Managing Quality and Risk

Chapter 9 Cultural Diversity in Health Care This chapter focuses on the importance of cultural considerations for patients and staff. Although it does not address comprehensive details about any specific culture, it does provide guidelines for actively incorporating cultural aspects into the roles of leading and managing. Diverse workforces are discussed, as well as how to capitalize on their diverse traits and how to support differences to work more efficiently. The chapter presents concepts and principles of transculturalism, describes techniques for managing a culturally diverse workforce, emphasizes the importance of respecting different lifestyles, and discusses the effects of diversity on staff performance. Scenarios and exercises to promote an appreciation of cultural richness are also included. Learning Outcomes • Describe common characteristics of any culture. • Evaluate the use of concepts and principles of acculturation, culture, cultural diversity, and cultural sensitivity in leading and managing situations. • Analyze differences between cross-cultural, transcultural, multicultural, and intracultural concepts and cultural marginality. Managing Quality and Risk

• Evaluate individual and societal factors involved with cultural diversity. • Value the contributions a diverse workforce can make to the care of people. Key Terms acculturation cross-culturalism cultural competence cultural diversity cultural imposition cultural marginality cultural sensitivity culture ethnicity ethnocentrism multiculturalism transculturalism Introduction Culture influences leadership from two perspectives. One is the way in which we meet patient needs; the other is the way in which we work together in a diverse workforce. Effective leaders can shape the culture of their organization to be accepting of persons from all races, ethnicities, religions, ages, lifestyles, and genders. These interactions of acceptance should involve a minimum of misunderstandings. Multicultural phenomena are cogent for each person, place, and time. Connerley and Pedersen (2005) provided 10 examples for leading from a complicated culture-centered perspective. For example, “3. Explain the action of employees from their own cultural perspective; 6. Reflect culturally appropriate feelings in specific and accurate feedback” (p. 29). Therefore culturecentered leadership provides organizational leaders, such as nurse managers and effective team members, the opportunity to influence cultural differences and similarities among their unit staff. Concepts and Principles What is culture? Does it exhibit certain characteristics? What is cultural diversity, and what do we think of when we refer to cultural sensitivity? Are culture and ethnicity the same? Various authors have different views. Cultural background stems from one’s ethnic background, socio-economic status, and family rituals, to name three key factors. Ethnicity, according to The Merriam-Webster Dictionary (Merriam-Webster Inc., 2013), is defined as related to groups of people who are “classified” according to common racial, tribal, national, religious, linguistic, or cultural backgrounds. This description differs from what is commonly used to identify racial groups. This broader definition encourages people to think about how diverse the populations in the United States are. Inherent characteristics of culture are often identified with the following four factors: 1.Culture develops over time and is responsive to its members and their familial and social environments. 2.A culture’s members learn it and share it. 3.Culture is essential for survival and acceptance. 4.Culture changes with difficulty. For the nurse leader or manager, the characteristics of ethnicity and culture are important to keep in mind because the underlying thread in all of them is that staff’s and patients’ culture and ethnicity have been with them their entire lives. All people view their cultural background as normal; the diversity challenge is for others to view it as normal also and to assimilate it into the existing workforce. Cultural diversity is the term currently used to describe a vast range of cultural differences among individuals or groups, whereas cultural sensitivity describes the affective behaviors in individuals—the capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people. Spector (2009) addressed three themes involved with acculturation. (1) Socialization refers to growing up within a culture and taking on the characteristics of that group. All of us are socialized to some culture. (2) Acculturation refers to adapting to a particular culture. An example of this might be what a particular society calls a particular food or how healthcare organizations are changing to blame-free environments to encourage safety disclosures. The overall process of acculturation into a new society is extremely difficult. “America” has a core culture and numerous subcultures. Managing Quality and Risk

