CULTURAL

COMPETENCY IN
APRN PRACTICE
Culture is the integrated pattern of thoughts,
communications, actions, customs, beliefs, values, and
institutions associated, wholly or partially, with racial, ethnic,
or linguistic groups as well as religious, spiritual, biological,
geographical, or sociological characteristics. Culture is
dynamic in nature, and individuals may identify with multiple
cultures over the course of their lifetimes.

Minorityhealth.hhs.gov
Factors which negatively impact
cultural and linguistic
competency
BIAS
A preference, especially one that inhibits
impartial judgment
Explicit: Person is aware
Implicit: Unrecognized bias against
individuals in a social group
Implicit Bias

The presence of implicit bias among

clinicians further suggests that it could play
a role in health care disparities just as it
plays a role in differential outcomes
elsewhere in society.
Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious
(Implicit) Bias and Health Disparities: Where Do We Go from Here?
The Permanente Journal, 15(2), 7178.
Implicit Bias in HTN Management

Permanente Journal (2011. Spring 15(2), 71-78

Weight bias
Discrimination
An action that denies equal treatment
to individuals
Example: Disabilities
The new doctor really didnt take me seriously, which I
kind of expected because I know that in the medical
professiondoctors dont have a lot of experience with
people with disabilities and also people with speech
impairments
A woman with cerebral palsy
Example: Transgender
Over a third of a sample of 1711 transgender individuals
in a 2008-2009 survey described blatant mistreatment
when they sought healthcare services

28% were denied treatment

32% described verbal harassment
1% described physical assault
Shires, D/A/ & Jaffee, K. (2015). Factors associated with health care discrimination
experiences among a national sample of female and male transgender individuals. Health
Social Work, 40(2). 134-41
Ethnocentrism
The belief in superiority of ones ethnic group
We often talk about British drivers driving "on
the wrong side" of the road. Why not just say
"opposite side" or even "left hand side"?
We talk about written Hebrew as reading
"backward." Why not just say "from right to left"
or "in the opposite direction from English."

https://home.snu.edu/~hculbert/ethno.htm
 Essentialism
Essentialism defines groups as essentially
different, with characteristics natural to a
group. Essentialism does not take into account
variation within a culture. Essentialism can lead
nurses to stereotype their patients. As such, their
clinical practice focuses on beliefs about
groups instead of individuals

American Home Health

http://www.ahhc-1.com/educational-pieces-clients-article.php?id=13
Power differences
The power imbalance in the patient-
provider relationship
Stereotypes
Oversimplified conceptions, opinions, or
beliefs about some aspect of an
individual or group
Self assessment of cultural
competency
Awareness: Are you aware of your biases and the presence of racism?
Skill: Do you know how to conduct a cultural assessment in a sensitive
manner?
Knowledge: Do you know about different cultures worldviews and the
field of bio-cultural ecology?
Encounters: How many face-to-face interactions and other encounters
have you had with people from different cultures?
Desire: Do you want to become culturally and linguistically
competent?

Campinha-Bacote, 2002
ETHNIC Model: A Cultural
Competency Framework
Exploration
Why do you think you have these symptoms? What do your
family, friends, others say about these symptoms? Do you now
anyone else with this problem? What have you heard about
this problem? (TV, radio, newspapers?)
Treatment
What kinds of treatments have you tried? Is there anything you
eat, drink or do on a regular basis to stay healthy? What
treatment are you seeking from me?
Healer
Have you sought any advice from alternative healers, friends or
other non-traditional health professionals?
ETHNIC Model
Negotiation
What options are acceptable for both of us?
What results would you like to see?
Intervention
What is the best intervention for you?
Have we considered alternative treatments as well?
Collaboration
How can the patient, family, health team members, healers
and community collaborate?
 A Chinese immigrant had surgery and was told to "force
fluids" by the nursing staff. The client refused to drink the
water from the pitcher left at his bedside and was told if
he did not drink then an IV would be started. The staff
decided that the client was uncooperative and
noncompliant. The next day the client's daughter told
the nursing staff that her father would drink hot herbal
tea, but not cold water (Leininger & McFarland, 2002).
 Patient: Suzy Lee, age 36, Vietnamese, born in America to American-born parents, is in
the hospital after giving birth to her first child.
Case story: Mrs. Lee had felt increasingly depressed for several weeks. She did not
mention her depression to her doctor because she had heard that feeling down was a
normal part of pregnancy. Now, at the hospital after her child's birth, she feels very
depressed.
Case
At shift change time, Mrs. Lee's two nurses were discussing her care. "She just doesn't
seem right," said the nurse who was going off duty. "She's so quiet, and she doesn't
seem excited about the baby at all. She won't eat either, and she didn't want to feed
the baby. When she wakes up, I think maybe you should do a mini-mental, just to be
sure things are OK before the doctor discharges her today." The nurse who was coming
on duty replied, "I'm sure she's fine. Asian woman are all quiet like that, and they never
show emotion, especially in public. It's part of their culture. I'm sure she'll perk up once
she gets home."
Explanatory model
I know different people have different
"

ways of understanding illnessplease help

me understand how you see things."
Importance of language assistance
services
A call from the mother and sister of a Spanish-speaking man
reported that he was "intoxicado." Paramedics and hospital
personnel incorrectly interpreted this as intoxicated or drunk, and
therefore, treated him for an overdose.

It turned out the man was actually having a intracerebellar

hemorrhage that continued to bleed for more than two days as
he lay unconscious in the hospital. As a result of this misdiagnosis,
the man became a quadriplegic. After settling out of court, the
health care institution was required to pay $71 million (Price-Wise,
2008).
Interpreter needed!!!
A Hispanic woman had to sign an informed consent form for a
hysterectomy. Her bilingual son served as the interpreter. When
he described the procedure to his mother, he appeared to be
interpreting accurately and indicating the appropriate body
parts. His mother signed willingly. The next day, however, when
she learned that her uterus had been removed, she became
very angry and threatened to sue the hospital.
 In any culture, it is inappropriate for a son to talk with his mother
about female body parts. In this case, the embarrassed son
explained that a tumor would be removed from her abdomen
and pointed to that general area. When his mother learned her
uterus had been removed, she was very angry and upset
because a Hispanic womans status is derived in large part from
the number of children she produces (Galanti, 2004).
Health literacy
The degree to which an individual has the capacity to
obtain, process, and understand basic health
information and services needed to make appropriate
health decisions (IOM, 2004).
What do you need to be concerned
about when you are not certain a
patient understands?
https://www.thinkculturalhealth.hhs.gov/Content/Co
ntinuingEd.asp
Cases
https://cccm.thinkculturalhealth.hhs.gov/videos/index.asp