Cultural competence in healthcare in the community: A concept analysis

This study aims to conduct a concept analysis on cultural competence in community healthcare. Clarification of the concept of cultural competence is needed to enable clarity in the definition and operation, research and theory development to assist healthcare providers to better understand this evolving concept. Rodgers’ evolutionary concept analysis method was used to clarify the concept's context, surrogate terms, antecedents, attributes and consequences and to determine implications for further research. Articles from 2004 to 2015 were sought from Medline, PubMed, CINAHL and Scopus using the terms “cultural competency” AND “health,” “cultural competence” OR “cultural safety” OR “cultural knowledge” OR “cultural awareness” OR cultural sensitivity OR “cultural skill” AND “Health.” Articles with antecedents, attributes and consequences of cultural competence in community health were included. The 26 articles selected included nursing (n = 8), health (n = 8), psychology (n = 2), social work (n = 1), mental health (n = 3), medicine (n = 3) and occupational therapy (n = 1). Findings identify cultural openness, awareness, desire, knowledge and sensitivity and encounter as antecedents of cultural competence. Defining attributes are respecting and tailoring care aligned with clients’ values, needs, practices and expectations, providing equitable and ethical care, and understanding. Consequences of cultural competence are satisfaction with care, the perception of quality healthcare, better adherence to treatments, effective interaction and improved health outcomes. An interesting finding is that the antecedents and attributes of cultural competence appear to represent a superficial level of understanding, sometimes only manifested through the need for social desirability. What is reported as critical in sustaining competence is the carers’ capacity for a higher level of moral reasoning attainable through formal education in cultural and ethics knowledge. Our conceptual analysis incorporates moral reasoning in the definition of cultural competence. Further research to underpin moral reasoning with antecedents, attributes and consequences could enhance its clarity and promote a sustainable enactment of cultural competence.     

A framework for cultural competence in health care organizations

Increased racial and ethnic diversity in the United States brings challenges and opportunities for health care organizations to provide culturally competent services that effectively meet the needs of diverse populations. The need to provide more culturally competent care is essential to reducing and eliminating health disparities among minorities. By removing barriers to cultural competence and placing a stronger emphasis on culture in health care, health care organizations will be better able to address the unique health care needs of minorities. Organizations should assess cultural differences, gain greater cultural knowledge, and provide cultural competence training to deliver high-quality services. This article develops a framework to guide health care organizations as they focus on establishing culturally competent strategies and implementing best practices aimed to improve quality of care and achieve better outcomes for minority populations.     

Improving care and interactions with racially and ethnically diverse populations in healthcare organizations

The need for healthcare managers to develop strategies that address culturally appropriate care for racial and ethnic populations continues to grow in importance. Healthcare organizations within the United States serve a range of diverse people, but they are not adequately meeting the needs of specific populations. Cultural and linguistic barriers are posing problems for an industry that is already financially strained. If strategies to provide more culturally appropriate care are not implemented, financial pressures will continue to rise and quality of care will suffer. Healthcare organizations can and should promote cultural competence among their physicians and employees. This article attempts to define the scope of the problem through literature and case studies. It also offers healthcare managers strategies for improving cultural understanding and competency within their organization.     

Towards cultural landscapes of care

This paper sets out a theoretical agenda for Cultural Landscapes of Care. It highlights the importance of engaging the cultural vectors within different ‘care-ful geographies’, in order to highlight the role of culture as both a lens of knowing a meaningful way of life, and a critical hermeneutic. Through revisiting discussions around everyday practices of care, both in this journal and elsewhere, we outline a research agenda that re-engages culture with inquiries into the relations between place and care, including spatialities of care, ethics and justice. We call for a shift to thinking with culture and its moral dimensions in order to make sense of the tensions, ambiguities and boundaries of care marked by austerity, neoliberalism and globalisation. We therefore coin the term ‘cultural landscapes of care’ to advance an agenda that is contextually and culturally sensitive, and committed to understanding what good care means in diverse trans-local contexts. Gathering together the papers in this collection, we show how culture ‘filters’ through meaningful everyday care practices. We argue for an understanding of culture as a toolkit and a condition for ethical encounters of care. Thus, we translate situated examples of caring experiences into a global standpoint of care-ful geography.     

