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HealthStream Regulatory Script [Cultural Competence: Background and Benefits] Version: [12.02.04] Lesson 1: Introduction Lesson 2: Clinical and Legal Significance of Cultural Competence Lesson 3: Theory of Cultural Competence Lesson 4: Practice of Cultural Competence

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Lesson 1: Introduction 1001

Introduction

Welcome to the introductory lesson on background and benefits of cultural competence. In the healthcare setting, cultural competence refers to the ability to provide appropriate and effective medical care and services to members of various cultural groups. This ability rests on a set of attitudes, skills, policies, and practices that make it possible for providers and organizations to understand and communicate with their patients on an in-depth level. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines.

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1002 Introduction: The Culturally Competent Provider

The culturally competent provider is able to learn, understand, and appreciate the health-related characteristics of both:

• Culturally diverse patient groups, in general • Each unique patient and family, in particular

These characteristics include any values, beliefs, attitudes, behaviors, practices, or other factors that may:

• Affect a patient�s health. • Influence or affect the delivery of healthcare.

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1003 Introduction: Using Cultural Understanding

The culturally competent provider uses his or her understanding of patient values, beliefs, and practices to:

• Improve the quality and efficacy of medical care for all patients.

• Correct disparities [ glossary] in health status among different cultural groups.

By contrast, failure to provide culturally competent care contributes to:

• Less-than-optimal care for many patients • Elevated rates of disease and mortality among certain

populations, due to social, economic, and cultural factors

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1004 Course Rationale

This course is the first in a two-part series designed to teach you the key elements of cultural competence, as a starting point for you to:

• Optimize your care and services for all patients. • Maintain compliance with laws and recommendations

related to the delivery of culturally competent medical care. This first course focuses on background and theory, including legal and clinical implications of providing culturally competent care. The second course in the series (Cultural Competence: Providing Culturally Competent Care) focuses on specific clinical best practices for delivering medical care and services in a culturally competent manner.

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1005 Course Goals

After completing this course, you should be able to:

• Distinguish the clinical outcomes associated with cultural competence vs. lack of cultural competence in the healthcare setting.

• Identify laws and recommendations related to cultural competence.

• Recognize key terms related to cultural competence. • List �typical� characteristics of selected cultural groups.

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Point 5 of 6

1006 Course Outline This introductory lesson presents the course rationale, course goals, and course outline. Lesson 2 provides additional background information on the significance of cultural competence, both from a clinical standpoint and a legal standpoint. After completing lesson 2, you should have a better appreciation of the importance of delivering culturally competent medical care. Lesson 3 takes a closer look at the policy of cultural competence, by defining terms and discussing theory. Finally, lesson 4 takes a more practical look at cultural competence, by reviewing some of the �typical� characteristics of various cultural groups.

FLASH ANIMATION: 1006.SWF/FLA

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Lesson 2: Clinical and Legal Significance 2001

Introduction

Welcome to the lesson on the clinical and legal implications of providing culturally competent medical care.


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2002 Objectives

After completing this lesson, you should be able to:

• Recall statistics related to the cultural diversity of the United States.

• List adverse patient outcomes that can result from the failure to provide culturally competent care.

• List potential benefits of improving your cultural competence.

• Describe laws and recommendations related to culturally competent healthcare delivery.

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Point 2 of 17

2003 Cultural Diversity in the United States

The United States is a nation of tremendous cultural diversity:

• Nearly 10% of all Americans today (28 million out of a total population of close to 300 million) were born outside of the United States.

• Forty-four million Americans speak a language other than English at home.

• Over 300 different languages are spoken in the United States.

Given this diversity, cultural competence is a necessity: providers must be capable of delivering healthcare in a manner appropriate to --- and respectful of --- any given patient�s language and culture.

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2004 Cultural Competence and the Practice of Medicine Today

Unfortunately, cultural competence is often lacking in the practice of medicine today. Instead of taking the time to learn, understand, and appreciate the values, beliefs, practices, and communication patterns of their patients, many providers --- whether consciously or subconsciously --- rely on stereotypes and their own biases to guide the delivery of healthcare. As a result of stereotypes and biases, racial and ethnic minorities in the United States today tend to receive lower quality care than similar non-minorities (i.e., non-minorities with similar income and health insurance). Source: Institute of Medicine (IOM)

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2005 Cultural Competence and Quality of Care (1)

In what ways do racial and ethnic minorities receive lower quality care? Lack of cultural competence in the healthcare setting can lead to the following adverse outcomes, with regard to medical care:

• Lack of medical care: Cultural minorities may choose not to seek medical care at all, for fear of being misunderstood or treated disrespectfully.

• Misdiagnosis: Miscommunication and misunderstanding between providers and their cross-cultural patients --- especially patients with limited English proficiency (LEP) [glossary] --- can lead to inaccurate or incomplete history-taking, ultimately resulting in misdiagnosis.

• Inappropriate testing: Providers may not order appropriate diagnostic tests for cultural minorities, because they do not understand or believe the patient�s description of symptoms. Alternatively, providers may overcompensate by ordering too many tests.

• Suboptimal disease screening: Providers may miss important opportunities for disease screening, because they are not aware of the rates of certain disease conditions among specific minority groups.

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2006 Cultural Competence and Quality of Care (2)

Additional adverse outcomes related to lack of cultural competence in the healthcare setting can include:

• Noncompliance: Cultural minorities may not follow the advice of medical providers, because of lack of trust and/or understanding.

