+1(978)310-4246 credencewriters@gmail.com

The purpose of this paper is to conduct a cultural self-assessment.

You will read each of the boxes in Chapter 2 of your textbook (one for each domain of the Purnell Model for Cultural Competence), answer these questions as they relate to you.

Remember to answer these questions from your personal perspective. At all times, explain why you do or do not adhere to the dominant cultural practices and beliefs of the ethnic group(s) with which you primarily identify.

If you do not wish to self-disclose a specific area from the Organizing Framework, indicate so instead of just not addressing it; of course, this should not happen very often.

Your paper should be formatted per APA and references should be current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions)

© 2008 F A Davis
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People of African American Heritage
The Amish
People of Appalachian Heritage
People of Arab Heritage
People of Chinese Heritage
People of Guatemalan Heritage
People of Egyptian Heritage
People of Filipino Heritage
People of French Canadian Heritage
People of German Heritage
People of Haitian Heritage
People of Iranian Heritage
People of Japanese Heritage
People of Jewish Heritage
People of Korean Heritage
People of Mexican Heritage
People of Russian Heritage
People of Polish Heritage
People of Thai Heritage
CULTURES COVERED ON THE DavisPlus WEB SITE (http://davisplus.fadavis.com)
People of Baltic Heritage: Estonians, Latvians, and Lithuanians
People of Brazilian Heritage
People of Greek Heritage
People of Cuban Heritage
People of Hindu Heritage
People of Irish Heritage
People of Italian Heritage
People of Puerto Rican Heritage
Navajo Indians
People of Turkish Heritage
People of Vietnamese Heritage
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Health Care
A Culturally Competent Approach
Third Edition
Larry D. Purnell, PhD, RN,
College of Health Sciences
University of Delaware
Newark, Delaware
Betty J. Paulanka, EdD, RN
Professor and Dean
College of Health Sciences
University of Delaware
Newark, Delaware
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© 2008 F A Davis
F. A. Davis Company
1915 Arch Street
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Copyright © 2008 by F. A. Davis Company
Copyright © 2003, 1998 by F. A. Davis Company. All rights reserved. This book is protected by
copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without
written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
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Library of Congress Cataloging-in-Publication Data
Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell,
Betty J. Paulanka. — 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1865-7
ISBN-10: 0-8036-1865-4
1. Transcultural medical care—United States. 2. Transcultural medical care—Canada. I. Purnell,
Larry D. II. Paulanka, Betty J.
[DNLM: 1. Delivery of Health Care—North America. 2. Cross-Cultural Comparison—North
America. 3. Ethnic Groups—North America. W 84 DA2 T7 2008]
RA418.5.T73T73 2008
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he rise in concern for cultural competence has become
one of the most important developments in American
health care over the past decade. Medicine and health
more generally have moved beyond their traditional
equanimous approach of application of scientific rationality to clinical problems to one that promotes an easier integration of clinical science with empathy. This development
has occurred with a rising tide of the diversity of the population of the United States. Some of this is driven by actual
numbers of immigrants, but other dimensions of this
awareness come from the visibility of the “new” ethnics
and the waning of the social ideology of the melting pot.
Beyond all of this is a younger generation that is much
more attuned to diversity as part of their cultural landscape
and their comfort with the globalization of perspectives
resulting from technological and economic change.
From within health care, the advocacy for culturally
competent approaches is driven in part by the dawning
recognition of the danger to patient safety and overall
inadequacy in the quality of outcomes in what we do.
The literature around the disparities of outcomes across
ethnic, social, and economic groups provides a compelling case to ensure that health care is attentive to these
differences. But there is also attention to the costs that are
driven up by health care that is not culturally competent
and discourages compliance. The excess expenditures are
associated with poor communication, the failure to use
culturally responsive methods, and ineffective attempts
to transfer treatment modalities to make the system cost
efficient. Finally, as the health system makes its glacial
move to more consumer and individual responsiveness,
the system is recognizing that a cultural perspective is
essential to provide services that earn high levels of consumer satisfaction.
Much of the activity aimed at advancing cultural competence has been centered on regulations and mandates.
However, a generational change that begins with the education of each new practitioner is needed to bring about a
culturally informed and competent professional community.
This edition of Transcultural Health Care provides the
critical lessons to introduce students and practitioners to
how different cultures construct the social world and the
dramatic impact that culture has on how health care,
medicine, community, and family interact. These insights
into the rich variety of human culture are only small steps
toward developing real wisdom regarding culture competence.
The first step in such a transformation is awareness of
the other. Most young students and many seasoned practitioners simply do not have an appreciation of the variety of backgrounds and perspectives that people bring to
an encounter with the health-care system. They have the
expectation that the patient or consumer will “fit” into
their clinic or admission process. Moreover, much of what
is done in health care follows a “procedure,” which
implies that there are predetermined steps by which any
one receiving the care or service must fit. For an increasingly large part of the population, nothing could be further from the truth. The care-seeking behavior, the attitude toward authority, the comfort with middle-class
America culture that makes up so much of the health-care
social world, and the relationship between genders are
just a few of the literally hundreds of places at which a
disconnect between the individual and the system can
occur. When disconnects occur, the efforts by the system
to maintain or return health may fail.
