgrade and integrate cultural competence into care.

6. The organization partners with diverse commu- nity agencies.

7. The organization networks with diverse com- munity leaders.

8. Administrators, managers, and staff are encour- aged to be active in public policy for the client base to whom they deliver care.

9. Policy statements include efforts to eliminate the bias and prejudice of clients and staff.

10. Programs reflect the needs of the diversity of the community.

11. The organization’s programs are advertised in community newspapers and on the radio and television in the languages of the community.

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3. Mentoring programs exist for diverse student and staff populations.

4. Diversity of the health professions is included in orientation.

5. All employees must be offered cultural general topics and cultural specific needs of popula- tions for whom they provide care.

6. Cultural celebrations are reflective of the staff and clients.

7. Resources are available to staff on the unit and in the library.

8. The staff is trained in language interpretation. 9. Health classes are offered to clients the commu-

nity serves. 10. Certification in culture for staff is offered at var-

ious levels. 11. Pharmacists, nurses, and physicians are edu-

cated in ethnopharmacology. 12. A lunch and learn series that supports the ongo-

ing development of cultural competence can be started.

LANGUAGE

1. Mechanisms must be in place for translation of written materials in the preferred language of the client.

2. Policies must address interpretation services. 3. Resources are available for translation of educa-

tional materials and discharge instructions in the languages of the client population.

4. The organization engages in activities that address health literacy of the population it serves.

5. Written documents undergo a cultural sensitiv- ity review.

6. Consent and procedure forms are translated into the languages of the population served.

7. English-as-a-second language classes exist for staff.

8. Language classes are offered to clients and fam- ily (English and language of the population served).

9. Waiting areas have literature in the language of the population served.

10. Directions to referral facilities are in the lan- guages of the client base.

11. Videos are in the language of the client and have pictures of the client base.

12. Diverse language includes sign language. 13. Need for interpreters is determined ahead of

time. 14. Telephone system is in the languages of the

community. 15. Television programs are in the languages of the

community.

16. Satisfaction surveys are in the languages of the community.

17. Staff surveys are in the languages of the employees.

18. Audiovisual materials for staff and clients are in their preferred languages.

19. Wellness and health promotion classes are offered in the languages of the client base.

12 • CHAPTER 1

Look at the list of activities that promote organiza- tional cultural competence. Which of these activities have you used to increase the organization’s cultural competence? Which ones can you easily add to increase the organization’s cultural competence? Which ones are the most difficult to accomplish?

Evidence-Based Practice: Developing Individual and Organizational Culture Section written by Susan Salmond

The mandate for evidence-based practice (EBP) to reduce the “know-do” gap (Antes, Sauerland, & Seiter, 2006) between known science and implementation in practice is being driven by the demand for improved safety and quality outcomes for clients. Although a laudable goal, it will require a culture shift. The prevailing culture in health care is an “opinion-based culture” grounded in intuition, clinical experience/expertise, and pathophysio- logical rationale (DiCenso, Guyatt, & Ciliska, 2005). A culture of EBP calls for the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals or groups of patients. However, evidence alone does not constitute EBP but requires the integration of this evidence with clinical expertise, patient values and preferences, and the clinical context of care (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). The achievement of best patient out- comes is not assumed but is continuously evaluated though measurement of outcomes and patient safety (Coopey, Nix, & Clancy, 2006). This evidence is fed back into the system for consideration, and improvement changes at the individual, group, and system levels. Figure 1–1 portrays the components of EBP process, and Table 1–1 examines the components of EBP and the change/resources needed to facilitate its implementation.

BEST EVIDENCE

The best evidence is usually found in clinically relevant research that has been conducted using sound methodol- ogy (Sackett, 2000). With more than 1500 new articles per day and 55 new clinical trials per day, individual clini- cians cannot hope to locate and read even a small portion of the relevant research published each year to assure best practices (Cilaska, Pinelli, DiCenso, & Cullum, 2001). The

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EBP process presents a more focused way of searching for information. Rather than routinely reviewing the con- tents of journals for interesting articles, the EBP process targets issues related to specific patient problems and pro- vides clinicians with a set of skills for developing clinical questions related to these problems, searching current databases to keep current with the literature, and apprais- ing the validity of the research on the topic of interest. In this process, the abstract exercise of reading and critically appraising the literature is converted into a pragmatic process of using the literature to benefit individual patients while simultaneously expanding the clinician’s knowledge base (Bordley, 1997).

Within EBP, not all evidence is the same. The EBP clin- ician must know the nature and strength of the evidence found and, therefore, the accompanying degree of cer- tainty/uncertainty with which to make decisions about whether the evidence should be applied to practice (Bhandari, 2003). Because much of research has been focused on the evaluation of “intervention effectiveness,” in the evidence pyramid, the gold standard has been the randomized controlled trial followed by cohort studies, case-controlled studies, case series, and qualitative studies (Fig. 1–2). Yet, much of nursing practice and the majority

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 13

Outcomes

Measurement

Outcomes

Measurement Best Patient Outcomes

“Best” Research Evidence

Clinical Expertise

Patient Values

Clinical Context

O utcom

es

M easurem

ent

O utcom

es

M easurem

ent

FIGURE 1–1 Components of evidence-based practice.

T A B L E 1.1 The Evidence-Based Practice Process

Components Resources/Change Needed

Identify best evidence Clinical inquiry: What knowledge is needed? Informed skepticism: Why are we doing it this

way? Is there a better way to do it? What is the evidence for what we do? Would doing this be as effective as doing that? (Salmond, 2007)

Convert information needs from practice into focused, searchable questions (patient- intervention-comparison-outcome [PICO] framework).

Search databases for highest level of evidence in a timely manner

• Shift from “know how” and doing to “know why” • Reflect on what information is needed to provide

“best” care • Generate questions about practice and care • Role model clinical inquiry at report, rounds, con-

ferences • Use interdisciplinary case reviews to evaluate

actual care • Include clinical librarians as members of teams

participating in clinical rounds and conferences • Differentiate between background and foreground

questions • Consider recurring clinical issues, need for infor-

mation, negative incidents/events as sources for questions or information needs

• Identify clinical issues sensitive to nursing inter- ventions

• Narrow broad clinical issues/questions into search- able, focused questions

• Use the mnemonic PICO to frame questions • Use evidence-searching skills to target relevant

focused evidence • Access evidence databases ideally at the point of

care. • Understand evidence pyramids • Databases available include pre-appraised litera-

ture sources for point-of-care answers regarding intervention

• Search strategies: key terms, multiple databases, point-of-care data

• Use assistance of clinical librarian

(Continued on following page)

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14 • CHAPTER 1

T A B L E 1.1 The Evidence-Based Practice Process (Continued)

Components Resources/Change Needed

Use critical appraisal process to determine strength and validity of evidence and relevance to one’s practice

Clinical experience Use clinical expertise to determine how to use and expertise evidence in care of patient and how to

manage patient in absence of evidence or presence of conflicting evidence

Patient values and Demonstrate ability to perform a culture preferences assessment and identify client preferences

and values that inform the clinical decision.

