Integrating Culturally Competent Strategies into Health Care Practice

Abstract

Providing culturally competent practice can potentially reduce disparities in racial and ethnic health outcomes. By integrating practices traditionally used by diverse populations, and after determining the safety of their integration with standard practice, improved health outcomes are possible because all parties have been involved with designing the plan of care. Cultural variations in beliefs and practices regarding health promotion and the prevention and treatment of illness are presented. To illustrate these cultural differences, three clinical practice topics are used as examples: maternity care, pain management, and traditional or complementary and alternative medicine (CAM). Cross-cultural skills of cultural assessment and mutual decision-making are discussed to guide providers when engaging and negotiating with patients and their families who adhere to diverse explanatory models of health and illness. Examples of how health-care providers can adapt their care are included. One comprehensive cultural assessment tool is provided.

Guideline: Nurses shall use cross cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care.

Douglas et al. (2014)

Appendix: Purnell Cultural Assessment Tool(version 2.1)

An extensive cultural assessment is rarely completed in the clinical setting because of time and other circumstances. A seasoned clinical practitioner will know when further assessment is required. Thus, this tool should be used as a guide. Shaded items in italics are part of any standard assessment. Other items may also be part of a standard assessment, depending on the organization, setting, and clinical area.

Cultural assessment question	Comments
Overview, inhabited localities, and topography
Where do you currently live?
What is your ancestry?
Where were you born?
How many years have you lived in this country?
Were your parents born in this country?
What brought you (your parents/ancestors) to this country?
Describe the land or countryside where you live. Is it mountainous, swampy, etc.?
Have you lived in other places in the United States/world?
What was the land or countryside like when you lived there?
What is your income level?
Does your income allow you to afford the essentials of life?
Do you have health insurance?
Are you able to afford health insurance on your salary?
What is your educational level (formal/informal/self-taught)?
What is your current occupation? If retired, ask about previous occupations
Have you worked in other occupations? What were they?
Are there (were there) any health hazards associated with your job(s)?
Have you been in the military? If so, in what foreign countries were you stationed?
Communications
What is your full name?
What is your legal name?
By what name do you wish to be called?
What is your primary language?
Do you speak a specific dialect?
What other languages do you speak?
Do you find it difficult to share your thoughts, feelings, and ideas with family? Friends? Health-care providers?
Do you mind being touched by friends? Strangers? Health-care workers?
How do wish to be greeted? Handshake? Nod of the head, verbal greeting only, etc.?
Are you usually on time for appointments?
Are you usually on time for social engagements?
Observe the patient’s speech pattern. Is the speech pattern high- or low-context? Note: patients from highly contexted cultures place greater value on silence
Observe the patient when physical contact is made. Does he/she withdraw from the touch or become tense?
How close does the patient stand when talking with family members? With health-care providers?
Does the patient maintain eye contact when talking with the nurse/physician, etc.?
Family roles and organization
What is your marital/partner status?
How many children do you have?
Who makes most of the decisions in your family?
What types of decisions do(es) the female(s) in your family make?
What types of decisions do(es) the male(s) in your family make?
What are the duties of the women in the family?
What are the duties of the men in the family?
What should children do to make a good impression for themselves and for the family?
What should children not do to make a good impression for themselves and for the family?
What are children forbidden to do?
What should adolescents do to make a good impression for themselves and for the family?
What should adolescents not do to make a good impression for themselves and for the family?
What are adolescents forbidden to do?
What are the priorities for your family?
What are the roles of the older people in your family? Are they sought for their advice?
Are there extended family members in your household? Who else lives in your household?
What are the roles of extended family members in this household? What gives you and your family status?
Is it acceptable to you for people to have children out of wedlock?
Is it acceptable to you for people to live together and not be married?
Is it acceptable to you for people to admit being gay or lesbian?
What is your sexual preference/orientation? (ask only if appropriate and later in the assessment after a modicum of trust has been established)
Workforce issues
Do you usually report to work on time?
Do you usually report to meetings on time?
What concerns do you have about working with someone of the opposite gender?
Do you consider yourself a “loyal” employee? How long do you expect to remain in your position?
What do you do when you do not know how to do something related to your job?
Do you consider yourself to be assertive in your job?
What difficulty does English (or another language) give you in the workforce?
What difficulties do you have working with people older (younger) than you?
What difficulty do you have in taking directions from someone younger/older than you?
What difficulty do you have working with people whose religions are different from yours?
What difficulty do you have working with people whose sexual orientation is different from yours?
What difficulty do you have working with someone whose race or ethnicity is different from yours?
Do you consider yourself to be an independent decision-maker?
Biocultural ecology
Are you allergic to any medications?
What problems did you have when you took over-the-counter medications?
