Spotlight On... Cultural Competence Assessment and Training

Many healthcare professionals who work to promote culturally competent medical practices take their definition of the term “cultural competence” from the 1998 book Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed, which defined it as “a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework.” The term, however, is thought to have been first used about a decade earlier, by psychologist Paul Pedersen. In his 1988 Handbook for Developing Multicultural Awareness, Pedersen developed a useful multicultural training model that was “an integration of awareness, knowledge, and skills.” It challenges educators to increase their awareness of and examine their own beliefs and stereotypes, acquire knowledge and “information that facilitates the development of an adaptable, non-stereotyping conception of family communications as well as the cultural, sub-cultural, and social dynamics of diverse groups,” and develop skills that will enable them to incorporate culturally sensitive methods and strategies that are reflected

in verbal and nonverbal communication.

Known as the Triad Training Model, this was Pedersen’s formula for achieving and teaching cultural competence. Although cultural competence can have an impact on a number of professions, the healthcare community stands to gain the most by incorporating these values into its day-to-day activities. In fact, many studies stress the importance of cultural competence as being vital to providing quality care. An example of this was demonstrated by the American College of Cardiology Foundation, which in 2001 conducted hundreds of studies in cardiac care and concluded that “it is likely that a mix of patient, provider,

and health system factors contribute to disparities in care… such as the varying scope of insurance benefits, patient preferences, or the availability of high-tech cardiac equipment in hospitals.” Another, condition-specific example of this is seen in the well-documented racial disparities in diabetes care outcomes, which include a higher prevalence of diagnosis and diabetes-related complications in minorities and, consequently, a higher rate of kidney disease, eye disease, and coronary artery disease. These are just two examples among many that reveal racial disparities in healthcare access and treatment outcomes, illustrating the importance and potential benefits of incorporating cultural competence training into medicine.

There are two ways in which an organization can improve its level of cultural competence: by hiring a company to conduct an assessment, or by obtaining the proper tools and conducting a self-assessment. Hospitals and healthcare facilities can contact the Center for Multicultural Competence in Healthcare Organizations (CMCHO), which conducts on-site, organizational surveys that review policies, procedures, clinical outcomes, and physician and employee perceptions, and then make a determination regarding the level of cultural competency at which the hospital is currently functioning. Following this assessment, the CMCHO suggests educational opportunities for the hospital to advance to the next level. Hospitals also have the opportunity to earn a “certification in cultural competency,” a process that includes hospital staff members, selected patients, and community members. Following initial certification, “post-survey measurement provides annual updates of hospital performance and regularly scheduled return visits every three years.” Additionally, an annual list of culturally competent hospitals is published in trade journals, peer-reviewed literature, and consumer magazines, providing incentive to be credited for their efforts. CMCHO is also available to clients for consultation regarding any “cultural competency development, maintenance, or enhancement opportunities” in areas such as administration, marketing, human resources, organizational development, and clinical care.

Organizations can also assess their own cultural competence by referring to online resources like the National Center forCultural Competence (NCCC). Clinicians can go to the NCCC website and fill out the cultural competence healthcare practitioner

assessment (CCHPA) or the cultural and linguistic competence policy assessment (CLCPA). The CCHPA asks a series of

questions in the following areas: values and belief systems; life cycle events; cross-cultural communication; and empowerment/

health management. Users who would like to take the CLCPA need to register with the site, at which point they will be able to

download .PDFs pertinent to the assessment. Once the online questionnaires are complete, the program reviews the responses

given for each category and provides feedback, telling users what areas they should improve upon and providing library and online resources that can help improve certain areas of competency.

Another organization that focuses on improving cultural competency in healthcare is the Cross Cultural Health CareProgram (CCHCP), which serves as “a bridge between communities and health care institutions to ensure full access to quality health care that is culturally and linguistically appropriate.” In addition to providing cultural competency training for healthcare providers and their staff and offering a “Bridging the Gap” medical interpreter training program, the CCHCP provides training in culturally and linguistically appropriate services (CLAs) assessment and implementation and assists in meeting Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) requirements related to CLAs. The CCHCP also provide access to its

Resource Center, which has the latest research in health disparities, publications related to crosscultural health issues such as community profiles, community perspectives on barriers in healthcare, and medical glossaries in 24 languages.