Translation evidence Use all four components in clinical decision- • Provide plan of care based on evidence, clinical from total process making process and implementation of judgment, patient preferences, and organizational into clinical decisions clinical decision context and strategies for best patient outcomes

Monitor patient Use outcome tools to track client outcomes • Develop audit systems to track client outcomes outcomes • Make clinical outcomes accessible electronically for

analysis • Analyze outcomes and effectiveness of “evidence-

based” clinical intervention

• Clinical Practice Guidelines available at www.clearinghouse.gov

• Preappraised sources such as Critically Appraised Topics (CATs)

• Demonstrate knowledge of research design • Demonstrate knowledge of statistics • Use critical appraisal tools to guide process of

research critique • Utilize journal clubs • Summarize findings from evaluation, resolving

conflicting evidence • Consider evidence in relation to own patient pop-

ulation • Consider cost-benefit ratio • Consider multidimensionality of patient and clini-

cal situation in relation to evidence that is often reductionistic

• Understand culture-general and culture-specific knowledge to guide interactions with client

• Use interview skills to avoid culture imposition and seek client’s true preferences

• Communicate evidence and treatment options considering patient values and preferences

• Involve client and family in both information giv- ing and decision making

of transcultural nursing knowledge are informed by research approaches that describe and explain an experi- ence or phenomenon. Consequently, the hierarchy of evi- dence focusing on description of experience is quite dif- ferent. Here, the lowest tier includes quantitative studies, and the highest tier includes qualitative studies and meta- syntheses of qualitative work (Fig. 1–3). Whether working from a quantitative or qualitative perspective, searching should begin from the top of the pyramid, where evi- dence is presented as systematic reviews or evidence- based guidelines. Systematic reviews are a rigorous research methodology that summarizes the research on a prescribed clinical question. This level of evidence is gen- erally most relevant to the clinical setting but may not be available. If evidence is not found at this level, one should continue searching at each subsequent level, being aware that there may be no good evidence to support clinical judgment (Rychetnik, Frommer, Hawe, & Shiell, 2002).

Guidelines

Systematic Reviews

Randomized Controlled Trials

Cohort Studies

Case-Controlled Studies, Case Series

Qualitative Studies, Program Evaluation, Opinion Surveys

FIGURE 1–2 Pyramid of evidence.

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Through consideration of this evidence or lack of evi- dence, clinicians and their affiliated health-care organiza- tions have increased their awareness of evidence gaps and provided insight into the need for more research into unanswered questions. Ongoing nursing-driven and nursing-conducted research must become part of the evi- dence-based environment and not an occasional educa- tional program or “window dressing” for the organization (Pravikoff, 2006).

CLINICAL EXPERTISE AND JUDGMENT

The value of expert clinical judgment can never be mini- mized in the clinical setting. Although drawing from best evidence is the goal, often there is insufficient evidence for the findings to be put into practice. Clinicians use their expertise to thoroughly assess the patient and differ- entiate nuances that influence treatment perspectives. With this expertise, the usefulness of the evidence in helping to care for a particular patient or patient popula- tion must be considered, and decisions about how to use that treatment must be made.

PATIENT VALUES

Combining the evidence with clinical expertise is neces- sary but not sufficient for driving quality care (Ivers, 2004; Rychetnik et al., 2002; Swales, 1998). Between the science (best evidence) and the final clinical decision, a judgment has to be made based on the values of the patient or group who will be exposed to the intervention (Swales, 1998). Cross-cultural comparisons provide abun- dant evidence for relativism of value systems. How the individual defines health and perceives the importance of health states such as mobility, freedom from pain, pro- longed life expectancy, and preservation of faculties may all be valued differently, and these values influence both clinician recommendations and patient decisions (Swales, 1998). Failure to consider these patient preferences and values leads to “unintentional biasing” toward a profes- sionals’ view of the world (Kitson, 2002). If EBP is to be value-added, it is critical to assure that the users of the

knowledge, the clients, become “active shapers” of knowledge and action (Clough, 2005). Clinicians must be prepared to make “real-time” adjustments to their approach to care based on client feedback.

To date, much of the focus on EBP has been on scien- tism and determination of best evidence. Unfortunately, little science examines intervention efficacy or desirabil- ity by cultural group. The study of culture and the indi- vidual nature of values is by its very nature holistic and adverse to a reductionistic approach that can be expressed as a population average. Clinicians armed with culture- general knowledge are more open to multiple ways of being. Understanding of culture-specific knowledge can guide clinicians in their assessment approach, leading to a patient-focused discussion of preferred approaches to treatment and care. This critical component of EBP needs to be more fully developed. How is it operationalized in practice? What are the best strategies for integrating patient values? Is there a preferred intervention by cul- tural group? This information is needed to facilitate best patient outcomes. The goal is not to achieve a single pre- scriptive system of care but to respect the individual nonuniform values that determine specific patient needs (Swales, 1998).

CLINICAL CONTEXT

The clinical context encompasses the setting in which practice takes place or the environment in which the pro- posed change is to be implemented (McCormack, Kitson, Harvey, Rycroft-Malone, Titchen, & Seers, 2002). Drennan (1992) argues that culture, or “the way things are done around here” at the individual, team, and organizational levels, creates the context for practice and change. Organizational culture is a paradigm—a way of thinking about the organization, comprising a linkage of basic assumptions, values, and artifacts (Schein, 1992).

Implementation of EBP is not so much about getting trained in the right protocol, although that will be neces- sary, as it is about changing the culture of the organiza- tion or practice to one that is measurement- and outcomes-orientated across all disciplines, not in isolated silos (Morrison, 2004). Implementation of evidence (trans- lation of evidence into practice) is explained as a dynamic, simultaneous relationship between evidence (best research evidence, clinical experience, and patient preferences) and context (organizational capacity, infrastructure, and culture).

The abundance of new evidence that has not been suc- cessfully translated into practice is a critical reminder of the importance of context and the strength of the exist- ing culture. Descriptive and qualitative data must be gath- ered to make an assessment of the likelihood of transfer- ability; organization-specific strategies need to be used to facilitate this process. Best evidence specific to knowledge transfer and practice change needs to be incorporated in the change plan. Measuring clinician, unit, or organiza- tional outcomes and benchmarking these outcomes pro- vide the feedback necessary to effect change. Difficult questions will need to be grappled with. What should be done with clinicians who cannot or will not adapt to EBP? How will lack of interdisciplinary collaboration be

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 15

Systematic Review of

Descriptive and Qualitative Studies

Evidence From a Single Descriptive or Qualitative Study

Expert Opinion, Expert Committees

Evidence based on Quantitative Approaches

FIGURE 1–3 Pyramid of evidence: Description of experience.