Programmatic barriers to providing culturally competent end-of-life care

Despite many efforts to increase access to end-of-life care, culturally diverse groups are still not being served. Interviews of 22 hospice and palliative care program directors in one southeastern state indicated that directors overestimated how well programs are doing in meeting the needs of diverse groups but were very interested in implementing cultural diversity training for their staff Those who were more concerned about such issues had recruited more diverse volunteers into their programs. The presence of diverse staff or volunteers predicted a more diverse patient population. A number of efforts were underway to develop cultural competence and provide culturally competent care. Several directors reported no efforts in this direction, however Directors described programmatic barriers and resources needed. The authors concluded that directors should provide leadership in their agencies in welcoming diversity. Implications for further research and work within the larger end-of-life care field are discussed.     

'It's different from my culture; they're very different': Providing community-based, 'culturally competent' palliative care for South Asian people in the UK

This article investigates the challenges faced by those trying to develop 'culturally competent' palliative care for South Asian cancer patients in Luton, UK. It discusses the findings of a phenomenological study of service providers' attitudes to and experiences of caring for South Asian patients. Ten semi-structured in-depth interviews were carried out with a range of staff who work in home and community-based palliative care settings, including nurses, community liaison personnel and representatives of non-statutory organisations. The authors begin by considering how these service providers construct ideas of cultural difference and how these relate to philosophies of palliative care. They then examine attempts to deal with cultural diversity in everyday practice, focusing in particular on the social context of care in the home. The paper considers the ways in which staff attempt to incorporate the cultural needs of patients, family, kin and community. Rather than criticising current working practices, the authors highlight the complexity of delivering culturally competent services from the perspective of those working directly with patients. In doing so, they contribute to ongoing debates about the development of anti-discriminatory practice in health and social care.     

Cultural competence dimensions and outcomes: a systematic review of the literature

It has been widely suggested that cultural competence is an individual's core requirement for working effectively with culturally diverse people. However, there is no consensus regarding the definition or the components of this concept and there is a dearth of empirical proof indicating the benefits of cultural competence. Therefore, a systematic review was conducted to identify the most common cultural competence dimensions proposed in recent publications and to identify whether sufficient evidence exists regarding the efficacy of cultural competence in the healthcare context. A total of 1204 citations were identified through an electronic search of databases, of which 18 publications included cultural competence frameworks, and 13 studies contained empirical data on cultural competence outcomes. The overarching themes of the review were centred around the challenges faced by the healthcare sector in many countries due to growing cultural diversity, but lack of cultural competence, leading to predicaments that arise during intercultural interactions between patients and clinicians. This review will benefit researchers exploring cultural competence as one of the research variables impacting research outcomes.     

From the perspective of CEOs: what motivates hospitals to embrace cultural competence?

The quality domains of patient-centered and equitable care are increasingly relevant to today's healthcare leaders as hospitals care for patients with increasingly diverse cultural and linguistic needs. Hospital leaders face substantial tensions in defining their organization's strategic priorities to improve care for diverse populations with limited resources, increased competition, and complex regulatory and accreditation requirements. We sought to understand what motivates hospitals to focus on and commit resources to supporting the delivery of culturally competent care by analyzing interviews with chief executive officers (CEOs) in 60 hospitals across the United States. Hospital CEOs in our study most often embraced cultural competence efforts because doing so helped them achieve the organization's mission and priorities and/ or meet the needs of a particular patient population. Less often, they were motivated by perceived benefits and legal or regulatory issues. Many CEOs articulated a link between quality and cultural competence, and a smaller number went on to link cultural competence efforts to improved financial outcomes through cost savings, increased market share, and improved efficiency of care. However, the link between quality and cultural competence is still in the early stages. Fortunately, frameworks for hospitals to adopt and steps that hospitals can take to improve the quality of care for all patients have been identified. They begin with a commitment from hospital leaders based on understanding the needs of patients and communities and are propelled by data that reveal the impact of efforts to improve care. Leaders must communicate and shepherd organizations to align the congruence between improvement efforts and business strategies.     

