1. Cultural Competence and
Patient-Centered Care
Horblit Health Sciences Library

2. Objectives
At the end of this presentation, you will be able to:
1. Define culture
2. Define cultural competency
3. Identify how cultural competency can improve
health communication
4. Identify the cultural factors that influence cross-
cultural patient-provider interactions
5. List ways to develop cultural competence and to
assess your own cultural competency development

3. Why Learn About Cultural
Competence?
• Patients bring many varied and cultural backgrounds,
beliefs, practices, and languages, requiring culturally
competent communication to maximize the quality
of care they receive.
• Providers also bring their own cultural backgrounds,
values and beliefs, and biases to health care
encounters. Culturally competent providers take into
account how their own cultural orientation and
background influence their perceptions and
behaviors.

4. Cultural Bias is Everywhere
• A review in Family Medicine found evidence that race,
ethnicity, and language impact the quality of the patient-
provider relationship.
• Patients who are culturally different from their providers,
especially those who are not proficient in English, are less
likely to:
– Have providers identify with and understand their
situation
– Establish a connection and trust with providers
– Receive sufficient information
– Be encouraged to participate in medical decision-making

5. What is Culture?
• Most people think of culture in terms of race,
nationality, and religion, but culture is broader than
that.
• Culture includes groups that we are born into, such
as gender, race, national origin, sexual orientation,
class, and religion.
• It also includes the social groups that influence our
identity, including age, disability, social and
economic status, and even career.

6. Characteristics of Culture
• Two people my have exactly the same cultural
background but may respond differently to a given
situation and have different values on similar issues.
• Culture may be affected by many factors, including:
– Personality – Experience/time
– Gender – Level of ability (physical and
– Age mental)
– Sexual orientation – Spirituality/religion
– Social and economic status

7. What Does Culture
Encompass/Impact?
• Communications • Customs
• Language • Family obligations
• Art • Illness and death
• Religion • Preventive care
• Diet • Gender roles
• Environment • Social groups

8. These are Cultural Groups, Too
• Gay/Lesbian • Visually impaired
• Transgender • Mentally ill
• Disabled

9. The Importance of Culture
• Culture is a central issue in people’s lives. It
influences their beliefs, values, attitudes, and
behavior.
• Although people may share the same culture, the
way in which that culture is expressed will differ
from person to person and will vary over time.

10. Culture and Health Care
A person’s culture can affect:
• What is considered to be a health problem
• How symptoms and concerns about the problem are
expressed
• Who provides the treatment for the problem
• What types of treatment should be given
• How and when health care information is received

11. Culture and Health Communication
• Patients may choose not to seek needed services
• Providers may make errors in diagnosis because of
miscommunication
• Patients may not follow medical advice because they
do not trust or understand the provider
• Providers may order fewer or more diagnostic tests
for patients because they may not understand or
believe the patient’s description of symptoms
HRSA

13. Social Structure
Egalitarian Hierarchical
• All are equal • Top down
– All competent adults – Husband makes
make decisions for their decisions
own health care – Patriarch makes decision
– Provider may be
expected to make
decision

14. What is Cultural Competence?
• Developing an awareness of one’s own thoughts,
attitudes, and environment without letting it
influence those from other backgrounds.
• Demonstrating understanding of a client’s culture.
Understand the cause and control of specific
diseases and the effectiveness of treatments in
different populations.
• Accepting and respecting cultural differences.
• Adapting care to accommodate the client’s culture.
HRSA

15. What is Cultural Competence?
The ability to acquire and use knowledge of the health-
related beliefs, attitudes, practices, and
communication of patients and their families to
improve services, strengthen programs, increase
community participation, and close the gaps in
health status among diverse population groups.

16. What is Cultural Competence?
• It begins with an honest desire not to allow biases to
keep us from treating every individual with respect.
• Learning to evaluate our own level of cultural
competence must be part of our ongoing effort to
provide better health care.

17. What is Cultural Competence?
Culturally competent providers consistently and
systematically:
•Understand and respect their patients’ values, beliefs,
and expectations
•Understand the cause and control of specific diseases
and the effectiveness of treatments in different
population groups
•Adapt the way they deliver care to each patient’s
needs and expectations

18. Why Provide Culturally Competent
Care?
• Every patient-provider encounter is a cross-cultural
encounter.
• Even patients with appearance and background
similar to yours can be culturally different due to life
experiences, personalities, interests, careers, etc.

19. Benefits of Culturally Competent Care
• Reduced health care disparities
• Improved health communication and health
outcomes
• Providing culturally competent care allows you to
develop trust and create partnerships with your
patients, and helps to ensure effective,
understandable, and respectful care for all patients.

