The topic of my discussion is about cultural diversity amongst healthcare providers and patients. This paper discusses the impact and improvements needed in our culturally diverse world. In today’s day and age, we have people from all around the world in our healthcare system. We as healthcare providers interact with different religions, cultures and ethnic backgrounds. This paper introduces the concept of cultural diversity and competence in healthcare, and provides a historical and social perspective, ethical implications and consequences, and explores ways to impact existent cultural barriers.
As diversity is expanding in the United States, the growth of minority populations is on an uphill rise (Lequerica & Krch, 2014). Cultural competence needs to be improved in the healthcare system to optimize healthcare outcomes. Lack of using cultural assessment tools leads to poor patient outcomes and builds mistrust between the patient and healthcare provider. Not understanding the cultural background upon meeting your patient can ruin the patient and healthcare provider relationship. Some cultures find eye contact as rude. Whom you are speaking to (whether it is the man, or the woman being addressed) can be a norm in some cultures versus others. Not having this knowledge can alter the patient/healthcare provider relationship and experience. It can be a frightening experience when seeking medical attention in a non-native country, especially when you are surrounded by healthcare providers who do not speak your native tongue, understanding your cultural beliefs, or religious preferences. Healthcare providers are relying on the younger English-speaking generation to interpret the medical language to family members. This causes a sense of violation of their healthcare privacy. Providing an interpreter or offering medical documents in their language provides a sense of trust and understanding. Understanding religious and cultural beliefs puts patients at ease because it gives them a sense of trust and understanding that we, as healthcare providers, recognize their cultural, ethical and religious differences. Having the knowledge, materials, and resources available will provide better patient outcomes, trust, decrease hospital admissions by offering more compliance to medical adherence, and better follow up outcomes. When healthcare providers utilize all cultural assessment tools available, patient outcomes are increased and healthcare quality rises to a higher standard of care. The goal is utilize all tools to become compliant in this regard.
Cultural diversity started getting recognized in 1969. A physician, Dr. Michael Balint, had a belief that each patient “has to be understood as a unique human-being” (Balint, 1969, p. 269). As time went on, Lipkin and colleagues (1984) grew to understand that this belief, or approach, to healthcare builds trust, provides ongoing communication, and overcomes barriers to communication. This, in turn, allows physicians to treat the disease and patient effectively (Lipkin, Quill, & Napodano, 1984). This belief is congruent with a patient-centered approach to medicine rather than following a traditional approach to care, or what is described as an illness-oriented approach (Balint, 1969). Over time, patient-centered care methods began to flourish. As patient-centered care flourished, cultural competence came into play in the early 1990’s.
As patient-centered care dimensions were being revised over time, terms like “cultural competence” began to rise in medical and nursing journals. “The primary impetus for the cultural competence movement of the last decade has been the demonstration of and publicity surrounding widespread racial and ethnic disparities in healthcare” (Saha, Beach, & Cooper, 2008, p. 1278). The philosophy of connecting cultural competence and patient-centered care together as the background focus in providing care have become the norm; its goal is improvement in the quality of healthcare (Saha et al., 2008).
According to Kaufman (2006), it is a daunting task to becoming culturally competent. A patient’s awareness, ideas, and beliefs of health and illness are very much influenced by culture and ethnicity. If, or when, providers of care are perceived as insensitive to the cultural nature of their patient, there lies a negative perception about the care that will be received.
Positive outcomes are seen when healthcare providers are culturally competent. Higher incidence rates with poor health outcomes are seen in minority (racial/ethnic) groups than in whites even while there is control over disease, income, insurance cover, or employment status. “Cultural bias is one contributor to this, according to the IOM Report Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care” (Kaufman, 2006, p. 1). Reducing health disparities is possible when healthcare professionals strive to become competent in diversity and about culture. Minorities with cultural differences fight an uphill battle. Obtaining insurance, lack of same language-speaking healthcare providers, and little to none cultural assessment tools being used in the healthcare field are issues surrounding this battle. These issues are leading to poor patient outcomes, lack of medical compliance, and follow up care to treat illnesses (Kaufman, 2006).
Diverse populations with specialized illnesses are consequentially being affected. Issues of cultural diversity in acquired brain injury (ABI) rehabilitation, for example, are being recognized as having a higher percentage of brain injury patients being minorities, which brings diversity into rehabilitation facilities. Poor outcomes are seen in these minorities suffering from ABI due to insurance barriers, mistrust of healthcare professionals, language barriers, and lack of culturally relevant assessment tools (Lequerica & Krch, 2014).
Having a language barrier builds mistrust among the patients with their healthcare providers and results in poor outcomes and noncompliance. Additionally, healthcare professionals are allowing the younger generation to translate medical information to their patient. Allowing this to happen upsets the patient because they might not want their family involved with their medical issues (Lequerica & Krch, 2014). Lequerica states, “further, use of a trained interpreter can promote feelings of being respected, resulting in improved patient satisfaction with services. Briefing the interpreter prior to the interaction with the patient informs them of the objectives of the visit and can minimize bias or undue influence on part of the interpreter” (p. 649). Although many healthcare providers are not fluent in their client’s native language, showing an effort to ensure culturally sensitive care builds confidence in the nurse-patient relationship and ensures patient needs are being fulfilled. “Patients with language barriers change how nurses work and organize patient care (Squires, 2018, p. 22). There are legal reasons, in addition to meeting communications needs, for why changes in the way care is provided to those with language barriers. In 1964, law was enacted to protect individuals with limited English proficiency (LEP). The U.S. Civil Rights Act was put in place to ensure that individuals with LEP would not be affected in discriminatory ways. Based upon law, healthcare entities must comply with interpreter services to LEP patients. The Affordable Care Act (ACA) implemented regulations that restrict usage of family members as interpreter. Additionally, the ACA mandates validation of language skills of healthcare workers. Evidence exists when there are language barriers and impacts patient outcomes and healthcare delivery. It is noted that the length of stay (LOS) for an LEP patient is longer than those who are not with LEP, even when there is a higher socioeconomic status. A LOS is increased by three days when an interpreter is not used at the time of admission or at the time of discharge. The 30-day readmission rates among LEP patients (in those with certain types of chronic diseases) are increased by as much as 25% (Squires, 2018).