The second step after awareness is knowledge. What is it
that we must know as practitioners in a system of care to
reach the other person and overcome the cultural barriers? And it is essential that this knowledge pass both
ways. What do they need to know about us in order to be
an equal part of a team-focused plan to address a problem? Knowledge also speaks to the need for every practitioner to be aware of his/her own attitudes, bias, and prejudices. Everyone has such prejudices; they are not the
issue. Awareness of them and the wisdom and insight to
adjust care to provide nonjudgmental and supportive
interventions is the challenge.
A culturally competent practitioner must also have a
sense of comfort with the experiential process of engaging
others from different cultures. This is perhaps the most
difficult of all skills to teach and may only be learned
through the practice of engaging others and being able to
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reflect critically on the experience and its impact on the
patient as well as on the provider. This process is a familiar one, of course, as it is the core of clinical education.
But students must come to value the variety of life and
learn how to adapt their clinical expertise to different cultures and the individual unique development in a multicultural context.
As we focus on cultural competence, one fear is that we
will make the knowledge more transactional than transformational. It needs to be the latter. For the patient or consumer, health care presented in a culturally competent
way must blend the traditions of the older culture with the
promise and resources of modern health care. For the practitioner or health-care institution, new patterns of service
and organization of care must be transformed using the
experience with the new culture. Such a critical perspective of cultural humility is essential for all practitioners in
all dimensions of health care and is a vital part of developing into a truly culturally competent provider.
This will be greatly assisted as care delivery moves
from profession-specific models of care to more interprofessional and team-based approaches. This has long been
a hope of many involved in efforts to reform health care.
If one is truly committed in becoming culturally competent, then one important lesson to learn is how to
expand competence and the facility from the culture of
nursing to an interdisciplinary culture that includes
pharmacy, medicine, and the allied health professions.
This seems obvious, but without these skills of closer
adaptation and accommodation among all health professions, how can you imagine practitioners adapting to
cultures that are more alien than those we encounter on
a routine basis?
Synthesizing cultural adaptations within the health professional perspectives and offering adapted care to patients
may not be sufficient to guarantee individual cultural competence. Practitioners who achieve such skill will need to
change their orientation from one that is focused on the
profession and its clinical world to one that is patient-centric.
This is easy to affirm but very difficult to deliver because of
the power and cultural hegemony of the clinical world. This
cultural blindness serves neither the patient nor the practitioner. It is also a source of much of the dysfunction of the
current system of care, both in terms of costs and quality.
The final stage in cultural competency is the ability to
balance self-awareness with other-awareness. Such a balance
is the hallmark of an outstanding clinician and is also the
basis of all true cultural competence. This value allows for
a response ability that transcends the simple knowledge of
all practitioners knowing every detail about particular cultures and allows a different relationship to emerge between
the provider of service and the recipient. In this way, the
work toward developing the skills of a culturally competent practitioner assists in the broader goal of becoming
an outstanding clinician in any setting. This edition of
Transcultural Health Care provides an outstanding guide to
the journey of becoming just such a practitioner.
Departments of Family and Community Medicine,
Preventive and Restorative Dental Sciences and
Social and Behavioral Sciences, and
Director of the Center for the Health Professions
University of California, San Francisco
San Francisco, California
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he editors would like to thank all those who helped in
the preparation of the third edition of this book. We especially thank acquisitions editor, Jonathan D. Joyce, and
associate acquisitions editor, Thomas A. Ciavarella, at F. A.
Davis for their support and enthusiasm for the project;
and Julie Catagnus, developmental editor, for her attention to detail, timeliness, and patience during the editing
process. We thank the copyeditors at F. A. Davis for their
assistance in bringing the book to completion. Most
importantly, we want to thank the many multicultural
populations and health professionals who are the impetus for this book. Finally, we thank our families, friends,
and colleagues for their patience and support during the
preparation of the book.