20. Cultural Factors Influencing Patient-
Provider Communication
There are several cultural factors that can influence the
quality of patient-provider communication, including:
•Personal biases
•Nonverbal communication
•Patients’ families and dynamics
•Cultural values and beliefs

21. Why is Cultural Competence
Important?
Population Changes
Hispanic populations Increase to 23% by 2050
Asian populations Increase to 10% by 2050
African American Double in size to 15.7% (62m)
Non-Hispanic Whites Decline by 20% by 2050
www.census.gov, Population
projections 2008

22. Why is Cultural Competence
Important?
Languages
• Over 44 million Americans speak a language other
than English at home.
• Over 300 different languages are spoken in the U.S.
• Over 48 languages are spoken in Danbury
www.usinfo.gov Language Use and
English-Speaking Ability: 2000

23. Aging and Health
Number of people over the age of 65
2008 38.7 million
2050 88.5 million
• Over age 65: up to 3 chronic conditions
• Over age 85: at least one disability
www.census.gov
2008 age projections; National
Academy on an Aging Society 1999

24. What can culture influence?
• Health, healing and wellness belief systems
• How patient and consumer perceive illness, disease,
and their causes
• Patients’ behaviors seeking health care and their
attitudes to healthcare providers
• The delivery of services by the provider who looks at
the world through his or her values
• Compliance to medication and treatment plan
HRSA

25. Healthcare Disparities
• Health disparities and minority and foreign-born
populations are increasing
• African Americans’ infant mortality rates are 2 – 5
times higher than for European Americans
• Influenza death rates are higher for African
Americans than for European Americans
HRSA

26. The Asian American Patient
• Diverse population – Chinese, Filipino, Vietnamese,
Korean, Japanese
• Traditional definition of causes of illness is based on
harmony: balance of hot and cold states or elements
• Modesty highly valued
• May be too polite to disagree
• Communication based on respect; familiarity is
unacceptable
• Eldest male is head of family and may take the lead
in health decision making

27. Hispanic Health Beliefs and Practices
• Preventative care may not be practiced.
• Illness is God’s will and recovery is in His hands.
• Hot and Cold Principles apply.
• Expressiveness of pain is culturally acceptable.
• Obesity may be seen as a sign of good health and
well being.
• Diet is high in salt, sugar, starches and fat.
• High respect for authority and the elderly.
• Provide same sex caregivers if at all possible.

28. Cultural Groups
• Anglo American • Native American
– Direct eye contact – Anecdotes/metaphors
– Informed about details – Avoid eye contact
– Aggressive approach – Don’t speak to loudly
– Killing germs – Traditional healing very
– Antibiotics even when important
unnecessary – Never touch or casually
– Belief in technology admire a ritual object.

29. No Stereotyping
• Culture is expressed through the individual
• Not all members of a cultural group will believe the
same thing
• Variation within cultural groups.

30. Tips for Communicating

31. Basic Strategies
• Speak clearly and slowly without raising your voice,
avoid slang, jargon, humor, idioms.
• Use Mrs., Miss, Mr. Avoid first names which may be
considered discourteous in some cultures.
• Avoid gestures – they may have a negative
connotation.
• Many carry or wear religious symbols – Sacred
threads worn by Hindus, native Americans-medicine
bundles. DO not touch them.

32. How would you make your practice
culturally competent?

33. Culturally Competent Care
• Treat people uniquely • Know your comfort
• Listen respectfully level
• Gender sensitivity • Establish trust
• Educate yourself
• Be aware of different
cultures

34. Scenario
A nurse, working as a community case manager, visited the
home of a toddler with severe physical and developmental
delays. She explained to the parents that with their consent she
would refer the child to a physiotherapy and occupational
therapy program that would help the child be more
independent. The parents refused, saying that it was their duty
to care for their child because the child’s condition is
punishment for having conceived before they were married.
They were not supportive of a program to increase
independence. The nurse was upset and felt the parents were
not acting in the child’s best interests.

35. Discussion
The nurse did not understand the family’s initial refusal of
treatment. After reflection and discussion with colleagues, she
realized that her personal and professional values of
independence were causing her to feel upset with the parents’
refusal. She decided to explore with the family their goals for
their child. In doing this, she learned that the parents wanted
their child to become stronger and have fewer infections. When
the same therapies were described as a means of meeting these
goals, the parents were quite willing to participate. The
program was developed to meet the goals that the family
identified as important.

36. Scenario
A couple comes to a walk-in clinic with a young child who is
crying and tugging at his ears. The couple has recently arrived in
the country but understands English well enough that the nurse
feels language is not an issue. An assessment reveals that the
child has an infection in both ears, and the couple is given a
prescription for an antibiotic and Tylenol drops for fever and
pain. The situation is fairly routine, and an interpreter is not
considered necessary. The parents are informed about the
diagnosis and treatment, and they nod in understanding.