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approached? How will it be handled if long-standing treatment approaches show no evidence of fostering improvement? What is the individual’s responsibility, as compared with the organization’s responsibility, in assur- ing readiness for EBP? How the organization handles these critical questions influences the outcomes of the change process.

FACILITATING THE SHIFT TOWARD EVIDENCE-BASED PRACTICE

Achieving this culture shift requires a commitment and a long-term investment in providing the leadership sup- port, skill development, and infrastructure necessary to advance and sustain this shift.

Leadership Commitment

The transition must begin with a commitment from upper administration at both the nursing and the hospi- tal administration levels to assure that all clinicians develop information literacy or the “ability to recognize that information is needed, find it, evaluate it, and use it in practice” (American Library Association, 2006). This commitment must include an investment of resources as well as a commitment to build EBP into organizational processes, to consistently communicate a vision for EBP, and to role-model and demonstrate ongoing commit- ment to EBP. A particularly difficult leadership challenge will be to move away from hierarchical, paternalistic processes and facilitate interdisciplinary involvement and commitment in EBP and to deal with the critical ques- tions that emerge when EBP goals are not being met (Cilaska et al., 2001; Stetler, 2003). Clinical management structures must be developed to support effective inter- disciplinary clinical decision-making activities (Mallach & Porter-O’Grady, 2006). Mink, Esterhuysen, Mink, and Owen’s model (1993) of transformational change is an appropriate implementation model for leaders to remove barriers to EBP and begin the journey to developing an interdisciplinary culture of EBP. The model calls for for- mation of interdisciplinary teams consisting of a central, transformational team that performs an environmental assessment, sets goals, and guides the practice change as well as unit-based interdisciplinary action teams who develop clinical practice protocols and practices and implement the change at the point of care. Resources include dedicated time for the teams to work and educa- tional support so that the teams can serve as support sys- tems within the organization for implementation of EBP and clinical research.

Developing the Needed Skill Set

Developing the needed skill set begins with a commit- ment on the part of every individual practitioner to mak- ing EBP the framework for clinical decision-making (Mallach & Porter-O’Grady, 2006). In addition to individ- ual responsibilities for developing needed knowledge and skills, an EBP organization has ongoing, leveled, onsite educational programs about information literacy, the EBP process, and research. Initial programs should attempt to

create a sense of urgency by helping clinicians see how science has changed practice, recognize the lag in trans- ferring this knowledge, and understand how outcomes vary based on the differential use of new science. Clinicians need to be helped with the new vocabulary of EBP. This should be done in a format that can be quickly retrieved and understood. Educational content must tar- get information literacy skills—how to access, interpret, synthesize, and apply most current evidence at the point of care. Table 1–1 summarizes educational targets that must be reached. Multiple approaches to learning, such as face-to-face programs, on-line references and modules, and small group learning, should all be used to reach the multiple audiences and multiple levels of learning.

Systematic reviews of traditional forms of continuing education, such as browsing journals, attending confer- ences, and listening to didactic lectures, have little impact on changing practice (Thomson O’Brien, Freemantle, & Oxman, 2001). Active learning strategies are needed to develop the capacity to engage in EBP. Journal clubs, poster presentations, EBP internships, clinical coaching/mentoring by expert clinical leaders or clinical nurse specialists, evidence-based scholar groups, and evidence-based rounds are all examples of active learning approaches that facili- tate development of a culture of inquiry or inquisitiveness, openness, and encouragement of learning new skills (Pravikoff, 2006; Turkel, Reidinger, Ferket, & Reno, 2005).

The expectation for EBP should be articulated at orien- tation as a universal expectation with differing skill sets evident at differing rungs of the clinical ladder. At the low- est rung, everyone should manifest clinical inquiry or informed skepticism and the ability to ask questions about care and know when information is needed. Incorporating more advanced skills can be integrated into the differing levels of a clinical ladder. These advanced skills include translating clinical questions into patient-intervention- comparison-outcome (PICO) format, searching presynthe- sized literature, critiquing research for reliability and valid- ity, comparing research findings with actual clinical populations and settings, planning for evidence transla- tion, implementing new EBP interventions, measuring the results of evidence implementation, and planning pri- mary research studies needed to fill in evidence gaps. Integrating EBP into career ladder expectations, different levels of clinicians can be advancing the EBP process for the organization.

Access to Information

In order for nurses to be able to use evidence in their busy clinical routines, there must be a systematic organiza- tional infrastructure to support EBP as a way of delivering care (Mallach & Porter-O’Grady, 2006). This includes access to a digital information framework that provides ready access to real-time information at the point of care delivery that is neither time nor place dependent. The technological/informational infrastructure needed to support EBP includes user-friendly, credible summaries of up-to-date evidence; the informatics structure to integrate EBP data (internal and external) into quality processes (electronic medical records and other clinical databases); access to clinical librarians or others who are expert in

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information literacy and who can coach staff; electronic library sources to guide the EBP process; and computer experts and technological support (Antes et al., 2006; Mallach & Porter-O’Grady, 2006). This technology must be at the point of care—either on a unit/service area or via hand-held technology to facilitate EBP as a clinical deci- sion process.

The interface among the information infrastructure, performance measurement, and quality patient care out- comes is critical. This requires integration between clinical practice and data management and is ideally tracked through clinical information management systems and/or clinical audits. This component of EBP, in which best prac- tices are implemented and outcomes are tracked, com- pletes the feedback loop needed to modify and adapt evi- dence in the practice setting. The internal findings can be used for ongoing competency development and perfor- mance approval as well as integrated with external evi- dence and analyzed for needed best practice changes.

SUMMARY

The move to a culture of EBP requires a shift from a cul- ture of doing to a culture of clinical reflection, in which care is evaluated based on the need for evidence and patient preferences. This culture change process must be actively managed so that all members of the health-care team are aware of the expectations regarding EBP, receive appropriate educational and mentor support for informa- tion literacy, and are held accountable through audit and performance appraisal for using EBP as a clinical decision model.