Although the programs are generally instituted by healthcare organizations dedicated to improving institutional awareness of cultural issues, there are numerous factors that are directly related to the success of these programs. Ira SenGupta, MA, Executive Director of the Cross Cultural Health Care Program and past director of cultural competency programs, explains that the following circumstances and conditions are necessary for success: commitment from leadership to sustain the initiative, dedicated intent by an organization to provide culturally and linguistically appropriate services, a centralized program in which the organization is dedicated to organizing these services, trained medical staff language interpreters, a team of internal trainers who can sustain the training efforts of the organization, effective community outreach programs, and community engagement and presence on institutional boards and advisory committees.

Although it has been gaining momentum and popularity as a fashionable term in the healthcare industry, there are still many critics who maintain that putting too much stress on cultural competency and sensitivity misses the point a bit, and that it is more important that physicians concentrate on providing sound, evidence-based treatments that meet accepted standards of care. Asked about this contrary point of view, representatives at the NCCC countered by referring to the Institute of Medicine’s book titled Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences, which states that racial and ethnic disparities in healthcare occur “in the context of broader historic and contemporary social and economic inequality;

many sources—including health systems, healthcare providers, patients, and utilization managers—may contribute to racial disparities in healthcare; and that bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.”

Representatives at the NCCC also stated that “if disparities and inequities could be solved by what is currently considered the

‘evidence-based treatments’ (a body of science that is seriously lacking in research that addresses cultural and biological

differences), then we would not be having this conversation, nor would the evidence continue to document the persistent

disparities in death, illness, and disability among specific racial and ethnic groups in the US.” In addition, SenGupta cites the

following reasons for providing cultural and linguistic services that are supported by research: access, quality, and cost of care;

risk management; federal requirements; and business sense.

There is plenty of evidence to suggest that culture is important in the clinical setting—it is crucial to diagnosis, treatment, and

care, and has been shown to shape health-related benefits, behaviors, and values; however, are there ways to improve how healthcare practitioners go about doing so?

Arthur Kleinman, MD, a psychiatrist at Harvard University, and Peter Benson, PhD, assistant professor at Harvard University,

both students of anthropology, explored the barriers to cultural competency in their 2006 article, “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” Published by the Public Library of Science, a peer-reviewed open-access journal, the article discusses the problem of how cultural competency suggests that “culture can be reduced to a technical skill for which clinicians can be trained to develop expertise,” and how this creates the idea that isolated societies share all cultural meanings (ie, “Koreans believe this,” and “Americans believe this”). Kleinman and Benson also noted that another problem with incorporating cultural factors in the healthcare setting is that they are not always central to a case and may actually hinder a more practical understanding of the issue at hand. They also note that “cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even

personality.” Because of these barriers, the two men came up with a different approach to incorporating culture into healthcare.

Kleinman and Benson contend that the best approach to making clinicians more culturally sensitive was to train them to perform social research from the native’s point of view by “appreciating and humanly engaging with their foreignness, and understanding their religion, moral values, and everyday practices.” They argue that this exercise in “mini-ethnography” is what really matters—understanding what is “really at stake for patients, their families, and, at times, their communities, and also what is at stake for themselves.” The reason for doing this is because cultural values may conflict with evidence-based clinical determinations (such as in the case studies referenced in their article). Cultural competency could become overbearing or even nonessential when dealing with a patient who identifies with more than one ethnic background. Clinicians should then be able to use this information in thinking through treatment decisions and negotiating with the patient. By doing this, the clinician can focus on “the patient as an individual, not a stereotype; as a human being facing danger and uncertainty, not merely a case; as an opportunity for the doctor to engage in an essential, moral task, not an issue in cost-accounting.”

Aside from demographic changes and health disparities, legislative, regulatory, and accreditation mandates will ensure that this area will continue to receive the attention it deserves. As SenGupta points out, the JCAHO, which accredits more than 15,000 healthcare organizations in the United States, has now teamed up with the National Committee for Quality Assurance and URAC (formerly known as Utilization Review Accreditation Commission) to combine standards into their accreditation

requirements. The NCCC sees a future in which “medical, health, and mental health professions’ academic training programs integrate core content on cultural and linguistic competency in all curricula and avoid having this content taught as a single course or elective.” As the push for cultural competence becomes more pronounced in the coming years, goals and implementation techniques are sure to evolve, and healthcare providers should be advised to embrace the addition of this knowledge, because, as Dr. Schyve put it, cultural competency is a “growing issue that is not going to go away.”