‘Creating a culturally competent pharmacy profession’: A qualitative exploration of pharmacy staff perspectives of cultural competence and its training in community pharmacy settings

Introduction

Cultural competence is an important attribute underpinning interactions between healthcare professionals, such as pharmacists, and patients from ethnic minority communities. Health- and medicines-related inequalities affecting people from underrepresented ethnic groups, such as poorer access to healthcare services and poorer overall treatment outcomes in comparison to their White counterparts, have been widely discussed in the literature. Community pharmacies are the first port of call for healthcare services accessed by diverse patient populations; yet, limited research exists which explores the perceptions of culturally competent care within the profession, or the delivery of cultural competence training to community pharmacy staff. This research seeks to gather perspectives of community pharmacy teams relating to cultural competence and identify possible approaches for the adoption of cultural competence training.

Methods

Semistructured interviews were conducted in-person, over the telephone or via video call, between October and December 2022. Perspectives on cultural competence and training were discussed. Interviews were audio-recorded and transcribed verbatim. The reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Ethics Committee (reference: 25680/2022).

Results

Fourteen participants working in community pharmacies were interviewed, including eight qualified pharmacists, one foundation trainee pharmacist, three pharmacy technicians/dispensers and two counter assistants. Three themes were developed from the data which centred on (1) defining and appreciating cultural competency within pharmacy services; (2) identifying pharmacies as ‘cultural hubs’ for members of the diverse, local community and (3) delivering cultural competence training for the pharmacy profession.

Conclusion

The results of this study offer new insights and suggestions on the delivery of cultural competence training to community pharmacy staff, students and trainees entering the profession. Collaborative co-design approaches between patients and pharmacy staff could enable improved design, implementation and delivery of culturally competent pharmacy services.

Patient or Public Contribution

The Patient and Public Involvement and Engagement group at Newcastle University had input in the study design and conceptualisation. Two patient champions inputted to ensure that the study was conducted, and the findings were reported, with cultural sensitivity.     

An investigation of culturally competent terminology in healthcare policy finds ambiguity and lack of definition

Objective : This research explored how the concept of cultural competence was represented and expressed through health policies that were intended to improve the quality and efficacy of healthcare provided to families from culturally marginalised communities, particularly women and children with refugee backgrounds. Method : A critical document analysis was conducted of policies that inform healthcare for families from culturally marginalised communities in two local government areas in South Australia. Results : The analysis identified two major themes: lack of, or inconsistent, definitions of ‘culture’ and ‘cultural competency’ and related terms; and the paradoxical use of language to determine care. Conclusions : Cultural competence within health services has been identified as an important factor that can improve the health outcomes for families from marginalised communities. However, inconsistency in definitions, understanding and implementation of cultural competence in health practice makes it difficult to implement care using these frameworks. Implications : Clearly defined pathways are necessary from health policy to inform culturally competent service delivery. The capacity for policy directives to effectively circumvent the potential deleterious outcomes of culturally incompetent services is only possible when that policy provides clear definitions and instructions. Consultation and partnership are necessary to develop effective definitions and processes relating to cultural competence.     

Cultural competence among physicians treating Mexican Americans who have diabetes: a structural model

Latinos, who constitute the fastest growing ethnically distinct US group, experience disproportionately high rates of type 2 diabetes. At the same time, linguistic and economic barriers, differing cultural expectations between patients and physicians, provider reactions based on stereotypes, and managed healthcare shortfalls limit diabetes care. Such trends highlight physicians' need to consider culture in the delivery of effective services. To address these issues we investigated predictors of culturally competent actions among a sample of 134 practicing San Diego County physicians. They provided demographic information and completed questions assessing their cultural knowledge, cultural awareness, and culturally competent actions specific to Mexican Americans with diabetes. We then developed a structural cultural competence model. Results indicated that participation in diverse medical education settings and experience in community clinics predicted cultural knowledge. Participation in diverse educational settings, Latino ethnicity, bilingual skills, and cultural knowledge predicted cultural awareness. An internal medicine specialty predicted less cultural awareness. Culturally competent actions were only predicted by cultural awareness. Goodness-of-fit statistics supported the overall model's acceptability. The number of Mexican Americans physicians see in practice did not predict any tested cultural competence dimension. Our model supports a number of conclusions. First, knowledge of cultural factors per se and simple exposure to Mexican Americans in practice do not directly facilitate culturally competent care. Rather, such care is most strongly predicted by recognition that cultural factors and awareness of personal biases are important. Results further support medical education that does not solely focus on basic information about Mexican Americans but also explores provider biases and preconceptions. Diverse educational experiences appear particularly helpful in this process. Community clinic settings also help practitioners gain cultural knowledge. While Latino ethnicity predicted cultural awareness, results also suggest that all physicians can take steps towards increasing their cultural competence.     