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Diane Alain, Med, RN
La Cité Collégiale
University of Ottawa
Ottawa, Ontario, Canada
Josepha Campinha-Bacote, PhD, MAR, APRN, BC,
Clinical Assistant Professor
Case Western Reserve University
Cleveland, Ohio
President, Transcultural C.A.R.E. Associates
Cincinnati, Ohio
Marga Simon Coler, EdD, APRN-C, FAAN
Professor Emeritus
University of Connecticut
Storrs, Connecticut
Adjunct Professor
University of Massachusetts
Amherst, Massachusetts
Collaborating Professor
Federal University of Paraíba
Paraíba, Brazil
Jessie M. Colin, PhD, RN
Barry University School of Nursing
Miami Shores, Florida
Ginette Coutu-Wakulczyk, RN, MSc, PhD
Associate Professor
School of Nursing
Faculty of Health Sciences
University of Ottawa
Ottawa, Ontario, Canada
Tina A. Ellis, RN, MSN, CTN
Nursing Instructor
Florida Gulf Coast University
Fort Myers, Florida
Rauda Gelazis, RN, PhD, CS, CTN
Associate Professor
Ursuline College
Pepper Pike, Ohio
Divina Grossman, PhD, RN, FAAN
College of Nursing and Health Sciences
Florida International University
Miami, Florida
Homeyra Hafizi, RN, MS, LHRM
Occupational Health
Dynamac Corporation
Kennedy Space Center, Florida
Sandra M. Hillman, PhD, MS, BSN
Nelson Mandela Metropolitan University
Port Elizabeth, South Africa
David Hodgins, MSN, RN, CEN
Indian Health Service
Shiprock, New Mexico
Olivia Hodgins, RN, PhD, MSA, BSN
Map Instructor and Nurse Executive
Indian Health Service
San Fidel, New Mexico
Kathleen W. Huttlinger, PhD, RN
Associate Director for Research and
Interim Director of Graduate Programs
School of Nursing
New Mexico State University
Las Cruces, New Mexico
Eun-Ok Im, PhD, MPH, FAAN
The University of Texas at Austin
Austin, Texas
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Misae Ito, MSN, RN, NMW
Associate Professor, Fundamental Nursing
Department of Nursing, Faculty of Health Sciences
Yamaguchi University School of Medicine
Yamaguchi-Ken, Japan
Anahid Dervartanian Kulwicki, RN, DNS, FAAN
Deputy Director
Wayne County Health and Human Services
Detroit, Michigan
Oakland University
Rochester, Michigan
Juliene G. Lipson, RN, PhD, FAAN
Professor Emerita
University of California, San Francisco School of
Mill Valley, California
Afaf Ibrahim Meleis, PhD, DrPS(hon), FAAN
Margaret Bond Simon Dean of Nursing
Professor of Nursing and Sociology
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania
Mahmoud Hanafi Meleis, PhD, PE
Retired Nuclear Engineer
Philadelphia, Pennsylvania
Denise Moreau, PhD, MSc, RN
Assistant Professor and Lecturer
University of Ottawa
Ottawa, Ontario, Canada
Dula F. Pacquiao, EdD, RN, CTN
Associate Professor and Director
Bergen Center for Multicultural Education,
Research and Practice
School of Nursing
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Irena Papadopoulos, PhD, MA, RN, RM, DipNEd,
NDN Cert
Professor of Transcultural Health and Nursing
Middlesex University, United Kingdom
Highgate Hill, London
Ghislaine Paperwalla, BSN, RN
Research Nurse in Immunology
Veterans Administration Medical Center
Miami, Florida
Henry M. Plawecki, RN, PhD
Professor of Nursing
Purdue University Calumet School of Nursing
Hammond, Indiana
Judith A. Plawecki, RN, PhD
University of South Florida
Tampa, Florida
Lawrence H. Plawecki, RN, JD, LLM
Health Law Consultant
Plawecki Consultants, LLC
Highland, Indiana
Martin H. Plawecki, PhD, MD
Indiana University School of Medicine
Indianapolis, Indiana
Jeffrey Ross, BFA, MA, MAT
Graphic Designer and Language Arts Teacher
Archbishop Hoban High School
Akron, Ohio
Ratchneewan Ross, PhD, MSc, RN, Certificate in
Assistant Professor
College of Nursing
Kent State University
Kent, Ohio
Maryam Sayyedi, PhD
Adjunct Professor
Department of Counseling
California State University, Fullerton
Fullerton, California
Janice Selekman, DNSc, RN
University of Delaware
Newark, Delaware
Linda S. Smith, MS, DSN, RN, CLNC
Associate Professor and Director
Idaho State University
Pocatello, Idaho
Jessica A. Steckler, MS, RNBC
National Program Manager
Employee Education System, VHA
Erie, Pennsylvania
Gulbu Tortumluoglu, PhD
Assistant Professor
Nursing Department Chief
Yuksekokulu, Canakkale, Turkey
Susan Turale, DEd, MNStud, BN,
DApSci(AdvPsychNurs), RN, RPN, FRCNA,
Professor of International Nursing
Department of Nursing, Faculty of Health Sciences
Yamaguchi University School of Medicine
Yamaguchi-Ken, Japan
Yan Wang, MSN, RN-BC
Nursing Informatics System Specialist III
Duke University Health System
Duke Health Technology Solutions
Durham, North Carolina
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Anna Frances Z. Wenger, PhD, RN, CTN, FAAN
Professor and Director of Nursing Emerita
Goshen College
Goshen, Indiana
Senior Scholar
Interfaith Health Program
School of Public Health
Emory University
Program Consultant
Ethiopia Public Health Training Initiative
The Carter Center
Atlanta, Georgia
Marion R. Wenger, PhD
Retired Professor of Foreign Languages and Linguistics
Emory University
Atlanta, Georgia
Sarah A. Wilson, PhD, RN
Associate Professor
Director, Institute for End of Life Care Education
Marquette University College of Nursing
Milwaukee, Wisconsin
Cecilia A. Zamarripa, RN, CWON
Wound, Ostomy, and Continence Nurse