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19

The Purnell Model for Cultural Competence

Chapter 2

LARRY D. PURNELL

This chapter presents the Purnell Model for Cultural Competence, its organizing framework, and the assump- tions upon which the model is based. In addition, American cultural values, practices, and beliefs are presented to assist non–native American health-care providers to understand American ways. The American references are meant to describe, not prescribe or predict, behaviors and practices. Although the authors recognize that Canada and Mexico are part of North America, American, as used in this chapter, refers to the dominant middle-class values of citizens of the mainland United States. Owing to space limitations, this chapter deals not with the objective culture—arts, literature, humanities, and so on—but rather with the subjective cul- ture. Many Americans are not aware of the subjective culture because they identify differences as individual personality traits and disregard political and social origins of culture. Many view culture as something that belongs only to for- eigners or disadvantaged groups. However, when Americans travel abroad, their host country inhabitants many times stereotypically identify them as Americans because of their values, beliefs, attitudes, behaviors, speech patterns, and mannerisms. Some feel that Americans are “fun lovers” and that, for some Americans, violence is a way of life. However, “the right to bear arms” is guaranteed by the Constitution. Most likely, the United States is not any more violent than, or even as violent as, many other societies, but American media coverage may be better than other countries, thereby giving the impression that the United States is more violent than it actually is. Accordingly, these stereotypes are not always accurate or desirable.

Western academic and health-care organizations stress structure, systematization, and formalization when

studying complex phenomena such as culture and eth- nicity. Given the complexity of individuals, the Purnell Model for Cultural Competence provides a comprehen- sive, systematic, and concise framework for learning and understanding culture. The empirical framework of the model can assist health-care providers, managers, and administrators in all health disciplines to provide holis- tic, culturally competent therapeutic interventions; health promotion and wellness; illness, disease, and injury prevention; health maintenance and restoration; and health teaching across educational and practice settings.

The purposes of this model are to

1. Provide a framework for all health-care providers to learn concepts and characteristics of culture.

2. Define circumstances that affect a person’s cul- tural worldview in the context of historical per- spectives.

3. Provide a model that links the most central rela- tionships of culture.

4. Interrelate characteristics of culture to promote congruence and to facilitate the delivery of con- sciously sensitive and competent health care.

5. Provide a framework that reflects human charac- teristics such as motivation, intentionality, and meaning.

6. Provide a structure for analyzing cultural data. 7. View the individual, family, or group within

their unique ethnocultural environment.

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Assumptions Upon Which the Model Is Based The major explicit assumptions upon which the model is based are

1. All health-care professions need similar infor- mation about cultural diversity.

2. All health-care professions share the metapara- digm concepts of global society, family, person, and health.

3. One culture is not better than another culture; they are just different.

4. Core similarities are shared by all cultures. 5. Differences exist within, between, and among

cultures. 6. Cultures change slowly over time. 7. The primary and secondary characteristics of

culture (see Chapter 1) determine the degree to which one varies from the dominant culture.

8. If clients are coparticipants in their care and have a choice in health-related goals, plans, and interventions, their compliance and health outcomes will be improved.

9. Culture has a powerful influence on one’s inter- pretation of and responses to health care.

10. Individuals and families belong to several sub- cultures.

11. Each individual has the right to be respected for his or her uniqueness and cultural heritage.

12. Caregivers need both culture-general and culture-specific information in order to provide culturally sensitive and culturally competent care.

13. Caregivers who can assess, plan, intervene, and evaluate in a culturally competent manner will improve the care of clients for whom they care.

14. Learning culture is an ongoing process that develops in a variety of ways, but primarily through cultural encounters (Campinha- Bacote, 2006).

15. Prejudices and biases can be minimized with cultural understanding.

16. To be effective, health care must reflect the unique understanding of the values, beliefs, attitudes, lifeways, and worldview of diverse populations and individual acculturation patterns.

17. Differences in race and culture often require adaptations to standard interventions.

18. Cultural awareness improves the caregiver’s self-awareness.

19. Professions, organizations, and associations have their own culture, which can be analyzed using a grand theory of culture.

20. Every client encounter is a cultural encounter.

Overview of the Theory, the Model, and Organizing Framework The Purnell model has been classified as holographic and complexity theory because it includes a model and orga- nizing framework that can be used by all health-care providers in various disciplines and settings. The model is a circle, with an outlying rim representing global society, a second rim representing community, a third rim repre- senting family, and an inner rim representing the person (Fig. 2–1). The interior of the circle is divided into 12 pie- shaped wedges depicting cultural domains and their con- cepts. The dark center of the circle represents unknown phenomena. Along the bottom of the model, a jagged line represents the nonlinear concept of cultural con- sciousness. The 12 cultural domains (constructs) provide the organizing framework of the model. A box following the discussion of each domain provides statements that can be adapted as a guide for assessing patients and clients in various settings. Accordingly, health-care providers can use these same questions to better under- stand their own cultural beliefs, attitudes, values, prac- tices, and behaviors.

MACRO ASPECTS OF THE MODEL

The macro aspects of this interactional model include the metaparadigm concepts of a global society, community, family, person, and conscious competence. The theory and model are conceptualized from biology, anthropol- ogy, sociology, economics, geography, history, ecology, physiology, psychology, political science, pharmacology, and nutrition as well as theories from communication, family development, and social support. The model can be used in clinical practice, education, research, and the administration and management of health-care services or to analyze organizational culture.

Phenomena related to a global society include world communication and politics; conflicts and warfare; nat- ural disasters and famines; international exchanges in education, business, commerce, and information tech- nology; advances in health science; space exploration; and the expanded opportunities for people to travel around the world and interact with diverse societies. Global events that are widely disseminated by television, radio, satellite transmission, newsprint, and information technology affect all societies, either directly or indirectly. Such events create chaos while consciously and uncon- sciously forcing people to alter their lifeways and worldviews.

20 • CHAPTER 2

Think of a recent event that has affected global society, such as conflict or war, health advances in technology, or recent travel and possible environ- mental exposure to health problems. How did you become aware of this event? How has this event altered your views and other people’s views of worldwide cultures?

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THE PURNELL MODEL FOR CULTURAL COMPETENCE • 21

Community

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The Purnell Model for Cultural Competence

FIGURE 2–1 Purnell’s Model for Cultural Competence. (Adapted with permission from Larry Purnell, Newark, DE.)

In the broadest definition, community is a group of people having a common interest or identity and goes beyond the physical environment. Community includes the physical, social, and symbolic characteristics that cause people to connect. Bodies of water, mountains, rural versus urban living, and even railroad tracks help people define their physical concept of community.

Today, however, technology and the Internet allow peo- ple to expand their community beyond physical bound- aries. Economics, religion, politics, age, generation, and marital status delineate the social concepts of commu- nity. Symbolic characteristics of a community include sharing a specific language or dialect, lifestyle, history, dress, art, or musical interest. People actively and passively

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interact with the community, necessitating adaptation and assimilation for equilibrium and homeostasis in their worldview. Individuals may willingly change their physi- cal, social, and symbolic community when it no longer meets their needs.

22 • CHAPTER 2

personal health status or the health status of the nation or community. Health can also be subjective or objective in nature.

How do you define your community in terms of objective and subjective cultural characteristics? How has your community changed over the last 5 to 10 years? The last 15 years? The last 20 years? If you have changed communities, think of the com- munity in which you were raised.

