30 Nursing Management October 2002

young female immigrant gets a job in a ruralMississippi eatery to help support her family. Sheholds out a plate of bacon to one of her cowork-ers and cries, “Is this toast? I need toast!”1

Thrown into the American culture withoutadequate preparation, this woman is a walk-ing example of how language and perceptiondifferences can impact the ability to function.

She’ll require extensive clinical and social resources to helpher protect her health and to ensure her ability to work andprovide for her family. Is this the business of health care?Unequivocally, yes. Is this a familiar scenario, one that weencounter on a daily basis? More than likely, yes.

Language and perception barriers not only impactpatient communication, but also discharge planning and thepatient’s overall ability to maneuver through the health caresystem. Gender, age, ethnicity, race, sexual orientation, anddisabilities create challenges for health care providers. We’rerunning into walls we didn’t even know existed, withouttools or an understanding of these unforeseen obstacles.Addressing institutional racism remains fundamental toaddressing organizational issues. But, before you can imple-ment meaningful changes to your environment, you mustbetter understand it.

By definition, cultural competence is a set of congruentbehaviors, attitudes, and policies that come together in asystem, agency, or among professionals and enables thatsystem, agency, or those professionals to work effectively incross-cultural situations.

Considering statisticsLet’s review the numbers:♦ U.S. residents speak at least 329 languages.♦ 44 million Americans don’t have health insurance.♦ Latinos are twice as likely as other Americans to lack

Abstract: Address the visible and nonvisible components of

multiculturalism to provide a culturally competent, appropri-

ate care environment. [Nurse Manage 2002:33(10):30-34]

1.5ANCC/AACN CONTACT HOURS

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ABy G. Rumay Alexander, RN, BSN, MSN, EdD

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October 2002 Nursing Management 31

managementhealth care coverage.♦ By 2030, the Hispanic population will increase 113% and theAsian American population by 132%.♦ African Americans’ infant mortality rate is 2.5 times greaterthan that of Caucasians.♦ African Americans’ death rate from HIV/AIDS is 7 timesgreater than that of Caucasians. Their homicide rate is 6 timesgreater. ♦ Native Americans are 2.5 times more likely than Caucasians todie from diabetes, and 3 times more likely to die of cirrhosis.♦ Vietnamese women have a 5 times greater incidence of cervicalcancer than Caucasian women.♦ Less than 2% of health care CEOs and COOs are non-Caucasian.2

New technologies and worldwide epidemics bring us into aglobal spotlight. Our colleagues and patients come from all overthe planet. Whether immigrants, refuges, or natural-born citizens,they require careful consideration and respectful treatment. Toensure an appropriate approach, the U.S. government institutedfederal and state civil rights laws and Medicaid regulations thatrequire patient access to medical information in their own lan-guage. The Joint Commission on Accreditation of Health CareOrganizations (JCAHO) requires hospitals to document thatpatients and families receive, and demonstrate understanding of,linguistically appropriate explanations and instructions.

Tailoring treatmentGrowing evidence indicates that treatment efficacy varies amongdifferent cultural populations, and that we must integrate thesevariations into quality measurements if we’re to provide cultural-ly competent treatment.

To offer quality care for all patients, health care service andsupport systems should inherently recognize that:♦ each culture defines the family as the primary support systemand preferred intervention.♦ most racial and ethnic minority populations speak more thanone language and that this may create a unique set of mentalhealth issues to which the system must be equipped to respond.♦ patients and their families make different choices based on cul-tural forces.

that celebrates patient diversity.

♦ culturally preferred choices, not cul-turally blind or culturally free interven-tions, drive practice in the servicedelivery system.♦ all cross-cultural interactions offerdynamics that require acknowledg-ment, adjustment, and acceptance.♦ health care systems must sanction ormandate the inclusion of culturalknowledge into practice and policymaking.3

An individual’s social status almostalways hinges on his or her socioeco-nomic status. In fact, 90% of a person’shealth status is determined by house-hold income, not actual access to care.4(See “The wealthier, the healthier?”)

Uncovering identitiesValuing diversity is the how-to of valu-ing and managing relationships, andvaluing relationships is the heart ofvaluing and managing diversity: Wecan’t do one without the other. It’s thatsimple, yet that complex. Regardless ofrace, creed, color, ethnicity, age, or sex-ual orientation, health care’s essence isto take care of people no matter whattheir needs, which calls for culturalcompetence at all organization levels.

Help your facility foster an environ-ment that values diversity every day inevery department. Encourage staff toperform a cultural assessment whencaring for diverse patients, whichshould include the following core com-ponents:♦ cultural/racial/ethnic identity♦ language/communication abilityand style♦ religious beliefs and practices♦ illness and wellness behaviors♦ healing beliefs and practices.