• Reaction to drugs: Patients may not respond well to medication, because providers fail to take into account differences in the body�s processing of drugs. (Many drug dosages and other medical standards are based on studies of Caucasian patients --- but evidence suggests that ethnic/racial makeup may affect how a patient metabolizes and responds to a drug.)

• Conflicting drugs: Harmful drug interactions may occur, when a provider prescribes medication without taking into account traditional remedies a patient may be using.

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2007 Cultural Competence and Health Disparities

Just as lack of cultural competence can lead to lower quality care for cultural minorities, lack of cultural competence may be a contributing factor in cross-cultural disease and outcome disparities. Examples of such disparities include:

• Increased risk of mortality among African-American women with breast cancer, as compared to European-Americans with breast cancer

• Higher infant mortality rates among African-Americans and Native Americans, as compared to European-Americans

• Increased mortality among African-Americans and Native Americans with the flu, as compared to European-Americans with the flu

• Increased mortality among African-Americans, Native Alaskans, and Native Hawaiians with colorectal cancer, as compared to European-Americans with colorectal cancer

• Elevated rates of HIV/AIDS among African-Americans and Latinos, as compared to European-Americans

For more examples of cross-cultural health disparities, see: http://erc.msh.org/mainpage.cfm?file=7.0.htm&module=provider&language=English&ggroup=&mgroup=

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2008 Potential Benefits of Cultural Competence: Clinical (1)

We have just reviewed some of the negative consequences of failing to provide culturally competent care. But what are the potential benefits of cultural competence in the healthcare setting? They include:

• More successful patient education for cultural minorities, as a result of targeting and communicating health-related messages in culturally appropriate ways

• Increased likelihood that cultural minorities will seek necessary healthcare, as a result of improved trust and understanding between patients and providers

• Fewer diagnostic errors, when providers have the cross-cultural understanding necessary to take accurate and thorough medical histories from all patients, regardless of cultural background

• More appropriate diagnostic testing and screening for cultural minorities, when providers know and understand the health-related practices, behavioral risk factors, and genetic risks common among various cultural groups

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2009 Potential Benefits of Cultural Competence: Clinical (2)

Potential benefits of cultural competence in the healthcare setting also include:

• Fewer harmful drug interactions, when providers find out about patient use of traditional remedies

• Greater patient compliance, when providers work with their patients to develop treatment plans that match patient values, beliefs, and lifestyle

• Expanded choices and access to high-quality clinicians, when patients are not limited to a small pool of providers who share their language and culture

• Ultimately, equalization of cross-cultural health disparities related to social, economic, and cultural factors

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2010 Quality of Care, Health Disparities, and Clinical Outcomes: Summary

Potential Effects of Culturally Competent and Non-Competent Care

on Healthcare Delivery and Patient Health Cultural Competence Lack of Cultural Competence

Increased likelihood that cultural minorities will seek necessary healthcare Lack of medical care

Fewer diagnostic errors Misdiagnosis

More appropriate diagnostic testing and screening for cultural minorities Inappropriate testing and suboptimal disease screening

Greater patient compliance Noncompliance

Fewer harmful drug interactions Drug reactions and interactions

Equalization of cross-cultural health disparities Health disparities

Expanded choices and access to high-quality clinicians for cultural minorities Limited healthcare choices for cultural minorities

More successful patient education for cultural minorities Limited/ineffective patient education for cultural minorities

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2011 Potential Benefits of Cultural Competence: Legal and Regulatory

Benefits of cultural competence relate not only to improved patient outcomes, but also to improved compliance with relevant laws and recommendations. Laws and recommendations related to cultural competence include:

• Title VI of the Civil Rights Act of 1964 • JCAHO [glossary] position on cultural competency • U.S. Department of Health and Human Services (HHS)

Office of Minority Health (OMH) recommendations for national standards on culturally and linguistically [glossary] appropriate services (CLAS)

Let�s take a closer look at each.


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2012 Title VI

Title VI of the Civil Rights Act of 1964 and its supporting legislation require that any health- or social- service organization that receives federal funding must provide language assistance to any patient/client with limited English proficiency (LEP). Language assistance is defined as services that ensure effective communication between the LEP patient and the provider, such that:

• The LEP patient is able to communicate all relevant information to the provider.

• The provider is able to understand all information communicated by the LEP patient.

• The LEP patient is able to receive and understand all necessary information, including a description of services and benefits available.

• The LEP patient is able to receive services for which he or she is eligible.

Guidelines for medical interpretation to achieve effective language assistance are discussed in greater detail in Part 2 of this series (Cultural Competence: Providing Culturally Competent Care).


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2013 JCAHO Position

Although JCAHO has not yet established any standards specifically related to cultural competence: The Joint Commission views the delivery of services in a culturally and linguistically appropriate manner as an important healthcare

safety and quality issue. Healthcare organizations are encouraged to provide equitable care, treatment, and services across diverse

populations.

In January 2004, JCAHO started a project on cultural competence (Hospitals, Language, and Culture: A Snapshot of the Nation). Over a 30-month period, JCAHO will collect data from 60 different hospitals, to determine the ability of these hospitals to address issues of patient language and culture. The results of this study will allow JCAHO to set realistic standards for hospitals, related to meeting the cultural and linguistic needs of their patients. Source: JCAHO: http://www.jcaho.org/about+us/hlc/


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2014 CLAS Standards

The U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) recently released 14 recommendations for national standards on culturally and linguistically appropriate services (CLAS). These recommendations address issues such as:

• Culturally representative staffing • Staff education and training • Language-assistance services and materials (both written

and verbal) • Organizational self-assessment • Data collection • Cross-cultural conflict and grievance processes

The goals of the recommendations are to:

• Correct disparities currently seen in patient access to and receipt of medical care and services.