Whom do you consider family? How have they influenced your culture and worldview? Who else has helped instill your cultural values?

A family is two or more people who are emotionally connected. They may, but do not necessarily, live in close proximity to each other. Family may include physically and emotionally close and distant consanguineous rela- tives as well as physically and emotionally connected and distant non–blood-related significant others. Family structure and roles change according to age, generation, marital status, relocation or immigration, and socioeco- nomic status, requiring each person to rethink individual beliefs and lifeways.

A person is a biopsychosociocultural being who is constantly adapting to her or his community. Human beings adapt biologically and physiologically with the aging process; psychologically in the context of social relationships, stress, and relaxation; socially as they interact with the changing community; and ethnocultur- ally within the broader global society. In Western cul- tures, a person is a separate physical and unique psycho- logical being and a singular member of society. The self is separate from others. However, in Asian and some other cultures, the individual is defined in relation to the fam- ily or other group rather than a basic unit of nature.

In what ways have you adapted (1) biologically and physiologically to the aging process, (2) psy- chologically in the context of social relationships, (3) socially in your community, and (4) ethnocul- turally within the broader society?

Health, as used in this book, is a state of wellness as defined by the individual within his or her ethnocultural group. Health generally includes physical, mental, and spiritual states because group members interact with the family, community, and global society. The concept of health, which permeates all metaparadigm concepts of culture, is defined globally, nationally, regionally, locally, and individually. Thus, people can speak about their

How do you define health? Is health the absence of illness, disease, injury, and/or disability? How does your profession define health? How does your nation or community define health? How do these definitions compare with your original ethnic background?

MICRO ASPECTS OF THE MODEL

On a micro level, the model’s organizing framework com- prises 12 domains and their concepts, which are common to all cultures. These 12 domains are interconnected and have implications for health. The utility of this organiz- ing framework comes from its concise structure, which can be used in any setting and applied to a broad range of empirical experiences and can foster inductive and deductive reasoning in the assessment of cultural domains. Once cultural data are analyzed, the practi- tioner can fully adopt, modify, or reject health-care inter- ventions and treatment regimens in a manner that respects the client’s cultural differences. Such adaptations improve the quality of the client’s health-care experiences and personal existence.

The Twelve Domains of Culture The 12 domains essential for assessing the ethnocultural attributes of an individual, family, or group are

1. Overview, inhabited localities, and topography. 2. Communication. 3. Family roles and organization. 4. Workforce issues. 5. Biocultural ecology. 6. High-risk behaviors. 7. Nutrition. 8. Pregnancy and childbearing practices. 9. Death rituals. 10. Spirituality. 11. Health-care practices. 12. Health-care practitioners.

OVERVIEW, INHABITED LOCALITIES, AND TOPOGRAPHY

This domain, overview, inhabited localities, and topography, includes concepts related to the country of origin, the current residence, the effects of the topography of the country of origin and current residence on health, eco- nomics, politics, reasons for migration, educational sta- tus, and occupations. These concepts are interrelated. For example, economic and political conditions may affect one’s reason for migration, and educational attainment is

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usually interrelated with employment choices and oppor- tunities. Sociopolitical and socioeconomic conditions influence individual behavioral responses to health and illness.

Learning about a culture includes becoming familiar with the heritage of its people and understanding how discrimination, prejudice, and oppression influence value systems and beliefs used in everyday life. Given the pri- mary and secondary characteristics of diversity (see Chapter 1), cultural specific generalizations may not be part of a particular individual’s beliefs or value system.

For most Americans, dominant cultural values and beliefs include individualism, free speech, rights of choice, independence and self-reliance, confidence, “doing” rather than “being,” egalitarian relationships, nonhierar- chal status of individuals, achievement status over ascribed status, “volunteerism,” friendliness, openness, futuristic temporality, ability to control the environment, and an emphasis on material things and physical comfort. These concepts are more fully described in other sections of this chapter.

Given the size, population density, and diversity of the United States, one cannot generalize too much about American culture. Every generalization in this chapter is subject to exceptions, although most people will agree with the descriptions to some degree and on some level. Moreover, we believe the descriptions about the domi- nant American culture are true for white middle-class European Americans (and many other groups as well) who hold the majority of prestigious positions in the United States. The degree to which people conform to this dominant culture depends on the primary and sec- ondary characteristics of culture discussed in Chapter 1 as well as individual personality differences. We recognize that some Americans do not think there is an American culture and resent any attempt at generalizations. Many foreigners believe that all Americans are rich, everyone lives in fancy apartments or houses, crime is everywhere, everyone drives an expensive gasoline-inefficient car, and there is little or no poverty. For the most part, these mis- conceptions come from the media and Americans who travel overseas.

Heritage and Residence

The United States comprises 3.5 million square miles and a population of nearly 300 million people, making it the world’s third most populous country (CIA Factbook, 2006). The United States is mostly temperate but tropical in Hawaii and Florida, arctic in Alaska, semiarid in the great plains west of the Mississippi River, and arid in the Great Basin of the southwest. Low winter temperatures in the northwest are ameliorated in January and February by warm Chinook winds from the eastern slopes of the Rocky Mounatins. There is a vast central plain; moun- tains in the west; hills and low mountains in the east; rugged mountains and broad river valleys in Alaska; and rugged, volcanic topography in Hawaii.

When Europeans began settling the United States in the 16th century, approximately 2 million American Indians, who mostly lived in geographically isolated tribes, populated the land. The first permanent European

settlement in the United States was St. Augustine, Florida, which was settled by the Spanish in 1565. The first English settlement was Jamestown, Virginia, in 1607. By 1610, the nonnative population in the United States was only 350 people. By 1700, the population increased to 250,900; by 1800, to 5.3 million; and by 1900, to 75.9 million (Time Almanac, 2001). From 1607 until 1890, most immigrants to the United States came from Europe and essentially shared a common European culture. The plantation economy of the South paid for the forced relo- cation of natives from (primarily Western) Africa begin- ning in 1619 and ending with the American Civil War (1861–1865). This group did not share the common cul- ture, and their acculturation was strongly influenced by their status as slaves.

In the 1830s, a war with Mexico resulted in the annex- ation of greater Texas. From 1860 until 1865, the North and South fought over the issue of slavery, which resulted not only in the elimination of slavery but also in the industrialization of the North and the establishment of the United States as a major military power. The Spanish- American War (1898) resulted in the United States becom- ing a colonial power, with the annexation of Spain’s last colony in the Western Hemisphere, Cuba, and also its colony in the Philippines. World War I (1914–1918) estab- lished the United States as one of the world’s superpow- ers, and World War II (1939–1945) significantly extended U.S. military power. In the postwar period, the ideological differences between the United States and the USSR resulted in the Cold War, which lasted until 1989. Today, U.S. military, cultural, and economic power affect almost every other country on the planet.