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Rick Zoucha, APRN, BC, DNSc, CTN
Associate Professor
Duquesne University School of Nursing
Pittsburgh, Pennsylvania
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Introduction ………………………………………………………………………………………….. xvii
Chapter 1
Transcultural Diversity and Health Care …………………………………. 1
Chapter 2
The Purnell Model for Cultural Competence ………………………… 19
Chapter 3
People of African American Heritage …………………………………….. 56
Chapter 4
The Amish ……………………………………………………………………………. 75
Chapter 5
People of Appalachian Heritage ……………………………………………. 95
Chapter 6
People of Arab Heritage ………………………………………………………. 113
Chapter 7
People of Chinese Heritage …………………………………………………. 129
Chapter 8
People of Guatemalan Heritage ……………………………………………. 145
Chapter 9
People of Egyptian Heritage…………………………………………………. 157
Chapter 10
People of Filipino Heritage …………………………………………………. 175
Chapter 11
People of French Canadian Heritage…………………………………….. 196
Chapter 12
People of German Heritage …………………………………………………. 213
Chapter 13
People of Haitian Heritage …………………………………………………… 231
Chapter 14
People of Iranian Heritage …………………………………………………… 248
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Chapter 15
People of Japanese Heritage …………………………………………………. 260
Chapter 16
People of Jewish Heritage …………………………………………………… 278
Chapter 17
People of Korean Heritage …………………………………………………… 293
Chapter 18
People of Mexican Heritage …………………………………………………. 309
Chapter 19
People of Russian Heritage …………………………………………………… 325
Chapter 20
People of Polish Heritage …………………………………………………….. 337
Chapter 21
People of Thai Heritage ………………………………………………………. 355
Cultural, Ethnic, and Racial Diseases and Illnesses……………….. 373
People of Baltic Heritage: Estonians, Latvians,
and Lithuanians …………………………………………………………………. 381
People of Brazilian Heritage…………………………………………………. 383
People of Greek Ancestry ……………………………………………………..385
People of Cuban Heritage…………………………………………………….. 387
People of Hindu Heritage …………………………………………………….. 389
People of Irish Heritage ………………………………………………………. 391
People of Italian Heritage…………………………………………………….. 393
People of Puerto Rican Heritage ………………………………………….. 395
Navajo Indians ……………………………………………………………………..397
People of Turkish Heritage ……………………………………………………399
People of Vietnamese Heritage ……………………………………………. 401
Glossary…………………………………………………………………………………………………. 403
Index …………………………………………………………………………………………………….. 411
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Contents –
People of Baltic Heritage: Estonians, Latvians, and Lithuanians
People of Brazilian Heritage
People of Greek Heritage
People of Cuban Heritage
People of Hindu Heritage
People of Irish Heritage
People of Italian Heritage
People of Puerto Rican Heritage
Navajo Indians
People of Turkish Heritage
People of Vietnamese Heritage
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he Purnell Model for Cultural Competence and its
accompanying organizing framework has been used in
education, clinical practice, administration, and research,
giving credence to its usefulness for healthcare providers.
They have been translated into Spanish, French, Flemish,
Portuguese, Turkish, and Korean. Healthcare organizations have adapted the organizing framework as a cultural
assessment tool and numerous students have used the
Model to guide research for theses and dissertations in the
United States and overseas. The Model’s usefulness has
been established in the global arena, recognizing and
including the client’s culture in assessment, healthcare
planning, interventions, and evaluation. The Model is
now being used more with organizational cultural competence as well.
The third edition of Transcultural Health Care: A
Culturally Competent Approach has been revised based
upon response from students and practicing healthcare
professionals such as nurses, physicians, physical therapists, emergency medical technicians, and nutritionists to
name a few as well as educators from associate degree,
baccalaureate, masters, and doctoral programs in nursing.
We appreciate their review and suggestions.
Chapter 1 has three important changes: (a) a more
extensive section on health disparities, (b) a more extensive section on organizational cultural competence, and
(c) a section on evidence-based practice as it relates to culture care. We have made a concerted effort to use nonstereotypical language when describing cultural attributes
of specific cultures, recognizing that there are exceptions
to every description provided and that the differences
within a cultural group may be greater than the diversity
between and among different cultural groups. We have
also tried to include both the sociological and anthropological perspectives of culture.
Chapter 2 expands the description of the Purnell Model
for Cultural Competence to include application of the
domains and concepts of culture to the dominant
American Culture in a cross-cultural fashion. Chapters 1
and 2 have critical thinking questions dispersed throughout
each chapter. The glossary remains as it did in the second
edition because users have noted its importance. Cultural
specific chapters have changes based on users’ suggestions.