Healthcare organizations, along with their care providers, can adopt patient centeredness and culturally competent care principles to increase their services for their clients. Adoption of assessment tools can also be utilized if the healthcare entity has them in place. Lequerica and Krch (2014) state that poor outcomes are seen in minority groups and that there lacks the use of culturally relevant assessment tools. A recommendation for utilizing all the tools in place at the healthcare institution can improve healthcare outcomes.
Physical assessment reveals much of a patient’s physiological state and, therefore, can also reveal various biocultural physiological aspects among members of the individual population of patients. Body proportions, laboratory values, vital signs, general appearance, musculoskeletal system variations, skin, and types of illness are physiological factors revealed when performing physical assessment (Treas, Wilkinson, Barnett, & Smith, 2018). Research by Treas et al. (2018) suggests using any of many tools available when performing cultural assessments, including but not limited to, Purnell’s Domains of Culture, Leininger’s Sunrise Model, or the Transcultural Assessment Model.
The Purnell model helps to solidify a foundation for realizing the variations in attributes of the many different cultures, which helps a nurse to appropriately learn about a client’s attributes (experiences, incitement, and notions) concerning their healthcare and illness. Each ethic group has traits that are important during the evaluation process (Albougami, Pound, & Alotaibi, 2016). There are twelve domains considered when using the Purnell Model: “overview or heritage, communication, family roles and organization, workforce issues, bio-cultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, healthcare practices, and healthcare professionals” (Albougami et al., 2016, p. 3).
Founded by Dr. Madeline Leininger in the early 1970’s, transcultural nursing focuses on cultural care diversity and universality as a worldwide nursing theory. Her theory’s focus is on the study and practice of the differences and similarities—comparative human caring—between varied beliefs, patterns of living, and values of diverse populations to ensure providing care is “culturally congruent, meaningful, and beneficial” to good health (TCNS.org., 2019). The Leininger Sunrise Model is used by nurses when evaluating clients and making culturally competent assessments. It is a designed systematic approach to identify the values and beliefs, along with the behaviors and customs, of their clients (Albougami et al., 2016). This assessment tool marries the nurse, person, and healthcare system to ensure culturally competent care (Treas et al., 2018).
The Transcultural Assessment Model, coined by Giger and Davidhizar, focuses on six dimensions that are common amongst cultures: communication, space, social organization, time, environmental control, and biological variation” (Albougami, 2016, p. 2). Albougami (2016) reports the holistic process of human conduct and interaction is that of communication, which is the very first of his six dimensions. Emphasis within this model is the uniqueness with which each person—each client—will possess within their culture.
Moving away from an illness-based approach of care to a more patient-centered focus is a quality improvement initiative. Understanding the historical timeline of cultural competence and its effects on a patient-centered care model are important measures to understanding the next steps of providing optimal care. Assessing for cultural barriers addresses the needs of the individual; patient outcomes rely on this assessment. There are ethical implications and consequences for not applying cultural compliance measures. Utilizing culturally competent assessment models help to reveal variations in physiological factors and barriers that will ultimately aid in providing optimal care.
Albougami, A. S., Pounds, K. G., & Alotaibi, J. S. (2016). Comparison of four cultural competence models in transcultural nursing: A discussion paper. International Archives of Nursing and Health Care, 2(4), 1-5.
Balint, E. (1969). The possibilities of patient-centered medicine. Journal of the Royal College of General Practitioners, 17, 269-276.
Kaufman, M. B. (2006). Promoting cultural diversity in healthcare settings [Case Study]. PrimeInc.org. Retrieved April 13, 2019, from https://primeinc.org/casestudies/pa_np/study/389/Promoting_Cultural_Diversity_In_Health_Care_Settings
Lequerica, A., & Krch, D. (2014). Issues of cultural diversity in acquired brain injury (ABI) rehabilitation. NeuroRehabilitation, 34(4), 645-653. doi: 10.3233/NRE-141079
Lipkin, M., Jr., Quill, T. E., & Napodano, R. J. (1984). The medical interview: a core curriculum for residencies in internal medicine. Annals of Internal Medicine, 100(2), 277–284.
Saha, S., Beach, M. C., & Cooper, L. A. (2008, November). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100(11), 1275-1285.
Squires, A. (2018, April). Strategies for overcoming language barriers in healthcare [Education CE]. Nursing Management, 49(4), 20-27.
Transcultural Nursing Society. (2019). Dr. Madeline M. Leininger Foundress, Transcultural Nursing Society, Leader in Human Care Theory and Research (July 13, 1925-August 10, 2012). TCNS.org. Retrieved March 13, 2019, from https://tcns.org/madeleineleininger/
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