What problems did you have when you took prescription medications?
What are the major illnesses and diseases in your family?
Are you aware of any genetic diseases in your family?
What are the major health problems in the country from which you come (if appropriate)?
With what race(s) do you identify?
With what ethnic group(s) do you identify?
Observe and document skin coloration and physical characteristics
Observe for and document physical handicaps and disabilities.
High-risk health behaviors
How many cigarettes a day do you smoke?
Do you smoke a pipe (or cigars)?
Do you chew tobacco?
For how many years have you smoked/chewed tobacco?
How much alcohol do you drink each day? Ask about wine, beer, spirits
How many energy drinks do you consume each day?
What recreational drugs do you use?
How often do you use recreational drugs?
What type of exercise do you do each day?
Do you use seat belts?
What precautions do you take to prevent getting sexually transmitted infections or HIV/AIDS?
Nutrition
Are you on a special diet?
Are you satisfied with your weight?
Which foods do you eat to maintain your health?
Do you avoid certain foods to maintain your health?
Why do you avoid these foods?
Which foods do you eat when you are ill?
Which foods do you avoid when you are ill?
Why do you avoid these foods (if appropriate)?
For what illnesses do you eat certain foods?
Which foods do you eat to balance your diet?
Which foods do you eat every day?
Which foods do you eat every week?
Which foods do you eat that are part of your cultural heritage?
Which foods are high-status foods in your family/culture?
Which foods are eaten only by men? Women? Children? Teenagers? Elderly?
How many meals do you eat each day?
What time do you eat each meal?
Do you snack between meals?
What foods do you eat when you snack?
What holidays do you celebrate?
Which foods do you eat on particular holidays?
Who is present at each meal? Is the entire family present?
Do you primarily eat the same foods as the rest of your family?
Where do you usually buy your food?
Who usually buys the food in your household?
Who does the cooking in your household?
How frequently do you eat at a restaurant?
When you eat at a restaurant, in what type of restaurant do you eat?
Do you eat foods left from previous meals?
Where do you keep your food?
Do you have a refrigerator?
How do you cook your food?
How do you prepare meat?
How do you prepare vegetables?
What type of spices do you use?
What do you drink with your meals?
Do you drink special teas?
Do you have any food allergies?
Are there certain foods that cause you problems when you eat them?
How does your diet change with each season?
Are your food habits different on days you work versus when you are not working?
Pregnancy and childbearing practices
How many children do you have?
What do you use for birth control?
What does it mean to you and your family when you are pregnant?
What special foods do you eat when you are pregnant?
What foods do you avoid when you are pregnant?
What activities do you avoid when you are pregnant?
Do you do anything special when you are pregnant?
Do you eat nonfood substances when you are pregnant?
Who do you want with you when you deliver your baby?
In what position do you want to be when you deliver your baby?
What special foods do you eat after delivery?
What foods do you avoid after delivery?
What activities do you avoid after you deliver?
Do you do anything special after delivery?
Who will help you with the baby after delivery?
What bathing restrictions do you have after you deliver?
Do you want to keep the placenta?
What do you do to care for the baby’s umbilical cord?
Death rituals
What special activities need to be performed to prepare for death?
What special activities need to be performed after death?
Would you want to know about your impending death?
What is your preferred burial practice? Interment, cremation?
How soon after death does burial occur?
How do men grieve?
How do women grieve?
What does death mean to you?
Do you believe in an afterlife?
Are children included in death rituals?
Spirituality
What is your religion?
Do you consider yourself deeply religious?
How many times a day do you pray?
What do you need in order to say your prayers?
Do you practice meditation, such as TM, mindfulness meditation, etc.?
What gives strength and meaning to your life?
In what spiritual practices do you engage for your physical and emotional health?
Health-care practices
In what prevention activities do you engage to maintain your health?
Who in your family takes responsibility for your health?
Who takes care of family members when they are sick?
What over-the-counter medicines do you use?
What herbal teas and folk medicines do you use?
For what conditions do you use herbal medicines?
What do you usually do when you are in pain?
How do you express your pain?
How are people in your culture viewed or treated when they have a mental illness?
How are people with physical disabilities treated in your culture?
What do you do when you are sick? Stay in bed, continue your normal activities, etc.?
What are your beliefs about rehabilitation?
How are people with chronic illnesses viewed or treated in your culture?
Are you averse to blood transfusions?
Is organ donation acceptable to you?
Are you listed as a potential organ donor?
Would you consider having an organ transplant if needed?
Are health-care services readily available to you?
Do you have transportation problems accessing needed health-care services?
Can you afford health care?
Do you feel welcome when you see a health-care professional?
What traditional health-care practices do you use? For example, mineral baths, sweating, acupuncture, acupressure, cai gao, coining, moxibustion, aromatherapy, etc.?
What home difficulties do you have that might prevent you from receiving health care?
Health-care practitioners
What health-care providers do you see when you are ill? Physicians, nurses?
Do you prefer a same-sex health-care provider for routine health problems? For intimate care?
What healers do you use besides physicians and nurses?
For what conditions do you use healers?

1. Adapted from Purnell, L. (2014). Guide to Culturally Competent Health Care (3^rd ed.) Philadelphia: F.A. Davis. Pp. 12–21. Reprinted with permission