Nursing responsibility and conditions of practice: are we justified in holding nurses responsible for their behaviour in situations of patient care?

Abstract This paper analyses a situation where a patient's suffering provoked feelings of compassion in a student nurse, and distress at her patient's circumstances. The reported behaviour of qualified nurses within the situation suggests that they lacked compassion, had inadequate knowledge, and that they failed to understand their patient's plight. An account of the situation is followed by an exploration of the nature of moral agency, and understanding in nursing. Nurses' capacity for moral imagination is shown to be of crucial importance to the care that patients receive. The extent of nurses' responsibility for their behaviour is considered, and in particular, the extent of nurses' responsibility during times when they experience strain. Argument leads to the conclusion that we are justified in holding nurses responsible for their behaviour in situations of patient care, although we must not judge a nurse's behaviour too hastily. Attention is drawn to the need for a moral climate to sustain those nurses who struggle to give good patient care, despite the strain that is ever present within today's world of health care.     

Chinese children’s justifications for sharing resources: why do we have to share?

Gilligan argued that Kohlberg’s justice‐based stage theory of morality reflects only one type of morality and does not consider people’s tendency to use care‐based moral judgements. This study examines Chinese children’s tendency to use justice‐based and care‐based justifications for moral reasoning. Children’s attitudes to conforming to the sharing rule were investigated by asking five‐year‐olds (N = 155) about a hypothetical situation in which there were conflicts between conforming to rules and fulfilling personal goals/desires in the family context. Children were asked to suggest appropriate solutions for the conflicts and to justify their suggestions. Results indicated that the majority of the Chinese children’s moral reasoning was characterised by care‐based morality that focuses on the importance of pro‐social behaviours (being helpful, caring for the needs of others). The findings highlight the need for teachers to critically examine how justice and care are taught in the preschool context, and to what extent cultural values affect children’s moral orientations.     

Examining the conflation of multiculturalism, sexism, and religious fundamentalism through Taylor and Bakhtin: expanding post-colonial feminist epistemology

In this post-9/11 era marked by religious and ethnic conflicts and the rise of cultural intolerance, ambiguities arising from the conflation of multiculturalism, sexism, and religious fundamentalism jeopardize the delivery of culturally safe nursing care to non-Western populations. This new social reality requires nurses to develop a heightened awareness of health issues pertaining to racism and ethnocentrism to provide culturally safe care to non-Western immigrants or refugees. Through the lens of post-colonial feminism, this paper explores the challenge of providing culturally safe nursing care in the context of the post-9/11 in Canadian healthcare settings. A critical appraisal of the literature demonstrates that post-colonial feminism, despite some limitations, remains a valuable theoretical perspective to apply in cultural nursing research and develop culturally safe nursing practice. Post-colonial feminism offers the analytical lens to understand how health, social and cultural context, race and gender intersect to impact on non-Western populations' health. However, an uncritical application of post-colonial feminism may not serve racialized men's and women's interests because of its essentialist risk. Post-colonial feminism must expand its epistemological assumptions to integrate Taylor's concept of identity and recognition and Bakhtin's concepts of dialogism and unfinalizability to explore non-Western populations' health issues and the context of nursing practice. This would strengthen the theoretical adequacy of post-colonial feminist approaches in unveiling the process of racialization that arises from the conflation of multiculturalism, sexism, and religious fundamentalism in Western healthcare settings.     

Bioethics in a Multicultural World: Medicine and Morality in Pluralistic Settings

Current approaches in bioethics largely overlook the multicultural social environment within which most contemporary ethical issues unfold. For example, principlists argue that the common morality of society supports four basic ethical principles. These principles, and the common morality more generally, are supposed to be a matter of shared common sense. Defenders of case-based approaches to moral reasoning similarly assume that moral reasoning proceeds on the basis of common moral intuitions. Both of these approaches fail to recognize the existence of multiple cultural and religious traditions in contemporary multicultural societies. In multicultural settings, patients and their families bring many different cultural models of morality, health, illness, healing, and kinship to clinical encounters. Religious convictions and cultural norms play significant roles in the framing of moral issues. At present, mainstream bioethics fails to attend to the particular moral worlds of patients and their family members. A more anthropologically informed understanding of the ethical issues that emerge within health care facilities will need to better recognize the role of culture and religion in shaping modes of moral deliberation.     