Instead of one large case study at the end of each chapter,
shorter vignettes covering several domains with study
questions are dispersed throughout each chapter.
Given the world diversity and the diversity within cultural groups, it is impossible to cover each group more
extensively. Space and cost concerns limit the number of
chapters that are included in the book; therefore, additional
cultural groups, PowerPoint slides, test banks, useful web
sites, and additional case studies are include on DavisPlus.
Specific criteria were used for identifying the groups
represented in the book and those included in electronic
format. Groups included in the book were selected based
on any of the six criteria that follow.
• The group has a large population in North
America, such as people of Appalachian, Mexican,
German, and African American heritage.
• The group is relatively new in its migration status,
such as people of Haitian, Cuban, and Arab heritage.
• The group is widely dispersed throughout North
America, such as people of Iranian, Korean, and
Filipino heritage.
• The group has little written about it in the healthcare literature, such as people of Guatemalan,
Russian, and Thai heritage.
• The group holds significant disenfranchised status, such as people of Navajo heritage, a large
American Indian group.
• The group was of particular interest to readers in
the second edition, such as people from Amish
Again, we have strived to portray each culture positively and without stereotyping. We hope you enjoy our
book and are as excited about the content as we are.
Larry D. Purnell
Betty J. Paulanka
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Transcultural Diversity
and Health Care
The Need for Culturally Competent
Health Care
Cultural competence in multicultural societies continues as
a major initiative for business, health-care, and educational
organizations in the United States and throughout most of
the world. The mass media, health-care policy makers, the
Office of Minority Health, and other Governmental organizations, professional organizations, the workplace, and
health insurance payers are addressing the need for individuals to understand and become culturally competent as one
strategy to improve quality and eliminate racial, ethnic, and
gender disparities in health care. Educational institutions
from elementary schools to colleges and universities also
address cultural diversity and cultural competency as they
relate to disparities and health promotion and wellness.
Many countries are now recognizing the need for
addressing the diversity of their society, including the
client base, the provider base, and the organization.
Societies that used to be rather homogeneous, such as
Portugal, Norway, Sweden, Korea, and selected areas in the
United States and the United Kingdom, are now facing significant internal and external migration, resulting in ethnocultural diversity that did not previously exist, at least
not to the degree it does now. As commissioned by the
U.K. Presidency of the European Union, several European
countries—such as Denmark, Italy, Poland, the Czech
Republic, Latvia, the United Kingdom, Sweden, Norway,
Finland, Italy, Spain, Portugal, Hungary, Belgium, Greece,
Germany, the Netherlands, and France—either have in
place or are developing national programs to address the
value of cultural competence in reducing health disparities (Health Inequities: A Challenge for Europe, 2005).
Whether people are internal migrants, immigrants, or
vacationers, they have the right to expect the health-care
system to respect their personal beliefs, values, and
health-care practices. Culturally competent health care
from providers and the system, regardless of the setting in
which care is delivered, is becoming a concern and expectation among consumers. Diversity also includes having a
diverse workforce that more closely represents the population the organization serves.
Health-care personnel provide care to people of diverse
cultures in long-term-care facilities, acute-care facilities,
clinics, communities, and clients’ homes. All health-care
providers—physicians, nurses, nutritionists, therapists,
technicians, home health aides, and other caregivers—
need similar culturally specific information. For example,
all health-care providers engage in verbal and nonverbal
communication; therefore, all health-care professionals
and ancillary staff need to have similar information and
skill development to communicate appropriately with
diverse populations. The manner in which the information is used may differ significantly based on the discipline, individual experiences, and specific circumstances
of the client and provider.
Culturally competent staff and organizations are essential ingredients in increasing clients’ satisfaction with
health care and reducing multifactor reasons for gender,
racial, and ethnic disparities and complications in health
care. If providers and the system are competent, most
clients will access the health-care system when problems
are first recognized, thereby reducing the length of stay,
decreasing complications, and reducing overall costs.
A lack of knowledge of clients’ language abilities and
cultural beliefs and values can result in serious threats to
life and quality of care for all individuals. Organizations
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and individuals who understand their clients’ cultural
values, beliefs, and practices are in a better position to be
coparticipants with their clients in providing culturally
acceptable care. Having ethnocultural specific knowledge,
understanding, and assessment skills to work with culturally diverse clients assures that the health-care provider
knows what questions to ask. Providers who know ethnoculturally specific knowledge are less likely to demonstrate negative attitudes, behaviors, ethnocentrism,
stereotyping, and racism. Accordingly, there will be
improved opportunities for health promotion and wellness; illness, disease, and injury prevention; and health
maintenance and restoration. The onus for cultural competence is on the health-care provider and the delivery
system in which care is provided. To this end, health-care
providers need both general and specific cultural knowledge to help reduce gender and ethnic and racial disparities in health care.
research. For example, in the Home Office Study (2002) in
the United Kingdom, migrants contributed U.S. $4 billion
more in taxes than they received in benefits. In the
United States, the National Research Council (1998) estimated that national income had expanded by U.S. $8 billion because of immigration. Thus, because migrants pay
taxes, they are not likely to put a greater burden on health
and welfare services than the host population. However,
undocumented migrants run the highest health risks
because they are less likely to seek health care. This not
only poses risks for migrants but also fuels sentiments of
xenophobia and discrimination against all migrants.