• Improve medical services by meeting the needs of each individual patient.

For more details on the CLAS recommendations, see: http://www.omhrc.gov/clas/ds.htm


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2015 Review

FLASH INTERACTION: 2015.SWF/FLA Drag and drop each of the terms in the word bank to its proper place in the table.

Cultural competence is characterized by:

Lack of cultural competence is characterized by:

Effective communication Use of stereotypes Thorough understanding of individual patients

Biased delivery of healthcare

Willingness to learn Making assumptions about patients

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2016 Review

Which of the following requires certain organizations to provide meaningful language assistance to clients with limited English proficiency (LEP)?

a. EMTALA b. CLAS standards c. Title VI of the Civil Rights Act of 1964 d. JCAHO standards on cultural competence

MULTIPLE CHOICE INTERACTION Correct answer: C Feedback for A: Incorrect. EMTALA requires Medicare-participating hospitals to provide emergency medical screening and stabilization to all patients, regardless of ability to pay. The correct answer is C. Title VI requires certain organizations to provide meaningful language assistance to LEP clients. Feedback for B: Incorrect. Although CLAS standards do address the issue of language assistance, these standards are recommendations only, not requirements. The correct answer is C. Title VI requires certain organizations to provide meaningful language assistance to LEP clients. Feedback for C: Correct. Feedback for D: Incorrect. Although JCAHO recognizes the importance of culturally and linguistically appropriate care, the Joint Commission has not yet formulated standards related to this issue. The correct answer is C. Title VI requires certain organizations to provide meaningful language assistance to LEP clients.

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2017 Summary

You have completed the lesson on the clinical and legal significance of cultural competence. Remember:

• The United States is a nation of tremendous cultural diversity.

• Cultural competence is often lacking in the practice of medicine today, leading to adverse patient outcomes and cross-cultural disparities in health status.

• Delivering medical services in a culturally competent way has many potential benefits for patients.

• Title VI of the Civil Rights Act of 1964 requires any health- or social- service organization that receives federal funding to provide effective language assistance to LEP patients/clients.

• JCAHO ��views the delivery of services in a culturally and linguistically appropriate manner as an important healthcare safety and quality issue.�

• To correct cross-cultural health disparities and improve medical services for patients, the HHS Office of Minority Health (OMH) recently released 14 recommendations for national standards on culturally and linguistically appropriate services (CLAS).

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Lesson 3: Theory of Cultural Competence 3001

Introduction Welcome to the lesson on theory of cultural competence.


Point 1 of 17

3002 Objectives


• Recognize examples of how values, worldview, time orientation, and social structure shape a patient�s healthcare-related attitudes, beliefs, behaviors, and practices.

• Distinguish between ethnocentrism [glossary] and cultural relativism [glossary].

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3003 Understanding Patients

As we have seen, cultural competence refers to the ability to provide appropriate and effective medical care and services to members of various cultural groups. This ability rests on a set of attitudes, skills, policies, and practices that make it possible for providers and organizations to understand their patients on an in-depth level. How can we, as healthcare providers, achieve the necessary in-depth understanding of our patients? Useful information for comprehensive understanding includes the patient�s healthcare-related beliefs, attitudes, behaviors, and practices --- many of which arise from the patient�s underlying:

• Values • Worldview • Time orientation • Traditional social structure

Let�s take a closer look at each of these four underlying characteristics.


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3004 Understanding Patients: Values

A value is anything of importance to an individual or a culture. For example, in the United States, we tend to value:

• Money • Freedom/independence • Privacy • Health/fitness • Physical appearance

At some level, values always drive behavior. Therefore, understanding a patient�s values can help you understand his or her behavior. When you understand a patient�s behavior at a value level, you are better able to respond to that behavior in a respectful, effective way.


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3005 Understanding Values: An Example

Mr. C is a 45-year-old patient under the care of Nurse Jones. Mr. C�s family members wish to participate in the non-technical aspects of his care. Initially, Nurse Jones responds with irritation and annoyance, not understanding why the C family refuses to recognize limitations on visiting hours or the importance of self-care for the patient. Mr. C explains that his family�s behavior arises out of the value they place on family loyalty and duty. He tells Nurse Jones that his wife and children would feel tremendous guilt and dishonor if they did not assist him in every way they could. Now that she understands that the C family is not ignoring her instructions out of spite or stubbornness, Nurse Jones finds ways of adapting the patient�s treatment plan to allow for significant family involvement.

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3006 Understanding Patients: Worldview (1)

A person�s worldview consists of his or her basic assumptions about the nature of reality. Most people believe their worldview without question. This can lead to ethnocentrism: the belief that one�s own way is right and natural, and that other ways are inferior, unnatural, uncivilized, etc. The opposite of ethnocentrism is cultural relativism. Cultural relativism:

• Looks at behavior and beliefs in their cultural context • Accepts that other ways may be different, but equally valid


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3007 Understanding Patients: Worldview (2)

Western healthcare tends to be ethnocentric, assuming that Western approaches to healing are best, and that other methods are not to be trusted or accepted. Cultural competence, however, demands cultural relativism. As culturally competent healthcare providers, we must be willing to:

• Acknowledge the potential validity of other methods. • As safe and appropriate, incorporate traditional or folk

medicine into treatment plans for patients who place a high value on spiritual, herbal, or other non-Western remedies.