The American colonies broke with the parent country, Britain, on July 4, 1776, and were recognized as the new nation of The United States of America with the original 13 colonies following the Treaty of Paris in 1783. During the 19th and 20th centuries, 37 new states were added to the original 13 as the nation expanded across the North American continent and acquired a number of overseas possessions.

The Constitution of the Untied States was ratified in 1789 and included seven articles, which laid the founda- tion for an independent nation. The Bill of Rights, the first 10 amendments to the Constitution, guarantees free- dom of religion, speech, and the press; the right to peti- tion, bear arms; and the right to a speedy trial. Only 17 additional amendments have been made to the Constitution. The 13th Amendment in 1865 prohibited slavery; the 14th Amendment in 1868 defined citizenship and privileges of citizens; the 15th Amendment in 1870 gave suffrage rights regardless of race or color; and the 19th Amendment in 1920 gave women the right to vote.

The United States is the world’s oldest constitutional democracy with three branches of government: (1) the executive branch, which includes the Office of the President and the administrative departments; (2) the leg- islative branch, Congress, which includes both the Senate and the House of Representatives; and (3) the judicial branch, which includes the Supreme Court and the lesser federal courts. The Supreme Court has nine members appointed by the President and approved by Congress. The Justices serve a life term if they so choose. The

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President serves a 4-year term and can be reelected only one time. The President is the Commander-in-Chief of the Armed Forces and oversees the executive depart- ments. The members of the House of Representatives are divided among the states based on the population of each state. Members of the House of Representatives serve 2- year terms. Each state has two senators, regardless of the population of the state. Senators serve 6-year terms. Each of the 50 states has its own constitution establishing, for the most part, a parallel structure to the federal govern- ment, with the executive branch headed by a governor, a state congress with representatives and senators, and a state court system.

No limitations were placed on immigrants from Europe until the late 1800s. From 1892 to 1952, most European immigrants to America came through Ellis Island, New York, where they had to prove to officials that they were financially independent. More severe restrictions were placed on other immigrant groups, particularly those from Asia. In the 1960s, immigration policy changed to allow immigrants from all parts of the world without favoritism to or restrictions on ethnicity. Today, the United States includes immigrants or descendents from immigrants from almost every nation and culture of the world and is the world’s premier international nation. The United States admitted 52,868 refugees during fiscal year 2003–2004, including 13,331 from Somalia, 6000 from Laos, 3482 from Ukraine, 2959 from Cuba, and 1787 from Iran. As of June 2005, 32,229 refugees had been admitted (CIA Factbook, 2006).

The United States has the largest and most technologi- cally powerful economy in the world, with a per capita gross domestic product (GDP) of $42,000. In this market- oriented economy, private individuals and business firms make most of the decisions, and the federal and state gov- ernments buy needed goods and services predominantly in the private marketplace. U.S. business firms enjoy greater flexibility than their counterparts in Western Europe and Japan in decisions to expand capital plant, to lay off surplus workers, and to develop new products. At the same time, they face higher barriers to enter their rivals’ home markets than foreign firms face entering U.S. markets. U.S. firms are at or near the forefront in techno- logical advances, especially in computers and in medical, aerospace, and military equipment; their advantage has narrowed since the end of World War II.

The on-rush of technology largely explains the gradual development of a “two-tier labor market,” in which those at the bottom lack the education and the professional/ technical skills of those at the top and, more and more, fail to get comparable pay raises, health insurance cover- age, and other benefits. Since 1975, practically all the gains in household income have gone to the top 20 per- cent of households.

The response to the terrorist attacks of September 11, 2001, showed the remarkable resilience of the economy. The war in March–April 2003 between a U.S.-led coalition and Iraq, and the subsequent occupation of Iraq, required major shifts in national resources to the military. The rise in GDP in 2004 and 2005 was supported by substantial gains in labor productivity. Hurricane Katrina caused extensive damage in the Gulf Coast region in August 2005

but had a small impact on overall GDP growth for the year. Soaring oil prices in 2005 and 2006 threatened infla- tion and unemployment, yet the economy continued to grow through mid 2006. Imported oil accounts for about two-thirds of U.S. consumption. Long-term problems include inadequate investment in economic infrastruc- ture, rapidly rising medical and pension costs of an aging population, sizable trade and budget deficits, and stagna- tion of family income in the lower economic groups (CIA Factbook, 2006).

People have been attracted to immigrate to the United States because of its vast resources and economic and per- sonal freedoms, particularly the dogma that “all men are created equal.” Immigrants and their descendants achieved enormous material success, which further encouraged immigration.

Reasons for Migration and Associated Economic Factors

The United States has a very large middle-class popula- tion and a small, but growing, wealthy population. Approximately 12.7 percent of the population lives in poverty, with higher rates among children (17.8 percent), older persons (20.5 percent), blacks (24.7 percent), and nonwhite Hispanics (21.9 percent) (U.S. Bureau of the Census: Poverty Rates, 2006c). The social, economic, reli- gious, and political forces of the country of origin play an important role in the development of the ideologies and the worldview of individuals, families, and groups and are often a major motivating force for emigration.

The earlier settlers in the United States came for better economic opportunities, because of religious and political oppression and environmental disasters such as earth- quakes and hurricanes in their home countries, and by forced relocation such as slaves and indentured servants. Others have immigrated for educational opportunities and personal ideologies or a combination of factors. Most people immigrate in the hope of a better life; however, the individual or group personally defines this ideology.

A common practice for many immigrants is to relocate to an area that has an established population with similar ideologies that can provide initial support, serve as cul- tural brokers, and orient them to their new culture and health-care system. For example, most people of Cuban heritage live in New York and Florida; French Canadians are concentrated in the Northeast; and the Amish are concentrated in Pennsylvania, Indiana, and Ohio. When immigrants settle and work exclusively in predominantly ethnic communities, primary social support is enhanced, but acculturation and assimilation into the wider society may be hindered. Groups without ethnic enclaves in the United States to assist them with acculturation may need extra help in adjusting to their new homeland’s language, access to health-care services, living accommodations, and employment opportunities. People who move volun- tarily are likely to experience less difficulty with accultur- ation than people who are forced to emigrate. Some indi- viduals immigrate with the intention of remaining in this country only a short time, making money, and returning home, whereas others immigrate with the intention of relocating permanently.

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Educational Status and Occupations

The value placed on formal education differs among cul- tural and ethnic groups and is often related to their socioe- conomic status in their homeland and their abilities and reasons for emigrating. The United States places a high value on education, which has recently become a major issue in federal and state elections. Some groups, however, do not stress formal education because it is not needed for employment in their homeland. Consequently, they may become engulfed in poverty, isolation, and enclave iden- tity, which may further limit their potential for formal educational opportunities and planning for the future.