Bioethics in pluralistic societies

Contemporary liberal democracies contain multiple cultural, religious, and philosophical traditions. Within these societies, different interpretive communities provide divergent models for understanding health, illness, and moral obligations. Bioethicists commonly draw upon models of moral reasoning that presume the existence of shared moral intuitions. Principlist bioethics, case-based models of moral deliberation, intuitionist frameworks, and cost-benefit analyses all emphasise the uniformity of moral reasoning. However, religious and cultural differences challenge assumptions about common modes of moral deliberation. Too often, bioethicists minimize or ignore the existence of multiple traditions of moral inquiry. Careful consideration of the presence of multiple horizons for moral deliberation generates challenging questions about the capacity of bioethicists to effectively resolve complex cases and social policy disputes.     

Conflict management styles of Asian and Asian American nurses: implications for the nurse manager

Foreign nurses and American nurses who are culturally diverse make up an increasing number of the US nursing workforce. Of foreign nurses, Asians constitute the largest number. Conflict is an inevitable aspect of human relations in health care settings. Nurses and other health team members with diverse cultural background bring to the workplace different conflict behaviors that directly impact the outcomes of conflicts. It is essential for health care team members and managers to be cognizant of different conflict behaviors as well as different conflict management styles so that strategies can be designed to build a culturally diverse health care team that is able to effectively achieve group and organizational objectives.     

Critical elements of culturally competent communication in the medical encounter: A review and model

Increasing the cultural competence of physicians is one means of responding to demographic changes in the USA, as well as reducing health disparities. However, in spite of the development and implementation of cultural competence training programs, little is known about the ways cultural competence manifests itself in medical encounters. This paper will present a model of culturally competent communication that offers a framework of studying cultural competence ‘in action.’ First, we describe four critical elements of culturally competent communication in the medical encounter – communication repertoire, situational awareness, adaptability, and knowledge about core cultural issues. We present a model of culturally competent physician communication that integrates existing frameworks for cultural competence in patient care with models of effective patient-centered communication. The culturally competent communication model includes five communication skills that are depicted as elements of a set in which acquisition of more skills corresponds to increasing complexity and culturally competent communication. The culturally competent communication model utilizes each of the four critical elements to fully develop each skill and apply increasingly sophisticated, contextually appropriate communication behaviors to engage with culturally different patients in complex interactions. It is designed to foster maximum physician sensitivity to cultural variation in patients as the foundation of physician-communication competence in interacting with patients.     

Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study

Ethnic minorities across the globe encounter disparities in healthcare. While a great deal of research has been conducted on the experiences of these patients, studies focusing on the perspectives of healthcare professionals are limited, particularly in the context of Asia. This study explores the perceptions of and challenges faced by Hong Kong healthcare professionals in the provision of culturally appropriate care to South Asian ethnic minority patients. Taking a qualitative approach, interviews were conducted with 22 healthcare professionals. Two main themes were identified: ‘lack of support’ at the healthcare system level and ‘dysfunctional relationship with South Asian ethnic minority patients’ at the interpersonal level. Challenges at the healthcare system level include information outreach, cultural competency, utilisation of available resources and time and workload, whereas challenges at the interpersonal level include patient–provider interaction, patient–provider perceptions of illness and care and patient–provider sociocultural discordance. Intercultural care was found to be influenced by both the healthcare system and interpersonal characteristics. The study highlights the need for healthcare professional education and training in cultural competency, in order to improve the provision of intercultural care. Identifying the challenges faced by healthcare professionals and the implications of these challenges for the provision of healthcare to South Asian ethnic minority patients will help practitioners, policy makers and care provider agencies to improve quality of care and health outcomes for culturally diverse patients.     

Cultural safety and the challenges of translating critically oriented knowledge in practice

Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge‐translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge‐translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of ‘culture’, ‘safety’, and ‘cultural safety’ need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge‐translation process is a ‘social justice curriculum for practice’ that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.