For example, think how differently people in rural American regions dress from those in urban centers, or how a city looks on Saturday night versus Sunday morning. In other words, subcultures expand on how the core culture might be described. (3) Assimilation refers to the change that occurs when nurses move from another country to the United States, or from one part of the country to another. They face different social and nursing practices, and individuals now define themselves as members of the dominant culture. An example of this might be when nurses no longer say they are from their country of origin. They say they are from where they live and practice. Providing care for a person or people from a culture other than one’s own is a dynamic and complex experience. The experience according to Spence (2004) might involve “prejudice, paradox and possibility” (p. 140). Spence used prejudice as conditions that enabled or constrained interpretation based on one’s values, attitudes, and actions. By talking with people outside their “circle of familiarity,” nurses can enhance their understanding of personally held prejudices. Prejudices “enable us to make sense of the situations in which we find ourselves, yet they also constrain understanding and limit the capacity to come to new or different ways of understanding. It is this contradiction that makes prejudice paradoxical” (Spence, 2004, p. 163). Paradox, although it may seem incongruent with prejudice, describes the dynamic interplay of tensions between individuals or groups. We have the responsibility to acknowledge the “possibility of tension” as a potential for new and different understandings derived from our communication and interpretation. Possibility therefore presumes a condition for openness with a person from another culture (Spence, 2004). Cultural marginality is defined as “situations and feelings of passive betweenness when people exist between two different cultures and do not yet perceive themselves as centrally belonging to either one” (Choi, 2001, p. 193). This “betweenness” is a time when managers might perceive disinterest in cultural considerations. This situation might actually reflect cognitive processing of information that isn’t yet reflected in effective behaviors. Ethnocentrism “refers to the belief that one’s own ways are the best, most superior, or preferred ways to act, believe, or behave” (Leininger, 2002b, p. 50), whereas cultural imposition is defined as “the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons” (Leininger, 2002b, p. 51). Such practices constitute a major concern in nursing and “a largely unrecognized problem as a result of cultural ignorance, blindness, ethnocentric tendencies, biases, racism or other factors” (Leininger, 2002b, p. 51). Providing quality of life and human care is difficult to accomplish if the nurse does not have knowledge of the recipient’s culture as it relates to care. Leininger believed that “culture reflects shared values, beliefs, ideas, and meanings that are learned and that guide human thoughts, decisions, and actions. Cultures have manifest (readily recognized) and implicit (covert and ideal) rules of behavior and expectations. Human cultures have material items or symbols such as artifacts, objects, dress, and actions that have special meaning in a culture” (Leininger, 2002b, p. 48). Leininger (2002b) stated that her views of cultural care are “a synthesized construct that is the foundational basis to understanding and helping people of different cultures in transcultural nursing practices” (p. 48). Managing Quality and Risk

(See the Theory Box on p. 157.) Accordingly, “quality of life” must be addressed from an emic (insider) cultural viewpoint and compared with an etic (outsider) professional’s perspective. By comparing these two viewpoints, more meaningful nursing practice interventions will evolve. This comparative analysis will require nurses to include global views in their cultural studies that consider the social and environmental context of different cultures. Theory How do leaders, managers, or followers take all of the expanding information on the diversity of healthcare beliefs and practices and give it some organizing structure to provide culturally competent and culturally sensitive care to patients or clients? Purnell and Paulanka (2008), Campinha-Bacote (1999, 2002), Giger and Davidhizar (2002), and Leininger (2002a) provided an overview of each of their theoretical models to guide healthcare providers for delivering culturally competent and culturally sensitive care in the workplace. Purnell and Paulanka’s (2008) Model for Cultural Competence provides an organizing framework. The model uses a circle with the outer zone representing global society, the second zone representing community, the third zone representing family, and the inner zone representing the person. The interior of the circle is divided into 12 pie-shaped wedges delineating cultural domains and their concepts (e.g., workplace issues, family roles and organization, spirituality, and healthcare practices). The innermost center circle is black, representing unknown phenomena. Cultural consciousness is expressed in behaviors from “unconsciously incompetent—consciously incompetent—consciously competent to unconsciously competent” (p. 10). The usefulness of this model is derived from its concise structure, applicability to any setting, and wide range of experiences that can foster inductive and deductive thinking when assessing cultural domains. Purnell (2009) described the dominant cultural characteristics of selected ethnocultural groups and a guide for assessing their beliefs and practices. The Purnell Model for Cultural Competence serves as an organizing framework for providing cultural care, which is based on 20 major assumptions. Campinha-Bacote’s (1999, 2002) culturally competent model of care identifies five constructs: (1) awareness, (2) knowledge, (3) skill, (4) encounters, and (5) desire. She defined cultural competence as “the process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client (individual, family, or community)” (Campinha-Bacote, 1999, p. 203). Cultural awareness is the self-examination and in-depth exploration of one’s own cultural and professional background. It involves the recognition of one’s bias, prejudices, and assumptions about the individuals who are different (Campinha-Bacote, 2002). “One’s world view can be considered a paradigm or way of viewing the world and phenomena in it” (Campinha-Bacote, 1999, p. 204). Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Obtaining cultural information about the patient’s health-related beliefs and values will help explain how he or she interprets his or her illness and how it guides his or her thinking, doing, and being (Campinha-Bacote, 2002).