World Diversity and Migration
The world’s population reached 6.5 billion people in the
year 2005 and is expected to approach 7.6 billion by 2020
and 9.3 billion by 2050. The estimated population growth
rate is 1.14 percent, with 20.05 births per 1000 population, 8.6 deaths per 1000 population, and an infant mortality rate of 48.87 per 1000 population. Worldwide, life
expectancy at birth is currently 64.77 years, with males at
63.17 years and females at 66.47 years (CIA, 2007).
As a first language, Mandarin Chinese is the most popular, spoken by 13.59 percent of the world’s population, followed by Spanish at 5.05 percent, English at 4.8 percent,
Hindi at 2.82 percent, Portuguese at 2.77 percent, Bengali
at 2.68 percent, Russian at 2.27 percent, Japanese at 1.99
percent, German at 1.49 percent, and Wu Chinese at 1.21
percent. Only 82 percent of the world population is literate. When technology is examined, more people now have
a cell phone than a landline: 1.72 billion versus 1.2 billion.
Slightly over 1 billion people are Internet users (CIA, 2007).
We currently live in a global society, a trend that is
expected to continue into the future. According to the
United Nations High Commissioner for Refugees, there is a
global population of 9.2 million refugees, the lowest number in 25 years, and as many as 25 million internally displaced persons. Migrants represent 2.9 percent or approximately 190 million people of the world population, up
from 175 million in the year 2000. Moreover, international
migration is decreasing while internal migration is increasing, especially in Asian countries. Only two countries in
the world are seeing an increase in their migrant stock—
North America and the former USSR (CIA, 2007).
The International Organization for Migration completed the first-ever comprehensive study looking at the
costs and benefits of international migration. According
to the report, ample evidence exists that migration brings
both costs and benefits for sending and receiving countries, although these are not shared equally. Trends suggest a greater movement toward circular migration with
substantial benefits to both home and host countries. The
perception that migrants are more of a burden on, than a
benefit to, the host country is not substantiated by
As of 2006, the U.S. population was over 300 million, an
increase of 16 million since the 2000 census. The most
recent census data estimates that 74.7 percent are white,
14.5 percent are Hispanic/Latino (of any race), 12.1 percent are black or African American, 0.8 percent are
American Indian or Alaskan Native, 4.3 percent are Asian,
0.1 percent are Native Hawaiian or other Pacific Islander,
6 percent are some other race, and only 1.9 percent are of
two or more races. Please note: These figures total more
than 100 percent because the federal government considers race and Hispanic origin to be two separate and distinct categories. The categories as used in Census 2000 are
What evidence do you see in your community that
migrants have added to the economic base of the
community? Who would be doing their work if
they were not available?
1. White refers to people having origins in any of
the original peoples of Europe, the Near East,
and the Middle East, and North Africa. This category includes Irish, German, Italian, Lebanese,
Turkish, Arab, and Polish.
2. Black or African American refers to people having
origins in any of the black racial groups of Africa,
and includes Nigerians and Haitians or any person who self-designates this category regardless
of origin.
3. American Indian and Alaskan Native refer to people
having origins in any of the original peoples of
North, South, or Central America and who maintain tribal affiliation or community attachment.
4. Asian refers to people having origins in any of
the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent. This category
includes the terms Asian Indian, Chinese, Filipino,
Korean, Japanese, Vietnamese, Burmese, Hmong,
Pakistani, and Thai.
5. Native Hawaiian and other Pacific Islander refer to
people having origins in any of the original peoples of Hawaii, Guam, Samoa, Tahiti, the Mariana
Islands, and Chuuk.
6. Some other race was included for people who are
unable to identify with the other categories.
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7. In addition, the respondent could identify, as a
write-in, with two races (U.S. Bureau of the
Census, 2006).
The Hispanic/Latino and Asian populations continue to
rise in numbers and in percentage of the overall population; although the black/African American, Native
Hawaiian and Pacific Islanders, Native American and
Alaskan Natives groups continue to increase in overall
numbers, their percentage of the population has
decreased. Of the Hispanic/Latino population, most are
Mexicans, followed by Puerto Ricans, Cubans, Central
Americans, South Americans, and lastly, Dominicans.
Salvadorans are the largest group from Central America.
