Standards of Culturally Competent Care

In 1963 Bob Dylan wrote the words “For the times they are a-changing” as part of the lyrics for a popular song of his. During the current millennium the term “global economy” has become a key word throughout the world of finance. These two well-known expressions are precursors to today’s major issue of “cultural competency”. The world has changed and is global in many aspects. The influx of immigrants into the United States has continued and differences in cultures have become more and more prominent. Throughout the United States especially cultural differences have had and will continue to have a major impact on the healthcare industry.

According to The Office of Minority Health “Cultural competency is one of the main ingredients in closing the disparities gap in health care. It’s the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Quite simply, health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes”. (The U.S. Department of Health and Human Services, 2013) Culture and language may influence: health, healing, and wellness belief systems; how illness, disease, and their causes are perceived; both by the patient/consumer and the behaviors of patients/consumers who are seeking health care and their attitudes toward health care providers; as well as the delivery of services by the provider who looks at the world through his or her own limited set of values, which can compromise access for patients from other cultures.

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My personal career track has been working in and supervising and directing in Emergency Departments where the proportional rate of foreign language, especially Spanish speaking, patients has continually risen. Emergency Departments across the United States have been an area where cultural differences have been evident for a long time. With the huge influx of English language challenged immigrants who not only have not had the means to secure jobs roviding health care plans, but have also been saddled with the fear of deportation if they are considered “illegal” hindering their health care options, Emergency Departments have had to change their cultural competency to address this populations’ immediate healthcare needs. On any given day the healthcare providers in an Emergency Department can be faced with incredible diversity including the ethnic groups of Mexicans, Dominicans, Haitians, Asians, Central and South Americans, Middle Easterners, Russians, Scandinavians, Orthodox Jews, and on and on.

Each of these ethnic groups brings with it their own cultural identities including language, beliefs, socio – economic status (the wealthy, the middle class, the poor and the homeless) and pre – conceived attitudes towards the American healthcare system. It is to say the least challenging to put aside our own cultural beliefs and methods in order to treat each and every culturally diverse patient with the same caring, competent healthcare each of us as individuals would expect.

My previous and current Emergency Departments have had to identify and define ways and means of meeting the cultural and language barrier differences in order to deliver systems of healthcare to this diverse population of patients. Outlining, establishing and implementing cross-culturally communication processes was only the first major step in delivering culturally competent healthcare to all who walk through the Emergency Department doors. Our healthcare delivery systems had to be gradually reorganized in order to meet the needs of these patients.

As healthcare providers we needed not only to solve the language barrier, we also needed to find ways to incorporate cultural beliefs into the delivery of healthcare processes. To achieve such a goal of providing the very best healthcare to each and every patient walking through the ED doors regardless of race, creed, color, language and cultural beliefs, we first had to accept the cultural differences between our health care systems and the patients and conquering the language barrier was the first step in the right direction and little did we know that it would be the easiest task to accomplish.

In 2001 the Office of Minority Health developed fourteen standards to assist health care organizations in providing culturally and linguistically appropriate services (CLAS) for the patient populations they serve. This effort was developed to improve the access of care, quality of care and in the long run patient outcomes. The fourteen standards are structured in themes: Culturally Competent Care (standards 1-3), Language Access Services (Standards 4-7) and Organizational Supports for Cultural Competence.

The Language Access Services standards are federally mandated for all health care organizations that are recipients of federal funds. The greatest difficulty for most professionals with little background in transcultural nursing is the implementation of the standards for cultural competence. There is a tendency to conform all standards for the ease of implementation. This inclination minimizes the fundamental principles inherent in culturally congruent and competent care. (Pacquiao, 2004) In 2004 the Joint Commission started to pay close attention to these standards, and how health care organizations were implementing the standards.

Finally in 2007 a document entitled Office of Minority Health National Culturally and Linguistically Appropriate Services (CLAS) Standards Cross walked to Joint Commission 2007 Standards was developed to create linkages between the CLAS standards and the Joint Commission Standards. This is the time that many healthcare organizations started to focus on the standards and adopt them into their day to day practices. Standard one and three refer to healthcare organizations ensuring that patients and consumers receive from all staff members’ understandable and respectful care.