37. Scenario, continued
The next day the couple returns with the child whose condition
seems to have worsened. There is now a pink discharge from
both ears, and the entire family is in distress. An interpreter is
called to assist. Through the interpreter, the nurse learns that
the parents had the prescription filled promptly, and they
understood the child was to be given the medicine every 4
hours. They had been administering the antibiotic orally, but
since they had treated previous infections with ear drops, they
had administered the Tylenol drops in the child’s ears.

38. Discussion
This example illustrates the importance of confirming
that accurate communication has been achieved. To
reduce the chance of confusion, the nurse could have
demonstrated how to measure, and then administer,
both medications. Culturally appropriate client
education materials would also have been helpful.

39. Scenario
A woman, 35, is admitted to the general medical unit.
While in the hospital, she expresses concern about her
partner’s ability to care for her children. She also
appears worried about how she will manage at home
after she is discharged. The nurse suggests that
perhaps a family meeting is necessary and offers to
contact her husband. The nurse further suggests that
maybe the patient’s mother, who has called often to
inquire about her daughter, should be involved in the
meeting.

40. Discussion
The nurse has made an assumption that the patient’s
partner is male and that the relationship with the
mother is one that will be supportive to the entire
family. For many couples in a same sex relationship,
the issue of family can be sensitive. For some people,
“family” is often their chosen family as opposed to kin.
By using the word “partner,” and asking the patient
who would be appropriate for a family meeting, the
nurse shows openness and a nonjudgmental attitude.

41. Scenario
A nurse is providing direct care to an elderly woman
newly diagnosed with angina. She has been prescribed
nitroglycerine to manage her angina attacks. The
patient reveals to the nurse her firm belief that her
illness is caused by the “evil eye,” a glance cast upon
her by another to cause this condition. She shows the
nurse her own remedy, which she claims will life the
curse of the evil eye and cure her.

42. Discussion
The nurse assesses the patient’s remedy for possible
health risks, such as high sodium content. As well, the
nurse negotiates with the patient to take the
nitroglycerine. In doing so, the nurse will need to be
vigilant to the potential objections the patient may
have to taking the medication. The goal is to have a
plan of care that includes the remedy for the evil eye,
but also includes the appropriate use of the
nitroglycerine. The nurse and the patient may not fully
understand each other’s preferences, but are willing to
accommodate both interventions.

43. The 4 C’s
• What do you call your problem?
• What do you think caused your problem?
• What have you done to cope with your problem?
• What concerns do you have about your problem,
about my recommendations?

44. Kleinman’s 8 Questions
1. What do you think caused the problem?
2. Why do you think it started when it did?
3. What does your sickness do and how does it work?
4. How severe is your sickness/ How long do you expect it to
last?
5. What problems has the sickness caused you?
6. What do you fear about your sickness?
7. What type of treatment do you think you should receive?
8. What are the most important results you hope to achieve
from this treatment?
Kleinman et al 1978

45. Benefits of Cultural Competence
• Greater patient compliance
• Fewer harmful drug interactions
• More appropriate testing and screenings
• Increased likelihood that minorities will seek health
care
• More successful patient education

46. Developing Cultural Competence
Attitude/skill-centered approach
• Recognize your own biases; understand how race,
ethnicity, gender, etc. play a role in healthcare
delivery and perception of health care.
https://implicit.harvard.edu/implicit/
• Acquire and apply culturally competent skills.

47. Developing Cultural Competence
Fact-centered approach
• Learn specific information, such as an ethnic groups’
history, their concepts of illness and disease, their
health-seeking behavior, disease patterns, etc.

48. Developing Cultural Competence
Organizational
• Build a foundation
• Collect and use data to improve services
• Accommodate the needs of special populations
• Establish internal and external collaborations

49. Developing Cultural Competence
Physician-specific
• Key stakeholders
• Programs and training
• Agents of change

50. Developing Cultural Competence
Educational Opportunities
• Films/videos and CDs
• CMEs
• Lectures
• Presentations on specific cultures
• Unit cultural gatherings

52. References
American Academy of Pediatrics. Plain Language Pediatrics. 2009. ElkGrove
Village, IL: American Academy of Pediatrics.
Arnold TL, Davis TC. Frempong JO et al. 2006. Assessment of newborn
screening parent education materials Pediatrics 117(5pt2): S341-s345.
HRSA Unified Health Communications Addressing Health Literacy, Cultural
Competency, and Limited English Proficiency.
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care:
Clinical lessons from anthropologic and cross-cultural research. Annals of
Internal Medicine, 88(2), 251-258.
Lenningert, M., & McFarland, M.R. (2002). Transcultural Nursing: Concepts,
theories, research & practice (3rd ed).New York: McGraw-Hill
National Academy on an Aging Society. Chronic Conditions : A challenge for
the 21st century, November 1999.
Pew Research Center.US Populations Projections 2005-2050.