Building Cultural and Linguistic Competence ■ 5
In all clinical practice areas—from institutional settings, such as acute and long-term care settings, to community-based settings, such as nurse practitioners’ and doctors’ offices and clinics, schools and universities, pub- lic health, and occupational settings—one observes diversity every day. The undeniable need for culturally and linguistically competent health care services for diverse populations has attracted increased attention from health care pro- viders and those who judge their quality and efficiency for many years. The mainstream health care provider is treating a more diverse patient population as a result of demographic changes and participation in insurance programs, and the interest in designing culturally and linguistically appropriate services that lead to improved health care outcomes, efficiency, and patient satisfaction has increased.
One’s personal cultural background, heritage, and language have a con- siderable impact on both how patients access and respond to health care services and how the providers practice within the system. Cultural and linguistic com- petence suggests an ability of health care providers and health care organiza- tions to understand and respond effectively to the cultural and linguistic needs brought to the health care experience. This is a phenomenon that recognizes the diversity that exists among the patients, physicians, nurses, and caregivers. This phenomenon is not limited to the changes in the patient population in that it also embraces the members of the workforce—including providers from other countries. Many of the people in the workforce are new immigrants and/or are from ethnocultural backgrounds that are different from that of the dominant culture.
In addition, health and illness can be interpreted and explained in terms of personal experience and expectations. We can define our own health or illness and determine what these states mean to us in our daily lives. We learn from our own cultural and ethnic backgrounds how to be healthy, how to recognize illness, and how to be ill. Furthermore, the meanings we attach to the notions of health and illness are related to the basic, culture-bound values by which we define a given experience and perception.
It is now imperative, according to the most recent policies of the Joint Commission of Hospital Accreditation and the Centers for Medicare & Med- icaid Services, that all health care providers be “culturally competent.” In this context, cultural competency implies that within the delivery of care the health care provider understands and attends to the total context of the patient’s situa- tion; it is a complex combination of knowledge, attitudes, and skills, yet
■ How do you really inspire people to hear the content? ■ How do you motivate providers to see the worldview and lived experi-
ence of the patient? ■ How do you assist providers to really bear witness to the living condi-
tions and lifeways of patients? ■ How do you liberate providers from the burdens of prejudice, xenopho-
bia, the “isms”—racism, ethnocentrism—and the “antis” such as anti- Semitism, anti-Catholicism, anti-Islamism, anti-immigrant, and so forth?
6 ■ Chapter 1
■ How do you inspire philosophical changes from dualistic thinking to holistic thinking?
It can be argued that the development of CULTURALCOMPETENCY does not occur in a short encounter with programs on cultural diversity but that it takes time to develop the skills, knowledge, and attitudes to safely and sat- isfactorily become “CULTURALLYCOMPETENT” and to deliver CULTURALCARE. Indeed, the reality of becoming “CULTURALLYCOMPETENT” is a complex process—it is time consuming, difficult, frustrating, and extremely interesting. It is a philosophical change wherein the CULTURALLYCOMPETENT person is able to hear, understand, and respect the nonverbal and/or non-articulated needs and perspectives of a given patient.
CULTURALCOMPETENCY embraces the premise that all things are con- nected. Look again at the dandelion that has gone to seed. Each seed is a dis- crete entity, yet each is linked to the other (Figure 1–1). Each facet discussed in this text—heritage, culture, ethnicity, religion, socialization, and identity— is connected to diversity, demographic change, population, immigration, and poverty. These facets are connected to health/HEALTH, illness/ILLNESS, curing/HEALING, and beliefs and practices, modern and traditional. All of these facets are connected to the health care delivery system—the culture, costs, and politics of health care, the internal and external political issues, public health is- sues, and housing and other infrastructure issues. In order to fully understand a person’s health/HEALTH beliefs and practices, each of these topics must be in the background of a provider’s mind.
I have had the opportunity to live and teach in Spain and to explore many areas, including Cadiz and the surrounding small villages. There was a fake door within the walls of a small village, Vejer de la Frontera (Figure 1–2), that appeared to be bolted shut. The door was placed there during the early 14th century to fool the Barbary pirates. The people were able to vanquish them while they tried to pry the door open. It reminded me of the attempt to keep other ideas and people away and not open up to new and different ideas. Another door (Figure 1–3), found in Avila, Spain, was made of translu- cent glass. Here, the person has a choice—peer through the door and view the garden behind it or open it and actually go into the garden for a finite walk. This reminded me of people who are able to understand the needs of others and return to their own life and heritage when work is completed. This polarity represents the challenges of “CULTURALCOMPETENCY.”
The way to CULTURALCOMPETENCY is complex, but I have learned over the years that there are five steps (Figure 1–4) to climb to begin to achieve this goal:
1. Personal heritage—Who are you? What is your heritage? What are your health/HEALTH beliefs?
2. Heritage of others—demographics—Who is the other? Family? Community?
3. Health and HEALTH beliefs and practices—competing philosophies 4. Health care culture and system—all the issues and problems
Building Cultural and Linguistic Competence ■ 7
5. Traditional HEALTH care systems—the way HEALTH was for most and the way HEALTH still is for many
Once you have reached the sixth step, CULTURALCOMPETENCY, you are ready to open the door to CULTURALCARE.
Each step represents a discrete unit of study, each building upon the one below it. The steps have been constructed with “bricks,” and they represent the fundamental terms, or language, of the content. Table 1–1 lists many examples
Table 1–1 Bricks: Selected CULTURALCARE Terms
Access Acupuncture Ageism Alien Allopathic philosophy Amulet Apparel Assimilation Bankes Borders Calendar Care Census Citizen CLAS Community Costs Cultural conflict CULTURALCARE CULTURALCOMPETENCY Culturally appropriate Culturally competent Culturally sensitive Culture Curandera/o Customs Cycle of poverty Demographic disparity Demographic parity Demography Diagnosis Diversity Documentation Education Empacho Envidia Ethics Ethnicity Ethnicity Ethnocentrism Evil eye Family Financing Food Garments Gender specific care Green Card Gris-gris Habits Halal HEALING Health HEALTH Health care system Health disparities HEALTH Traditions Healthy People 2020 Herbalist Heritage Heritage consistency Heritage inconsistency