This care should be compatible with their cultural beliefs and practices and preferred language. At my current organization we achieve this standard by having all staff attend cultural competency training upon hire. This class is taught by representatives from human resources and administration. The intent of this class is to bring awareness to the fact that patients are very diverse and that we have to remember as caretakers, the patients and their families’ cultural beliefs are imperative for a successful outcome in the patient’s recovery.

After the completion of the class on hire, it is followed up with yearly competencies for our reviews. Standard two calls for healthcare organizations to implement strategies to recruit, retain and promote at all levels a diverse staff and leadership that represent the demographic area that the organizations resides in. Our leadership team and human resource department often attend many job fairs in the area to enhance diversity. On our applications for employment there are clear statements that our organization does not discriminate at any level.

Standard four and five must offer language assistance services, including bilingual staff and interpreter services at no cost to the patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. This service must be offered verbally and followed up in writing by the health care organization. This standard is easily met in my organization. We have offered employees the option to become certified interpreters throughout the hospital, and those staff that chose to participate are given a stipend each year for their service.

We also have two different communication systems (wall phones, and cell phones) which provide instant communication of all desired languages to the patient and staff. This service is carried and housed on all units, and all employees are trained how to access it and use it. Standard six emphasizes the Joint Commission Standard that friends and families cannot be used at interpreters, and all interpreters have to be trained in interpretation. If families are informed of the risk of having friends and families interpret and sign understanding of that risk, then the organization is relieved of their obligation.

Standard seven requires that organizations make available easily understood patient-related materials and post signage in the language of the commonly encountered groups. Spanish is the language that is most common in the area that surrounds my healthcare organization. Each sign that is displayed in English has a sign next to it in Spanish. All of our forms that are in English can also be printed in Spanish using “form software”. We also have the availability using this program to search and translate forms into other languages.

Another feature that the organization takes into consideration is the average reading level of the surrounding population, and has all forms translated into that grade level. Standard eight and nine suggest that organizations should conduct ongoing organizational self-assessments of CLAS related activities and are encouraged to implement changes to their current practices, based on the need of the growing population. Currently at my facility we have a multidiscipline committee that tackles the ongoing education and needs of the community.

This committee recently added to our performance measures some questions to evaluate how the staff integrates cultural competence into their daily practice. This performance measure is also on the leadership team, including the chief executive officer. Standards ten and eleven propose that organizations collect data and perform a needs assessment to identify the population of the area. Profiles of the different cultures have to be available to the staff and the community for review.

Our nursing program tackles this issue many years ago, and continues to work hard on addressing the needs of the population. As each patient enters the facility there is an initial intake done on the patient to identify not only their “learning readiness needs” but also their cultural needs. Potential barriers are discovered at this point in their hospital stay, and referrals are made according to the needs of the patients. Nursing does not have to obtain a doctor order for this referral.

This has helped patients tremendously in their journey to achieve their prior state of health. Standard twelve requests that healthcare organizations develop participatory and collaborative partnerships with communities and to ensure that patients and consumers are participating at all levels with the organization. We have very strong community partner relations with many different organizations. It is important for our hospital to meet the needs of the surrounding community and in turn have them meet the needs that we have.

The hospital employs a liaison to the minority community who serves as a advocate for them while keeping the mission and scope of the hospital in the forefront. Standard thirteen necessitates that a grievance procedure that is culturally and linguistically appropriate that resolves conflicts and complaints. Our patient advocates in nursing continue to not only be the voice of the patients, but the staff as well. The complaints and grievances are kept and reviewed for any trends or concerns. We also have a mechanism for the staff to report any practice that becomes questionable when it relates to patient safety or quality.

This reporting mechanism is anonymous, and is encouraged for all staff to use to ensure we continue to deliver patient centered quality care. Standard fifteen encourages organizations to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards. This is the only standard that I am not sure is addressed by my organization. There are many regulatory agencies that we are associated with where our data is transparent. This data might be on the senior level, and be presented at board meetings, and published in our annual report.