Three-quarters of Hispanics live in the West or South,
with 50 percent of the Hispanics living in just two states,
California and Texas. The median age for the entire U.S.
population is 35.3 years, and the median age for
Hispanics is 25.9 years (U.S. Bureau of the Census, 2006).
The young age of Hispanics in the United States makes
them ideal candidates for recruitment into the health
professions, an area with crisis-level shortages of personnel, especially of minority representation.
Before 1940, most immigrants to the United States
came from Europe, especially Germany, the United
Kingdom, Ireland, the former Union of Soviet Socialist
Republics, Latvia, Austria, and Hungary. Since 1940,
immigration patterns to the United States have changed:
Most are from Mexico, the Philippines, China, India,
Brazil, Russia, Pakistan, Japan, Turkey, Egypt, and
Thailand. People from each of these countries bring their
own culture with them and increase the cultural mosaic
of the United States. Many of these groups have strong
ethnic identities and maintain their values, beliefs, practices, and languages long after their arrival. Individuals
who speak only their indigenous language are more likely
to adhere to traditional practices and live in ethnic
enclaves and are less likely to assimilate into their new
society. The inability of immigrants to speak the language
of their new country creates additional challenges for
health-care providers working with these populations.
Other countries in the world face similar immigration
challenges and opportunities for diversity enrichment.
However, space does not permit a comprehensive analysis
of migration patterns.
What changes in ethnic and cultural diversity have
you seen in your community over the last 5 years?
Over the last 10 years? Have you had the opportunity to interact with newer groups?
Racial and Ethnic Disparities
in Health Care
A number of organizations have developed documents
addressing the need for cultural competence as one strategy for eliminating racial and ethnic disparities. In 1985,
the Department of Health and Human Services released
the Secretary’s Task Force’s report on Black and Minority
Health (Perspectives on Disease Prevention and Health
Promotion, 1985). Two goals from Healthy People 2010 are
to increase quality and years of healthy life and eliminate
health disparities (Healthy People 2010, 2005). In 2005,
the Agency for Healthcare Research and Quality (AHRQ)
released the Third National Healthcare Disparities Report
(Agency for Healthcare Research and Quality [AHRQ],
2005) that provides a comprehensive overview of health
disparities in ethnic, racial, and socioeconomic groups in
the United States. This report is a companion document
to the National Healthcare Quality Report (NHQR) that is
an overview of quality health care in the United States.
These two documents highlight four themes: (1)
Disparities still exist, (2) some disparities are diminishing,
(3) opportunities for improvement still exist, and (4)
information about disparities is improving. These documents address the importance of clinicians, administrators, educators, and policymakers in cultural competence.
Disparities are observed in almost all aspects of healthcare, including
1. Effectiveness, patient safety, timeliness, and
patient centeredness.
2. Facilitators and barriers to care and health-care
3. Preventive care, treatment of acute conditions,
and management of chronic disease.
4. Clinical conditions such as cancer, diabetes, endstage renal disease, heart disease, HIV disease,
mental health and substance abuse, and respiratory diseases.
5. Women, children, elderly, rural residency, and
individuals with disabilities and other special
health-care needs.
6. Minorities and the financially poor receive a
lower quality of care (AHRQ, 2005).
When ethnocultural specific populations are examined, although some disparities have shown improvement, many have not improved and some have worsened. With whites as the comparison group, the report
1. Blacks were 10 times more likely to be diagnosed
with AIDS, 59 percent less likely to be given
antibiotics for the common cold, 9 percent more
likely to receive poorer quality care, 17 percent
more likely to lack health insurance, 7 percent
less likely to report difficulties in getting care,
and 10 percent more likely to have worse access
to care.
2. Non-white Hispanics/Latinos were 3.7 times
more likely to be diagnosed with AIDS, 16 percent more likely to receive poorer quality care,
2.9 times for under age 65 to lack health insurance, 18 percent less likely to report difficulties
or delays getting care, and 87 percent more likely
to have worse access. However, they were 40 percent less likely to die of breast cancer.
3. Asians were 57 percent more likely to report communication problems with the child’s provider,
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40 percent less likely to report difficulties or
delays in getting care, and 20 percent more likely
to have worse access to care.
4. American Indians and Alaskan Natives were
twice as likely to lack early prenatal care, 67 percent less likely to develop late-stage breast cancer, 8 percent more likely to receive poorer quality care, twice as likely for the under-age-65
group to not have health insurance, 23 percent
more likely to lack a primary-care provider, and 4
percent more likely to have worse access to care.
5. Data for Native Hawaiians and other Pacific
Islanders were not available for this report but
will be in future reports (AHRQ, 2005).