Also consider determining thepatient’s:♦ typical nutritional regimen♦ family system functions (identifyingthe chief decision maker)♦ lifestyle and habits.

The word culture implies an inte-grated pattern of human behavior thatincludes thoughts, communications,actions, and customs. Keep in mind

that, regardless of race or ethnicity, cer-tain cultural phenomenons apply toevery individual, even those of thedominant culture. These factorsinclude: communication, spatial needs,time considerations, social organiza-tion, environmental control (fate vs.controlling your own destiny), and bio-logical variations (skin color, diseasepropensity). (See “Cultural competencybenefits.”)

Step back and view culture from abroad perspective, exploring popularU.S. health care assumptions and whatthese may entail for culturally diversepatient populations. Because our cul-ture emphasizes individual rights, westrive to keep our patients as “in theloop” as possible. But other culturesmay believe that a patient should beprotected from treatment specifics.These families may work to keep thepatient as unaware of treatment detailsas possible.

Other popular U.S. assumptionsregarding health care include:♦ Moral obligations and medical ethicsare based on Judeo-Christian beliefs.♦ Health care providers maintain theobligation to tell the truth and to giveall information to the competentpatient or her surrogate.♦ Every patient receives the facility’swritten bill of rights upon admission. ♦ Informed consent doesn’t includefamily unless the patient is legallyunable to make her own decisions.5

Relating to othersExperts recognize four cultural syn-dromes that contain patterns andbeliefs centered on identifiable themes:complexity, individualism, collec-tivism, and tightness. 1. Complexity: the measure of howmany distinctions are made amongobjects and events in the environment.Examples: the number of occupationsfrom which an individual has tochoose or the number of roles an indi-vidual within a culture must transitionbetween.2. Individualism: the dominance of

individual versus group within a cul-ture. People in individualistic cultures,such as the United States, give priorityto their own goals. 3. Collectivism: the dominance ofgroup versus individual within a cul-ture. People in collectivist cultures,such as Arabic, eastern European, LatinAmerican, and Japanese, give priorityto group goals, defining self in terms ofthe group. The more homogenous aculture, the more likely it’s collectivist.It’s important to note that environmen-tal conditions lead to individualismand collectivism—neither has anadvantage over the other. An individu-alist culture in a threatening situationfrom an outside force will galvanizeand become more collectivist becauseof the need to band together for sur-vival. Personal relationships or rapportin working relationships is importantin collectivist cultures, yet group needstake precedence over individual ones.4. Tightness: the degree to which a cul-ture tolerates deviation from culturalnorms. U.S. residents enjoy flexibilityand not a great deal of tightness.Population density, low contact withother cultures, and cultural similarityare typically found in tighter cultures.

A cultural group consciously or uncon-sciously shares these identifiable valuesand norms, and transmits them from onegeneration to another. A firm understand-ing of cultural syndromes will enablecaregivers to give the same meanings towords and actions as the patient withwhom they’re communicating.6

To increase awareness of complexity,individualism, collectivism, and tight-ness, encourage staff to ask questionsin a manner that elicits the most appro-

www.nursingmanagement.com32 Nursing Management October 2002

Multicultural managementThe wealthier, thehealthier?A look at the relationship between house-hold income and health status.

Household income Percentage with poor or fair health status

Less than $15,000 20.6%$15,000 to $24,999 15.1%$25,000 to $34,999 8.1%$35,000 to $49,999 5.9%$50,000 and greater 2.7%Source: Healthy People 2010, HHS.

priate responses and promotes a morein depth understanding of the cultural-ly diverse patient. For example, beforediscussing test results, staff might askthe patient who he’d like present whendiscussing the results, who’ll share theresults with others, and who’ll helpdecide the preferred treatment course.

To effectively function cross cultural-ly, be mindful of diversity’s develop-mental stages. Also remember thatpeople are ethnocentric: They interpretother cultures within the context andunderstanding of their own culture.(See “Degrees of acceptance.”)

Rising to another levelFrom policymaking to administrationand practice, culturally competentfacilities value diversity, offer culturalself-assessments, remain aware of the

inherent dynamics when cultures inter-act, institutionalize cultural knowledge,and adapt service delivery to reflect anunderstanding of diversity.7

These progressive organizations cel-ebrate multiculturalism at every level,reflecting it in their attitudes, struc-tures, policies, and services. If you askemployees to name their facility’s chiefdiversity officer and they say the chiefexecutive officer, you’ve found anorganization that’s truly striving forcultural competence.

References1. Schwartz, B., and Schwartz, C.: “The

Order of the Day,” Atlantic Monthly,January 1996.