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3008 Understanding Worldview: An Example

According to the worldview of Western medicine, infection is caused by microorganisms (i.e., bacteria, viruses, fungi). Ms. P believes that her bacterial pneumonia is the result of an imbalance of �heat� and �cold� in her body. Although Western medicine would insist that antibiotics can cure bacterial pneumonia, antibiotics are unlikely to help Ms. P:

• Ms. P may not take prescribed antibiotics, since she does not see how they could be useful to her.

• Even if Ms. P takes antibiotics, she may not reach a true state of healing, since she will not believe she has corrected the underlying problem of heat/cold imbalance.

In other words, a patient�s mind/beliefs must always be considered and accommodated when treating the body, both to:

• Help ensure compliance. • Help ensure full healing.

Explaining and discussing treatment options with a patient, to arrive at a culturally appropriate and mutually acceptable treatment plan, is discussed in greater detail in Part 2 of this series (Cultural Competence: Providing Culturally Competent Care).

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3009 Understanding Patients: Time Orientation

Time orientation has two aspects:

• Emphasis on past, present, or future • Attention to clock time

Let�s take a closer look at each.


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3010 Time Orientation: Past, Present, or Future

Persons with a past-time orientation tend to:

• Be traditional. • Do things the way they have always been done.

Persons with a present-time orientation tend to:

• Look to today. • Make few plans or provisions for the future.

Persons with a future-time orientation tend to:

• Place trust and faith in technologic innovations. • Plan for the future.

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3011 Past, Present, or Future Time: An Example

Western healthcare tends to be future-focused, emphasizing preventive medicine and follow-up care, and eagerly adopting the newest techniques and medications. Patients with a more present focus may have difficult complying with medical advice related to prevention or follow-up, or any condition not causing symptoms right now. For example, it may be difficult for such patients to remember to take medication for high blood pressure, or to complete a course of antibiotics once they start to feel better.

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3012 Time Orientation: Clock Time

Some people pay careful attention to the passage of time, according to the clock. Others mark time by activities or other means. Western healthcare is clock-focused: arriving at 11:00 means that you are late for a 10:15 appointment. Patients who are not clock-focused would consider both 11:00 and 10:15 �mid-morning,� and would not worry about being late.

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3013 Understanding Patients: Social Structure

In terms of power, authority, and opportunity, a social structure may be egalitarian or hierarchical [glossary}. In an egalitarian society, such as the United States, all people are equal (in theory, if not in practice). In a hierarchical society, by contrast, people are not considered inherently equal. Social status is based on characteristics such as age, sex, lineage, or occupation.


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3014 Understanding Social Structure: An Example

Western healthcare operates within a presumed egalitarian social structure, in which all competent adult patients have equal authority and power to make healthcare decisions for themselves. Some patients, however, may be used to a more hierarchical structure. For example:

• Husbands within certain cultural traditions may expect to make healthcare decisions for their wives and children.

• A patient from a cultural tradition that holds professionals such as doctors and teachers in exceptionally high regard may expect the provider to make treatment decisions for him or her.

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3015 Review Which of the following best supports the development of cultural competence?

a. Ethnocentrism b. Cultural relativism c. Future time orientation d. Focusing exclusively on observed patient/family behavior

MULTIPLE CHOICE INTERACTION Correct answer: B Feedback for A: Incorrect. Ethnocentrism is the belief that one�s own way is right and natural, and that other ways are inferior, unnatural, uncivilized, etc. Although Western healthcare tends to be ethnocentric, cultural competence demands cultural relativism (answer choice B) --- a willingness to accept that other ways may be different, but equally valid. Feedback for B: Correct. Cultural competence demands cultural relativism --- a willingness to accept that other ways may be different, but equally valid. Feedback for C: Incorrect. Future time orientation is common in Western medicine, but may not match the present time orientation of many patients. The correct answer is C. Cultural competence demands cultural relativism --- a willingness to accept that other ways may be different, but equally valid. Feedback for D: Incorrect. Focusing exclusively on observed behavior can block cultural competence, when a provider misunderstands or comes into conflict with his or her patients because of a failure to consider the core values that underlie the observed behavior. The correct answer is C. Cultural competence demands cultural relativism --- a willingness to accept that other ways may be different, but equally valid.

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3016 Review FLASH INTERACTION: 3016.SWF/FLA Complete the following table with terms from the word bank.

A person with a� Tends to: Past-time orientation Do things the way they have always

been done. Present-time orientation Look to today. Future-time orientation Trust technological innovations.

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3017 Summary You have completed the lesson on practice of cultural competence. Remember:

• A value is anything of importance to an individual or culture.

• A person�s worldview consists of his or her basic assumptions about the nature of reality.

• Western medicine tends to be ethnocentric. Cultural competence, however, demands cultural relativism.

• Time orientation has two aspects: emphasis on past, present, or future, and level of attention to clock time.

• A social structure may be egalitarian or hierarchical. • Cultural values, worldview, time orientation, and social

structure can shape healthcare-related attitudes, beliefs, behaviors, and practices.