In looking at how nursing has contributed to assessing the needs of cultural based care, one must not forget all of the work done by Madeline Leininger. In her days as a pediatric nurse she was shocked by patterns of behavior in children that seem to stem from a cultural basis. Leininger identified a lack of cultural and care knowledge as the missing link to nursing standards of the many variations required in patient care support to compliance, healing, and wellness (George, 2011). These insights led to nursing theory of transcultural nursing.

Leininger’s goal was to creatively use culturally based knowledge to provide culturally congruent care. Culturally congruent care is defined as care that is holistic and focuses on the many aspects of a patient’s life. The focus might be geared towards religion, education, environment, and language. Madeline Leininger’s theory of transcultural nursing embodies a well thought out philosophy of the four concepts of the metaparadigm. The four concepts of the metaparadigm are person, health, environment and nursing.

She understood the concepts, but did not agree with all the terms according her theory. First, she believed that the term “person” did not embrace the human as a whole. A person was also defined by their community, family and groups. Health needed to be aligned as a state of wellbeing while being aligned with cultural beliefs. ”. “Nursing” was to be replaced by care. Leininger stated often that “there could no curing without caring, but caring can exist without curing. ” Environment was not clearly defined in her theory, but her worldview concept illustrates her ideas to her audience perfectly. Armed with all of the above information – the outlining of diversity issues in healthcare followed by the changes that have been already implemented in many healthcare facilities in the past few decades to address these issues, the involvement of the Department of Health and Human Services – one can clearly see that the idea of “cultural competency” in the healthcare industry has truly been recognized and tremendous changes have already been implemented in order to close the disparity gap.

Cultural competency is only going to continue to improve and with that improvement the care and treatment of all patients along with the training and attitudes of the nurses tending to them will be enhanced along the way. Better care and better nursing will be beneficial to both the caretaker and the cared for. Cultural competency as it continues to grow and expand will enhance the quality of care for all populations and like so many other changes in nursing the ideas implemented will become accepted and as routine as taking the blood pressure of a atient. “In 1985, the United States Department of Health and Human Services (HHS) released a landmark report documenting the existence of health disparities for minorities in the United States. It called such disparities, “an affront both to our ideals and to the ongoing genius of American medicine. ” In the decades since the release of that report much has changed in our society—including significant improvements in health and health services throughout the nation.

Nevertheless, health and healthcare disparities continue to exist and, in some cases, the gap continues to grow for racial and ethnic minorities, the poor, and other at-risk populations. Beyond the heavy burden that health disparities represent for the individuals affected, there are additional social and financial burdens borne by the country as a whole. These burdens constitute both ethical and practical mandates to reduce health disparities and achieve health equity”.

Therefore, despite the strides that have been made in an effort to close the disparity gap between those who speak a foreign language, those who have and cannot afford health insurance, those who have cultural differences in areas of religion, personal beliefs etc. , there is still so much more to be achieved in order to ensure competent health care availability for every single man, woman and child who steps through the doors of an Emergency Department, a health clinic, an urgent care center and/or a Doctor’s office seeking medical treatment.

One thing I personally have learned through the field of Emergency Medicine is that almost every person who comes into an ER is there because they believe that they have a medical emergency. Not understanding their language or their culture is no longer an acceptable excuse for poor or non-delivery of emergency services. So just as “the times they were a changing” in 1963 for Bob Dylan, the time of disparity in healthcare has reached its peak and can no longer be tolerated or allowed no matter the cost to healthcare providers or to federal and local governments.

The responsibility to shoulder any burden for fair and competent healthcare rests on all. Medical care providers can no longer simply be there when the Haitians, the Italians or the Japanese suffer from an earthquake or when a Tsunami hits the Thais, or even when Hurricane Sandy wreaks havoc and destruction along the American Coastline – we need to be there 24/7, ready, willing and most importantly able to protect lives – young and old, rich or poor, American or immigrant – living p to the all-important modern day version of the Hippocratic Oath as outlined in The Declaration of Geneva which clearly states:I solemnly pledge to consecrate my life to the service of humanity; and I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.


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