2. U.S. Bureau of Census. Available on-line:http://www.census.gov.

3. Health Resources and ServicesAdministration. Available on-line:http://www.hrsa.gov.

4. U.S. Department of Health and HumanServices, Office of Civil Rights: “HealthyPeople 2010.” Avalable on-line:http://www.health.gov/healthypeople

5. Crow, K., Matheson, L., and Steed, A.:“Informed Consent and Truth-Telling:Cultural Directions for Health CareProviders,” Journal of NursingAdministration. 30(3):148-152, 2000.

6. Triandis, H.: Culture and Social Behavior,McGraw-Hill: New York, N.Y. 1994.

7. Health Resources and ServicesAdministration: Guidelines to HelpAssess Cultural Competence in ProgramDesign, Application, and Management.Available on-line:http://Gphc.hrsa.gov:80/cc/guidelines.htm.

About the authorG. Rumay Alexander is President and CEO,The Roxie Company, Nashville, Tenn. She’salso a board member of the AmericanOrganization of Nurse Executives (AONE)and chairs the organization’s Committee onCultural Diversity.

www.nursingmanagement.com October 2002 Nursing Management 33

Cultural competencybenefitsA culturally competent managementand staff yield:

♦ products/services consistent withpatient population needs♦ increased customer recruitment, sat-isfaction, retention, and care access♦ maximum use of limited resources♦ improved overall health outcomes.Source: Creative Teaching for NursingEducators, by Alexander, G. Rumay.

Degrees of acceptanceThe developmental stages of diversity include:

Knowledge: A move from stereotypes to information: The extent to which an individualpossesses information about others from diverse backgrounds and cultures.

Understanding: A move from awareness to empathy: The extent to which an individualcomprehends how others feel and why they behave as such.

Acceptance: A move from tolerance to respect: The extent to which an individualrespects and values diverse characteristics and behaviors of others.

Behavior: A move from self-awareness to interpersonal skills: The extent to which anindividual is able to interact effectively with others different from herself.Source: The Challenge of Cultural Inclusiveness, by Alexander, G. Rumay.

TO EARN CE CREDIT, FOLLOW THESE INSTRUCTIONS:1. Choose one answer for each question and darken box.2. Fill in registration information and evaluation on answer form

(Social Security or nursing license number must be included toprocess test).

3. Mail your answer form (copies accepted) and $12.95 process-ing fee to: Lippincott Williams & Wilkins, 2710 YorktowneBlvd., Brick, NJ 08723. Make checks payable to LippincottWilliams & Wilkins; if paying by credit card, include number andexpiration date. Within 4 weeks, you’ll be notified of your testresults.

4. New discount procedure: Take 75¢ off the price of each test ifsubmitting two or more tests at a time from any issue.

5. Fax-back service: Fax your test (credit card orders only) to732-255-2926 and we’ll fax back your CE certificate within 2business days. Provide a fax number for a location where con-fidential information will be safe (home/workplace). Faxes sentto a workplace will be accompanied by a cover letter. Wearen’t responsible for faxes not received due to malfunctioningmachine on receiving end. A CE certificate will be mailed afterattempts to fax have failed.

6. Take tests on-line at http://www.nursingcenter.com/prodev/ce_online.asp and have them processed immediately.

The passing score for tests is 70%. If you pass, a certificate for earned con-

tact hours will be awarded by Lippincott Williams & Wilkins. You’ll alsoreceive an answer sheet with the rationale for each correct answer. If you failthe test, you can take the test again for free. For questions about testresults, contact Lippincott Williams & Wilkins, Springhouse Office, CEDept., 1111 Bethlehem Pike, P.O. Box 908, Springhouse, PA 19477;1-800-346-7844, ext. 6513.

PROVIDER INFORMATION:This continuing nursing education (CNE) activity for 1.5 con-tact hours is provided by Lippincott Williams & Wilkins, whichis accredited as a provider of continuing education in nursingby the American Nurses Credentialing Center’s Commission onAccreditation and by the American Association of Critical-CareNurses (AACN 9722; category O). This activity is alsoprovider-approved by the California Board of RegisteredNursing, provider #CEP11749, for 1.5 contact hours.Lippincott Williams & Wilkins is also an approved provider ofCNE in Alabama (#ABNP0114), Florida (#FBN2454), and Iowa(#75).* All of its home study activities are classified for Texasnursing continuing education requirements as Type I. Your cer-tificate is valid in all states.

*In accordance with Iowa Board of Nursing administrative rulesgoverning grievances, a copy of your evaluation of this CE

Take the test on page 34—and earn CE credit.

Earn 1.5 contact hours for A Mind for Multicultural Management test.

10-02

$12.95 FEE(1st test)