• Understanding a patient�s values, worldview, time orientation, and social structure can help you better understand and respond to the patient�s healthcare-related attitudes, beliefs, behaviors, and practices, in a respectful and effective way.

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Lesson 4: Practice of Cultural Competence 4001

Introduction

Welcome to the lesson on the practice of cultural competence.


Point 1 of 22

4002 Objectives


• Distinguish between generalizations and stereotypes. • Identify the appropriate use of generalizations, with regard

to providing culturally competent care. • Recognize selected generalizations, applicable to specific

culture groups.

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Point 2 of 22

4003 Culture Groups

As discussed in lesson 3, cultural values, worldview, time orientation, and social structure can shape a patient�s healthcare-related attitudes, beliefs, behaviors, and practices. Let�s take a look at specific culture groups, giving consideration to how the cultural characteristics of these groups influence their healthcare-related attitudes and behaviors. Important note: The cultural characteristics listed on the following screen are generalizations. They indicate common trends and patterns seen in various culture groups. Remember, however, that each patient is unique. Never use generalizations as an ending point --- but rather, as a starting point to learn more about a patient�s unique values, beliefs, and practices. Generalizations should NEVER be used to stereotype any given individual patient, by assuming that the patient must fit the generalizations assigned to his or her culture group!


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4004 Culture Groups: African-American (1)

Religion tends to be important in the lives of African-Americans. Patients should be given time and privacy to pray, and clergy should be allowed to participate in the patient�s care, as requested and appropriate. The father or eldest male may be the spokesperson for the family, and may have final say in healthcare decisions for family members. African-Americans tend to have a present-time orientation. Providers should emphasize the importance of preventive medications and/or taking medication even when symptoms have abated or are not apparent.


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4005 Culture Groups: African-American (2)

African-Americans may refer to �high blood� or �low blood,� conditions thought to be caused and corrected by eating certain foods. Be sure to distinguish high blood from high blood pressure, as some of the foods thought to correct high blood can worsen high blood pressure. The tradition of herbal remedies is strong in the African-American culture. Be sure to ask patients whether they are taking any herbal remedies before prescribing medication, to avoid potentially dangerous drug interactions. Remember! These are generalizations, and should not be used to stereotype any individual patient. These also are selected examples only. If you treat a large number of African-American patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/african_american.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu

age=English, page 5 of 14 • http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu

age=English, page 8 of 15 • www.diversityresources.com/rc21d/african.html


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4006 Culture Groups: Anglo-American (1)

Anglo-American patients expect to be informed of the details of their condition. They value direct eye contact, privacy, and emotional control. They may expect nurses to provide psychosocial [glossary] care. Patients in this culture group generally make healthcare decisions for themselves (and/or, if parents, for their minor children), and value self-care. Poverty may lead to a present-time orientation, and consequent non-compliance with preventive medicine recommendations. Middle- and upper-class Anglo-Americans, on the other hand, tend to have a future focus, and are likely to comply with medical advice related to preventive and follow-up care.


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4007 Culture Groups: Anglo-American (2)

Anglo-Americans often prefer biomedicine [ glossary], but also may use alternative approaches. Be certain to ask about herbal remedies and other complementary medicine. Patients in this group expect an aggressive approach to treatment, and assume that treatment will focus on killing germs. They may demand antibiotics, even when unnecessary. Remember! These are generalizations, and should not be used to stereotype any individual patients. These also are selected examples only. If you treat a large number of Anglo-American patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/anglo.html


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4008 Culture Groups: Asian (1)

Asian patients may agree with their provider, to show respect. Agreement does not necessarily indicate understanding, or an intention to comply with the treatment plan. Avoid yes or no questions (instead, ask for responses that demonstrate understanding), and always stress the importance of compliance. Also to show respect, Asian patients may avoid eye contact with the provider. Do not assume this means that the patient is angry or uninterested. Family members will expect to be involved in treatment decisions and patient care. Allow family members to fulfill their family duty by providing as much non-technical care as possible to the patient, and expect that men may make healthcare decisions for their wives.


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4009 Culture Groups: Asian (2)

Asian patients may not express pain. Pain medication should be offered when appropriate, even if the patient does not request it. Family members may wish to protect a patient from hearing a poor prognosis or terminal diagnosis. Before the need arises, ask the patient which family member(s) should receive information about his or her condition. Coining [glossary] and cupping [glossary] are traditional medical practices in many Asian cultures, and should not be mistaken for signs of abuse. Remember! These are generalizations, and should not be used to stereotype any individual patient. These also are selected examples only. If you treat a large number of Asian or Asian-American patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/asian.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu



age=English, page 6 of 10 • www.diversityresources.com/rc21d/asian.html


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4010 Culture Groups: East Indian

East Indians may consider direct eye contact rude or disrespectful. Silence may indicate acceptance or approval. Family members are likely to take over the activities of daily living (ADL�s) for an East Indian patient. Unless patient self-care is medically necessary, allow this expression of familial love and duty. The Sikh religion forbids cutting or shaving head or facial hair. Be sure to consult with patients before surgical prep. Remember! These are generalizations, and should not be used to stereotype any individual patients. These also are selected examples only. If you treat a large number of East Indian patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/eastindian.html


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4011 Culture Groups: Hispanic/Latino (1)

Latinos place high value on direct eye contact, friendly physical contact, and friendly interpersonal interaction. Therefore, it is appropriate to maintain a friendly manner with Latino patients, and to ask patients about their families and interests before focusing on more direct health-related issues. Children are highly valued and loved. Allow family members to express their love and concern by spending as much time as possible with pediatric patients, as well as adult patients. Healthcare decisions are thought of as family decisions. Involve the family in decisions, and expect that wives may defer to their husbands.