In the United States, preparation in elementary and secondary education varies widely. There is no national curriculum that each school is expected to follow, although there is standardized testing at a national level, which is used in the selection process for admission to institutions of higher education. Most states require chil- dren to attend school until the age of 16, although the child can drop out of school at a younger age with parents’ signed permission. Overall, the United States has the goal of producing a well-rounded individual with a variety of courses and 100 percent literacy. Theoretically, people have the freedom to choose a profession, regardless of gen- der and background. Educational attainment in the United States varies by race, gender, and region of the country. Eighty-seven percent of all adults age 25 years and older have completed high school, and 27 percent have completed a bachelor’s degree or higher. Of Asians, 87.6 percent have completed high school and 49.8 percent have a bachelor’s degree or higher. Of blacks, only 80 per- cent have completed high school and 17.3 percent have a bachelor’s degree or higher. Of Hispanics, only 57 percent have completed high school and only 1.4 percent have a bachelor’s degree or higher (U.S. Bureau of the Census, 2006b). In regard to learning styles, the Western system places a high value on the student’s ability to categorize information using linear, sequential thought processes. However, not everyone adheres to this pattern of think- ing. For example, many Native Americans, Asians, and others have spiral and circular thought patterns that move from concept to concept without being linear or sequen- tial; therefore, they may have difficulty placing informa- tion in a stepwise methodology. When someone is unaware of the value given to such behaviors, she or he may see such individuals as disorganized, scattered, and faulty in their cognitive patterns, resulting in increased difficulty with written and verbal communications.

The American educational system stresses application of content over theory. Most European educational pro- grams emphasize theory over practical application, and Arab education emphasizes theory with little attention

given to practical application. As a result, Arab students are more proficient at tests requiring rote learning than at those requiring conceptualization and analysis. Being familiar with the individual’s personal educational values and learning modes allows health-care providers, educa- tors, and employers to adjust teaching strategies for clients, students, and employees. Educational materials and explanations must be presented at a level consistent with clients’ educational capabilities and within their cul- tural framework and beliefs.

THE PURNELL MODEL FOR CULTURAL COMPETENCE • 25

What is your cultural heritage? How might you find out more about it? Does your cultural her- itage influence your current beliefs and values about health and wellness? What brought you/your ancestors to your current country of residence? Why did you/your ancestors emigrate?

How strongly do you believe in the value of educa- tion? Who in your life is responsible for instilling this value? Do you consider yourself to be a more linear/sequential learner or a random-patterned learner?

Immigrants bring job skills from their native home- lands and traditionally seek employment in the same or similar trades. Sometimes, these job skills are inadequate for the available jobs in the new society; thus, immigrants are forced to take low-paying jobs and join the ranks of the working poor and economically disadvantaged. Immigrants to America are employed in a broad variety of occupations and professions; however, limited experien- tial, educational, and language abilities of more recent immigrants often restrict employment possibilities. More importantly, experiential backgrounds sometimes encour- age employment choices that are identified as high risk for chronic diseases, such as exposure to pesticides and chem- icals. Others may work in factories that manufacture hepa- totoxic chemicals, in industries with pollutants that increase the risk for pulmonary diseases, and in crowded conditions with poor ventilation that increase the risk for tuberculosis or other respiratory diseases.

Understanding clients’ current and previous work background is essential for health screening. For example, newer immigrants who worked in malaria-infested areas in their native country, such as Egypt, Italy, Turkey, and Vietnam to name a few, may need health screening for malaria. Those who worked in mining, such as in Ireland and Poland, may need screening for respiratory diseases. Those who lived in overcrowded and unsanitary condi- tions, such as refugees and migrant workers, may need to be screened for infectious diseases such as tuberculosis, parasitosis, and respiratory diseases.

Box 2–1 identifies guidelines for assessing the cultural domain overview, inhabited localities, and topography.

COMMUNICATION

Perhaps no other domain has the complexities of com- munication. Communication is interrelated with all other domains and depends on verbal language skills that include the dominant language, dialects, and the contex- tual use of the language as well as paralanguage varia- tions, such as voice volume, tone, intonations, reflec- tions, and willingness to share thoughts and feelings. Other important communication characteristics include nonverbal communications such as eye contact, facial

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expressions, use of touch, body language, spatial distanc- ing practices, and acceptable greetings; temporality in terms of past, present, or future orientation of worldview; clock versus social time; and the degree of formality in the use of names. Communication styles may vary between insiders (family and close friends) and outsiders (strangers and unknown health-care providers). Hierarchical relationships, gender, and some religious beliefs affect communication.

Dominant Language and Dialects

The health-care provider must be aware of the dominant language and the difficulties that dialects may cause when communicating in the client’s native language. American English is a monochromic, low-contextual lan- guage in which most of the message is in the verbal mode, and verbal communication is frequently seen as being more important than nonverbal communication. Thus, Americans are more likely to miss the more subtle nuances of communication. Accordingly, if a misunder- standing occurs, both the sender and the receiver of the message take responsibility for the miscommunication.

Americans speak American English, which differs some- what in its pronunciation, spelling, and choice of words from English spoken in Great Britain, Australia, and other English-speaking countries. Within the United States, sev- eral dialects exist, but generally the differences do not cause a major concern with communications. Aside from people with foreign accents, in certain areas of the United States people speak with a dialect; these include the South and Northeast, in addition to local dialects such as “Elizabethan English” and “western drawl.” For the most part, these dialects and accents are not as different as in

some other countries; for example, the English spoken in Glasgow, Scotland, is utterly unlike the English spoken in Central London. The Spanish spoken in Spain differs from the versions spoken in Puerto Rico, Panama, or Mexico, which has as many as 50 different dialects within its borders. In such cases, dialects that vary widely may pose substantial problems for health-care providers and interpreters in performing health assessments and in obtaining accurate health data, in turn increasing the dif- ficulty of making accurate diagnoses.

Of the nearly 300 million people in the United States, almost 250 million were born in the United States. When language ability is looked at, 217 million speak only English, 23 million speak English less than very well, and 52 million speak a language other than English (CIA Factbook, 2006).

26 • CHAPTER 2

B O X 2.1

Overview, Inhabited Localities, and Topography Overview, Inhabited Localities, and Topography 1. Identify the part of the world from which this cultural

or ethnic group originates and describe the climate and topography of the country.

Heritage and Residence 2. Identify where this group predominantly resides and

include approximate numbers.

Reasons for Migration and Associated Economic Factors 3. Identify major factors that motivated this group to

emigrate. 4. Explore economic or political factors that have influ-

enced this group’s acculturation and professional development in America.

Educational Status and Occupations 5. Assess the educational attainment and value placed on

education by this ethnic group. 6. Identify occupations that individuals in this group pre-

dominantly seek on immigration.