The skill of conducting a cultural assessment is learned while assessing one’s values, beliefs, and practices to provide culturally competent services. The process of cultural encounters encourages direct engagement in cross-cultural interactions with individuals from other cultures. This process allows the person to validate, negate, or modify his or her existing cultural knowledge. It provides culturally specific knowledge bases from which the individual can develop culturally relevant interventions. Cultural desire requires the intrinsic qualities of motivation and genuine caring of the healthcare provider to “want to” engage in becoming culturally competent (Campinha-Bacote, 1999). The Giger and Davidhizar Transcultural Assessment Model identified phenomena to assess provision of care for patients who are of different cultures (2002). Their model includes six cultural phenomena: communication, time, space, social organization, environmental control, and biological variations. Each one is described based on several premises (e.g., culture is a patterned behavioral response that develops over time; is shaped by values, beliefs, norms, and practices; guides our thinking, doing, and being; and implies a dynamic, everchanging, active or passive process). Leininger’s (2002a) central purpose in her theory of transcultural nursing care is “to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups” (p. 190). She uses her classic “Sunrise Model” to identify the multifaceted theory and provides five enablers beneficial to “teasing out vague ideas,” two of which are The Observation, Participation, and Reflection Enabler and the Researcher’s Domain of Inquiry. Managing Quality and Risk

Nurses can use Leininger’s model to provide culturally congruent, safe, and meaningful care to patients or clients of diverse or similar cultures. See the following Theory Box. National and Global Directives The American Nurses Association (ANA) has a long and vital history related to ethics, human rights, and numerous efforts to eliminate discriminatory practices against nurses as well as patients. The ANA Code of Ethics for Nurses with Interpretive Statements, Provision 8, states, “The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs” (2008, p. 23). This provision helps the nurse recognize that health care must be provided to culturally diverse populations in the United States and on all continents of the world. Although a nurse may be inclined to impose his or her own cultural values on others, whether patients or staff, avoiding this imposition affirms the respect and sensitivity for the values and healthcare practices associated with different cultures. This provision is reinforced by the ANA position statement (2010), The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings. The value of human rights is placed in the forefront for nurses whose specific actions are to promote and protect the human rights of every individual in all practice care environments. Similar statements are made with an international emphasis and a specialty emphasis. The ICN Code of Ethics for Nurses (2012) states: The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent to care and related treatment. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. (p. 3) Nurse educators, as a specialty example, are expected to recognize “multicultural, gender, and experiential influences on teaching and learning”; “identify individual learning styles and unique learning needs of international, adult, multicultural, educationally disadvantaged, physically challenged, at-risk, and second degree learners”; and ensure “that the curriculum reflects institutional philosophy and mission, current nursing and health care trends, and community and societal needs so as to prepare graduates for practice in a complex, dynamic, multicultural health care environment.” (National League for Nursing, 2005, pp. 1, 2, 4) These examples illustrate a global concern for cultural sensitivity. Although the emphasis has been on recipients of care, the same attentiveness is needed in the workforce. Patients are aware of how they are treated; and they also see how staff interact with each other. Special Issues Health disparities between majority and ethnic minority populations are not new issues and continue to be problematic because they exist for multiple and complex reasons. Causes of disparities in health care include poor education, health behaviors of the minority group, inadequate financial resources, and environmental factors. Disparities in health care that relate to quality of care include provider/patient relationships, actual access to care, treatment regimens that necessarily reflect current evidence, provider bias and discrimination, mistrust of the healthcare system, and refusal of treatment (Baldwin, 2003). Managing Quality and Risk

Health disparities in ethnic and racial groups are observed in cardiovascular disease, which has a 40% higher incidence in U.S. blacks than in U.S. whites; cancer, which has a 30% higher death rate for all cancers in U.S. blacks than in U.S. whites; and diabetes in Hispanics, who are twice as likely to die from this disease than non-Hispanic whites. Native Americans have a life expectancy that is less than the national average, whereas Asians and Pacific Islanders are considered among the healthiest population groups. However, within the Asian and Pacific Islander population, health outcomes are more diverse. Solutions to health and healthcare disparities among ethnic and racial populations must be accomplished through research to improve care. Consider how these disparities in disease and in healthcare services might affect the healthcare providers in the workplace in relationship to their ethnic or racial group. It is necessary to increase healthcare providers’ knowledge of such disparities so that they can more effectively manage and treat diseases related to ethnic and racial minorities, which increasingly might include themselves. The healthcare system in the United States has consistently focused on individuals and their health problems, but it has failed to recognize the cultural differences, beliefs, symbolisms, and interpretations of illness of some people as a group. As health care moves toward provision of care for populations, culture can have an even greater influence on approaches to care. Commonly, patients for whom healthcare practitioners provide care are newcomers to health care in the United States. Similarly, new staff are commonly neither acculturated nor assimilated into the cultural values of the dominant culture. Currently, accessibility to health care in the United States is linked to specific social strata. This challenges nurse leaders, managers, and followers who strive for worth, recognition, and individuality for patients and staff regardless of their ascribed economic and social standing. Beginning nurse leaders, managers, and followers may sense that the knowledge they bring to their job lacks “real-life” experiences that provide the springboard to address staff and patient needs. In reality, although lack of experience may be slightly hampering, it is by no means an obstacle to addressing individualized …
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