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4012 Culture Groups: Hispanic/Latino (2)

Latinos may refuse hospital foods that would upset their hot/cold body balance. Offer alternatives. Many traditional Mexican foods are high in salt and fat. Be certain to discuss nutrition, especially with diabetics and hypertensives [glossary]. Latino patients may use herbal remedies. Be sure to ask before prescribing medication. Remember! These are generalizations, and should not be used to stereotype any individual patient. These also are selected examples only. If you treat a large number Latino patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/hispanic.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu



age=English, page 4 of 10 • www.diversityresources.com/rc21d/hispanic.html


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4013 Culture Groups: Middle Eastern (1) Your Middle Eastern patients may believe that communication should be two-way. Thus, you may need to share information about yourself, to receive information from the patient. Sexual segregation is an important aspect of Middle Eastern culture. Be certain to assign same-sex caregivers and interpreters (as necessary). Middle Eastern men may answer for their wives. Women may allow their husbands to make healthcare decisions for the family.


Point 13 of 22

4014 Culture Groups: Middle Eastern (2) Islam is important to most Middle Eastern people. Be sure to allow time and privacy to pray. Be aware that the attitude that personal health is in the hands of Allah may lead Middle Eastern patients to avoid taking an active role in their own healthcare. Middle Easterners may be accustomed to heavy use of medication, and may expect that all treatment plans should involve a prescription for medication. Remember! These are generalizations, and should not be used to stereotype any individual patient. These also are selected examples only. If you treat a large number of Middle Eastern patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/middle_eastern.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu

age=English, page 9 of 14 • www.diversityresources.com/rc21d/me.html


Point 14 of 22

4015 Culture Groups: Native American (1)

Patients in this group may communicate through anecdotes and metaphors [glossary]. During a conversation, the patient may pause for an extended length of time, to indicate careful consideration of the question or issue. Do not press the patient for an answer. Avoid direct eye contact and/or speaking loudly. Any illness concerns the entire family. Depending on the family structure of the patient�s tribe, healthcare decisions may be made by the male head of the family, the female head of the family, or the patient. Native Americans tend not to have a clock-focused time orientation.


Point 15 of 22

4016 Culture Groups: Native American (2)

Native American patients may be quite stoic [glossary] about pain. Offer pain medication when appropriate, even if the patient does not request it. If a patient wears a medicine bag [glossary], do not treat the bag casually, or remove it without asking the patient. Traditional healing may be an important part of any treatment plan for a Native American patient. Accommodate traditional healers and allow traditional rituals whenever possible. Never touch or casually admire a ritual object. Remember! These are generalizations, and should not be used to stereotype any individual patients. These also are selected examples only. If you treat a large number of Native American patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/native.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu



age=English, page 5 of 10


Point 16 of 22

4017 Culture Groups: Russian/Eastern European (1)

When caring for patients in this cultural group, be sure to be firm and respectful, making direct eye contact. Russians tend to have a high threshold for --- and a stoic attitude toward --- pain. Offer pain medication when appropriate, even if the patient does not request it. Food is appreciated and a good appetite is admired. Patients and family members may offer small gifts of food or chocolate. Be sure to accept these, to avoid appearing rude.


Point 17 of 22

4018 Culture Groups: Russian/Eastern European (1)

Russian and/or Eastern European patients may not feel comfortable with too many personal questions, and may be suspicious of providers who take notes. Smoking, excessive use of alcohol, and lack of exercise may be problematic. Remember! These are generalizations, and should not be used to stereotype any individual patients. These also are selected examples only. If you treat a large number of Russian/Eastern European patients, you may wish to learn more about this culture group at:

• www.ggalanti.com/cultural_profiles/russian.html • www.diversityresources.com/rc21d/russian.html • www.diversityresources.com/rc21d/sov.html • http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu



age=English, page 8 of 10


Point 18 of 22

4019 The Culture of Western Medicine

Now that we have looked at a few of the culture groups you may encounter in your practice, let�s take a brief look at the culture of Western medicine. As you review the following generalizations regarding Western healthcare providers, consider whether any of them characterize(s) you:

• Western healthcare tends to standardize definitions of health and illness, and emphasizes that technology is all-powerful.

• The practice of Western medicine stresses health maintenance and disease prevention, through immunizations, regular screenings, etc.

• Western healthcare providers are systematic and methodical. They like promptness, organization, and efficiency. They dislike tardiness, chaos, and inefficiency.

• Use of jargon is common in Western healthcare. • Western healthcare providers recognize and adhere to a

hierarchical system, in which a provider�s status is based on education, experience, and professional accomplishments.

• Western healthcare observes certain rituals around the physical exam, surgical procedures, birth, death, etc.

IMAGE: 4019.SWF/FLA

Point 19 of 22

4020 Review All patients within a given cultural group fit the generalizations applicable to that group.

a. True b. False

TRUE / FALSE INTERACTION Correct answer: B Feedback for A: Incorrect. Generalizations indicate common trends and patterns seen in various culture groups. Remember, however, that each patient is unique. Generalizations should NEVER be used to stereotype any given individual patient, by assuming that the patient must fit the generalizations assigned to his or her culture group. Feedback for B: Correct. Generalizations indicate common trends and patterns seen in various culture groups. Remember, however, that each patient is unique. Generalizations should NEVER be used to stereotype any given individual patient, by assuming that the patient must fit the generalizations assigned to his or her culture group.