What is your dominant language? Do you have difficulty understanding other dialects of your dominant language? Have you traveled abroad where you had difficulty understanding the dialect or accent? What other languages beside your dom- inant language do you speak?

When speaking in a nonnative language, health-care providers must select words that have relatively pure meanings, be certain of the voice intonation, and avoid the use of regional slang and jargon to avoid being mis- understood. Minor variations in pronunciation may change the entire meaning of a word or a phrase and result in inappropriate interventions.

Given the difficulty of obtaining the precise meaning of words in a language, it is best for health-care providers to obtain someone who can interpret the meaning and message, not just translate the individual words. Remember, translation refers to the written word and inter- pretation refers to the spoken word. Children should never be used as interpreters for their family members. Not only does it have a negative bearing on family dynamics, but sensitive information may not be transmitted. California’s law Government Code 7290 et seq. prohibits using chil- dren as interpreters. Here are some guidelines for commu- nicating with non–English-speaking clients:

1. Use interpreters who can decode the words and provide the meaning behind the message.

2. Use dialect-specific interpreters whenever possible.

3. Use interpreters trained in the health-care field. 4. Give the interpreter time alone with the client. 5. Provide time for translation and interpretation. 6. Use same-gender interpreters whenever possible. 7. Maintain eye contact with both the client and

the interpreter to elicit feedback: read nonver- bal cues.

8. Speak slowly without exaggerated mouthing, allow time for translation, use the active rather than the passive tense, wait for feedback, and

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restate the message. Do not rush; do not speak loudly.

9. Use as many words as possible in the client’s language and nonverbal communication when unable to understand the language.

10. Use phrase charts and picture cards if available. 11. During the assessment, direct your questions to

the patient, not to the interpreter. 12. Ask one question at a time and allow interpre-

tation and a response before asking another question.

13. Be aware that interpreters may affect the report- ing of symptoms, insert their own ideas, or omit information.

14. Remember that clients can usually understand more than they can express; thus, they need time to think in their own language. They are alert to the health-care provider’s body lan- guage, and they may forget some or all of their English in times of stress.

15. Avoid the use of relatives, who may distort information or not be objective.

16. Avoid using children as interpreters, especially with sensitive topics.

17. Avoid idiomatic expressions and medical jargon. 18. If a certified interpreter is unavailable, the use of

a translator may be acceptable. The difficulty with translation is omission of parts of the mes- sage, distortion of the message, including trans- mission of information not given by the speaker and messages not being fully understood.

19. If available, use an interpreter who is older than the patient.

20. Review responses with the patient and inter- preter at the end of a session.

21. Be aware that social class differences between the interpreter and the client may result in the interpreter’s not reporting information that he or she perceives as superstitious or unimportant.

Those with limited English ability may have inade- quate vocabulary skills to communicate in situations in which strong or abstract levels of verbal skills are required, such as in the psychiatric setting. Helpful com- munication techniques with diverse clients include tact, consideration, and respect; gaining trust by listening attentively; addressing the client by preferred name; and showing genuine warmth and openness to facilitate full information sharing. When giving directions, be explicit. Give directions in sequential procedural steps (e.g., first, second, third). Do not use complex sentences with con- junctions or contractions.

Before trying to engage in more sensitive areas of the health interview, the health-care practitioner may need to start with social exchanges to establish trust, use an open- ended format rather than yes or no closed-response ques- tions, elicit opinions and beliefs about health and symp- tom management, and focus on facts rather than feelings. An awareness of nonverbal behaviors is essential to estab- lishing a mutually satisfying relationship.

The context within which a language is spoken is an important aspect of communication. The German, English, and French languages are low in context, and most of the message is explicit, requiring many words to express a thought. Chinese and Native American languages are highly contextual, with most of the information either in the physical context or internalized, resulting in the use of fewer words with more emphasis on unspoken under- standings.

Voice volume and tone are important paralanguage aspects of communication. Americans and people of African heritage may be perceived as being loud and bois- terous because their volume carries to those nearby. Compared with Chinese and Hindus, Americans and African Americans generally talk loudly. Their loud voice volume may be interpreted by Chinese or Hindus as reflecting anger, when in fact a loud voice is merely being used to express their thoughts in a dynamic manner. In contrast, Westerners witnessing impassioned communi- cation among Arabs may interpret the excited speech pat- tern and shouting as anger, but emotional communica- tion is part of the Arab culture and is usually unrelated to anger. Thus, health-care providers must be cautious about voice tones when interacting with diverse cultural groups so their intentions are not misunderstood. In addition, the speed at which people speak varies by region; for example, in parts of Appalachia and the South, people speak more slowly than do people in the northeastern part of the United States.

THE PURNELL MODEL FOR CULTURAL COMPETENCE • 27

Give some examples of problems communicating with patients who did not speak or understand English. What did you do to promote effective communication?

On a scale of 1 to 10, with 1 low and 10 high, where do you place yourself in the scale of high- contextual versus low-contextual communication? Do you tend to use a lot of words to express a thought? Do you know family members/friends/ acquaintances who are your opposite in terms of low-contextual versus high-contextual communi- cation? Does this sometimes cause concerns in communication? Do you think biomedical lan- guage is high or low context?

Cultural Communication Patterns

Communication includes the willingness of individuals to share their thoughts and feelings. Many Americans are willing to disclose very personal information about them- selves, including information about sex, drugs, and fam- ily problems. In fact, personal sharing is encouraged in a wide variety of topics, but not religion as in Central America, politics as in Spain, or philosophical things as discussed in most of Europe. In the United States, having

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well-developed verbal skills is seen as important, whereas in Japan, the person who has very highly developed ver- bal skills is seen as having suspicious intentions. Similarly, among many Appalachians, the person who has well- developed verbal skills may be seen as a “smooth talker”; and therefore, her or his actions may be suspect. In some cultural groups, such as many Asian cultures, individuals are expected to be shy, withdrawn, and diffident—at least in public—whereas in other cultures, such as Jewish and Italian, individuals are expected to be more flamboyant and expressive. Most Appalachians and Mexicans will- ingly share their thoughts and feelings among family members and close friends, but they may not easily share thoughts, feelings, and health information with “out- side” health-care providers until they get to know them. By engaging in small talk and inquiring about family members before addressing the client’s health concerns, health-care providers can help establish trust and, in turn, encourage more open communication and sharing of important health information.

fortable standing closer to each other than Americans; in fact, they interpret physical proximity as a valued sign of emotional closeness. Middle Eastern clients, who stand very close and stare during a conversation, may offend health-care practitioners. These clients may interpret American health-care providers as being cold because they stand so far away. An understanding of personal space and distancing characteristics can enhance the quality of communication among individuals.