Point 20 of 22

4021 Review FLASH INTERACTION: 4021.SWF/FLA Drag and drop appropriate terms from the word bank to complete the table.

The following characteristic of Western healthcare�

�may conflict with the following characteristic of certain patients:

Desire for efficiency Use of long pauses during conversation, to indicate careful consideration

Value placed on promptness Lack of attention to clock-time Emphasis on preventive medicine Present-time orientation Belief in the value and efficacy of modern technology and biomedicine

Belief in the value and efficacy of traditional/folk medicine

Point 21 of 22

4022 Summary

You have completed the lesson on practice of cultural competence. Remember:

• Generalizations indicate common trends and patterns within a group, but should never be used to stereotype any given individual.

• Familiarize yourself with generalizations applicable to the culture groups of patients served at your facility. Use these generalizations as a starting point to 1) help understand various culture groups, and 2) learn more about the unique values, beliefs, and practices of each individual patient.

NO IMAGE

Point 22 of 22

Course Glossary

# Term Definition coining using a coin to vigorously rub the skin in a prescribed manner, causing a mild dermabrasion, with

the goal of releasing excess force "wind" from the body, hence restoring balance cupping placing small, heated glasses on the skin, forming a suction that leaves a red circular mark, with the

goal of drawing out a bad force disparity inequality or difference LEP limited English proficiency; used to describe people who do not speak English fluently JCAHO Joint Commission on the Accreditation of Healthcare Organizations linguistic having to do with language ethnocentrism the belief that one�s way of doing things is the only right way cultural relativism the belief that other ways may be different from one�s own, but equally valid in their

cultural context egalitarian a type of social organization that assumes the equality of all people, in which every

individual has an equal opportunity to obtain resources and the esteem of others in leadership activities

hierarchical a social structure in which there are ordered groupings of people exacerbate make worse psychosocial involving both psychological and social aspects biomedicine the branch of medical science that applies biological and physiological principles to clinical

practice hypertensive a patient with high blood pressure anecdote short account of an incident metaphor a figure of speech in which an expression is used to suggest a similarity between two

different things stoic seeming unaffected by pleasure or pain medicine bag a magical object used to control and direct supernatural forces; a charm

[Cultural Competence] Pre-Assessment 1. Providers often do not order appropriate diagnostic tests for cultural minorities, because they do not understand or believe the patient�s description of symptoms.

a. True b. False

Correct: True Rationale: This statement is true. Alternatively, providers may overcompensate by ordering too many tests. 2. Culturally competent delivery of healthcare can contribute to:

a. Fewer diagnostic errors b. Fewer harmful drug interactions c. Greater patient compliance with medical recommendations d. All of these e. None of these

Correct: All of these Rationale: Cultural competence in the healthcare setting can contribute to more accurate diagnoses, fewer harmful drug interactions, and greater patient compliance, as well as more successful patient education for cultural minorities; increased likelihood that cultural minorities will seek necessary healthcare; improved healthcare access for cultural minorities; more appropriate health screening for cultural minorities; and, ultimately, equalization of cross-cultural health disparities. 3. Your 10:15 patient arrives at 11:00. This patient is intentionally behaving in an inconsiderate and disrespectful manner.

a. True b. False

Correct: False Rationale: Although it may seem inconsiderate and disrespectful for a patient to arrive at 11:00 for a 10:15 appointment, if that patient comes from a culture that is not clock-focused, he may consider both times mid-morning, and would not consider his arrival inconsiderately late. 4. In general, in which of the following cultures is direct eye contact valued as a way for patients to show respect for their healthcare provider?

a. Asian b. East Indian c. Native American

d. All of these e. None of these

Correct: None of these Rationale: All of these culture groups would tend to consider direct eye contact rude or disrespectful, when interacting with a healthcare provider. 5. Be certain to inquire regarding current use of herbal remedies before prescribing medication to:

a. Latino patients b. Anglo-American patients c. African-American patients d. All of these e. None of these

Correct: All of these Rationale: The tradition of herbal healing is strong in the African-American culture group. Latinos and Anglos also might use herbal remedies. To help avoid potentially harmful interactions, it is important to ask any patient about the current use of herbal remedies before prescribing medication. 6. Which of the following is (are) true of the African-American culture group, as compared to European-Americans?

a. The African-American culture group has a higher infant mortality rate. b. The African-American culture group has a higher rate of mortality due to flu. c. The African-American culture group has a higher rate of mortality due to colorectal cancer. d. All of these statements are true. e. None of these statements is true.

Correct: All of these statements are true. Rationale: African-Americans, as a group, have all of these health disparities, as compared to European-Americans. 7. Which of the following is (are) often problematic for Russian/Eastern European patients?

a. Smoking b. Lack of exercise c. Excessive use of alcohol d. All of these e. None of these

Correct: All of these Rationale: All of these problems are relatively common in the Russian/Eastern European culture group. 8. Title VI of the Civil Rights Act of 1964 mandates that federally funded health-service organizations must:

a. Make hiring and firing decisions without regard to race, color, or gender.

b. Provide emergency medical care to all patients, regardless of ability to pay. c. Provide language assistance to any patient with limited English proficiency (LEP). d. All of these are correct. e. None of these is correct.

Correct answer: Provide language assistance to any patient with limited English proficiency (LEP). Rationale: Title VI requires health- and social- services organizations to provide meaningful language assistance to LEP patients/clients. 9. The Western healthcare system, as a whole, is characterized by:

a. Ethnocentrism b. Cultural relativism c. A present-time orientation d. An egalitarian organizational structure

Correct: Ethnocentrism Rationale: The Western healthcare system tends to be future-focused (emphasizing preventive medicine and the omnipotence of the latest technology), hierarchical (according status based on education, experience, and professional accomplishments), and ethnocentric (assuming that Western approaches to healing are best, and that other methods are not to be trusted or sanctioned). 10. You are explaining a treatment plan to an Asian patient. The patient expresses agreement with your instructions. You can assume that the patient intends to comply with the treatment plan.

a. True b. False

Correct: False Rationale: Asian patients may agree with their provider, to show respect. Agreement does not necessarily indicate understanding, or an intention to comply with the treatment plan. Avoid yes or no questions (instead, elicit responses that demonstrate understanding), and always stress the importance of compliance.

Final Exam Question Title: Question 1 Question: Nearly ___% of all Americans today were born outside the United States. Answer 1: 1 Answer 2: 5 Answer 3: 10 Answer 4: 20 Correct Answer: 10 Answer Rationale: Nearly 10% of all Americans today (28 million out of a total population of close to 300 million) were born outside of the United States. Question Title: Question 2 Question: Ethnic/racial makeup cannot affect the metabolism of drugs. Answer 1: True Answer 2: False Correct Answer: False Answer Rationale: Many drug dosages and other medical norms are based on studies of Caucasian patients --- but evidence suggests that racial/ethnic makeup can affect how a patient metabolizes and responds to a drug. Question Title: Question 3 Question: The CLAS standards are meant to: Answer 1: Correct current disparities in patient access to and receipt of medical care and services. Answer 2: Improve medical services by making them better meet the needs of each individual patient. Answer 3: Both of these are correct.

Answer 4: Neither of these is correct. Correct Answer: Both of these are correct. Answer Rationale: Both of these are goals of the CLAS standards. Question Title: Question 4 Question: Understanding a patient�s values can help you better understand his or her behavior. Answer 1: True Answer 2: False Correct Answer: True Answer Rationale: At some level, values always drive behavior. Therefore, understanding a patient�s values can help you understand his or her behavior. Question Title: Question 5 Question: Which of the following is an example of cultural relativism? Answer 1: A healthcare provider tells an African-American patient that voodoo is nonsense, and that he must take antibiotics if he wants to feel better. Answer 2: A healthcare provider acknowledges the importance of spiritual healing, and encourages a Native American patient to perform a traditional healing ritual, in addition to using biomedicine. Answer 3: Both of these are examples of cultural relativism. Answer 4: Neither of these is an example of cultural relativism. Correct Answer: A healthcare provider acknowledges the importance of spiritual healing, and encourages a Native American patient to perform a traditional healing ritual, in addition to using biomedicine. Answer Rationale: Cultural relativism accepts that other ways may be different, but equally valid. Question Title: Question 6 Question: A patient is most likely not to take medication for asymptomatic high blood pressure if he or she comes from a(n) ________ culture. Answer 1: Egalitarian Answer 2: Hierarchical Answer 3: Future-focused

Answer 4: Present-focused Correct Answer: Present-focused Answer Rationale: Patients with a present-time orientation tend to look today, and make few plans or provisions for the future. Therefore, these patients may have difficulty complying with medical advice related to prevention, or any condition not causing symptoms right now. Question Title: Question 7 Question: Which of the following patients is most likely to have a future-time orientation? Answer 1: A middle-class Anglo-American Answer 2: A middle-class African-American Answer 3: An impoverished Anglo-American Answer 4: An impoverished African-American Correct Answer: A middle-class Anglo-American Answer Rationale: African-Americans tend to have a present-time orientation. Poverty also can lead to a present-time orientation. Middle- and upper- class Anglo-Americans, on the other hand, tend to be future-focused. Question Title: Question 8 Question: Sexual segregation is an important part of ________ culture. Answer 1: Middle Eastern Answer 2: Anglo-American Answer 3: African-American Answer 4: All of these Answer 5: None of these Correct Answer: Middle Eastern Answer Rationale: Sexual segregation is an important part of Middle Eastern culture. For patients who practice sexual segregation, be certain to assign same-sex caregivers and/or interpreters. Question Title: Question 9 Question: During a conversation/consultation, a Native American patient may pause for long periods of time to indicate: Answer 1: Lack of interest or concern

Answer 2: Annoyance with the healthcare provider Answer 3: Careful consideration of the question or issue Answer 4: Disapproval of the question or topic of discussion Correct Answer: Careful consideration of the question or issue Answer Rationale: During a conversation/consultation, a Native American patient may pause for long periods of time to indicate careful consideration of the question or issue. Show respect for this communication style/pattern by not rushing or pressing the patient for an answer. Question Title: Question 10 Question: ______ patients tend to be quite stoic about pain. Pain medication should be offered when appropriate, even if not requested. Answer 1: Asian Answer 2: Russian Answer 3: Native American Answer 4: All of these Answer 5: None of these Correct Answer: All of these Answer Rationale: All of these culture groups value stoicism. Patients may not indicate pain or request medication. Therefore, medication should be offered when appropriate, even if not requested.

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