The health of the lesbian, gay, bisexual, and transgender populations has not been addressed in the Healthy
People 2010 document or in other government publications. However, the Gay and Lesbian Medical Association
(www.glma.org) in 2001 developed Healthy People 2010
Companion Document for Lesbian, Gay, Bisexual, and
Transgender Health. Salient disparities are noted in this
publication. Gays and lesbians are more likely than their
heterosexual cohort groups to have higher rates of
tobacco, alcohol, and recreational drug use. Sexually
transmitted infections, HIV (especially for men), suicide
and suicide ideation, depression, being a victim of street
violence (especially for men) and home violence (especially for women), sexual abuse among men, hate crimes,
and psychological and emotional disorders are higher
among these groups. They are also more likely to be discriminated against by health-care providers owing to
homophobia. Because of the stigma that alternative identity gender discrimination brings, especially among
racially and ethnically diverse populations (Purnell,
2003), these populations were less likely to disclose their
sexual orientations. They are also less likely to have
health insurance, have a primary-care provider, or take
part in prevention programs; in fact, 57 percent of transgender people do not have health insurance (Healthy
People 2010 Companion Document for Lesbian, Gay,
Bisexual, Transgender Health, 2001; Purnell, 2003). To help
combat violence and crimes against lesbians, gays, and
transgender people, several cities such as Washington,
D.C.; Fargo, North Dakota; and Missoula, Montana, in the
United States have initiated Gay and Lesbian Crime Units
(Police Unit Reaches Out to Gay Community, Inspires
Others, 2006).
What health disparities have you observed in your
community? To what do you attribute these disparities? What can you do as a professional to help
decrease these disparities?
Only broad categories of health disparities are
addressed in this chapter. More specific data are included
in individual chapters on cultural groups. As can be seen
by the overwhelming data, much more work needs to be
accomplished to improve the health of the nation. Space
does not permit an extensive discourse on racial and
ethnic disparities in other countries. However, documents
that include other countries, conditions, and policies are
listed as a resource herein. Additional information on the
role of cultural competence on eliminating racial and
ethnic disparities includes:
1. Transcultural Nursing Society, International
2. U.S. Department of Health and Human Services
Office of Minority Health: Physician’s Toolkit
and Curriculum (http://www.omhrc.gov/assets/
3. Institute of Medicine’s Unequal Treatment
study (http://www.iom.edu/?id=4475)
4. The Commonwealth Fund Report on Health
Care Quality (http://www.cmwf.org/)
5. Delivering Race Equality: A Framework for
Action (http://www.londondevelopmentcentre.
6. Protecting Vulnerable Populations (www.wccassembly.info/en/news-media/news/english)
7. Canadian Institutes of Health Research:
Reducing Health Disparities and Promoting
Equity for Vulnerable Populations (www.cihr-irsc.
8. American Physical Therapy Association’s document and monographs on cultural competence
9. Health Inequalities: A Challenge for Europe that
includes health policies for the Czech Republic,
England, Denmark, Finland, Greece, Germany,
Hungary, Ireland, Latvia, the Netherlands,
Northern Ireland, Poland Portugal, Scotland,
Spain, Sweden, and Wales (www.fco.gov.uk/
10. American Academy of Family Physicians documents on health disparities and cultural competence (http://www.aafp.org)
11. American Academy of Physician Assistants document The Four Layers of Diversity (http://
12. Health Resources and Services Administration
publication “Indicators of Cultural Competence
in Health Care Delivery Organizations” and
Cultural Competence Works (www.hrsa.gov)
13. American Student Medical Association Culture
and Diversity Curriculum (http://www.amsa.org/
14. American Academy of Nursing Standards of
Cultural Competence (in press).
15. Diversity Rx (www.diversityRx.org)
Self-Awareness and Health
Culture has a powerful unconscious impact on health
professionals. Each health-care provider adds a new and
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unique dimension to the complexity of providing culturally competent care. The way health-care providers perceive themselves as competent providers is often reflected
in the way they communicate with clients. Thus, it is
essential for health professionals to think about their cultures, their behaviors, and their communication styles in
relation to their perceptions of cultural differences. They
should also examine the impact their beliefs have on others, including clients and coworkers, who are culturally
diverse. Before addressing the multicultural backgrounds
and unique individual perspectives of each client, healthcare professionals must first address their own personal
and professional knowledge, values, beliefs, ethics, and
life experiences in a manner that optimizes interactions
and assessment of culturally diverse individuals.
Self-knowledge and understanding promote strong
professional perceptions that free health-care professionals from prejudice and allow them to interact with others
in a manner that preserves personal integrity and respects
uniqueness and differences among individual clients. The
process of professional development and diversity competence begins with self-awareness, sometimes referred to
as self-exploration. Although the literature provides
numerous definitions of self-awareness, discussion of
research integrating the concept of self-awareness with
multicultural competence is minimal. Many theorists and
diversity trainers imply that self-examination or awareness of personal prejudices and biases is an important step
in the cognitive process of developing cultural competence (Andrews & Boyle, 2005; Campinha-Bacote, 2006;
Giger & Davidhizar, 2008). However, discussions of emotional feelings elicited by this cognitive awareness are
somewhat limited, given the potential impact of emotions and conscious feelings on behavioral outcomes.
In your opinion, why is there conflict about working with culturally diverse clients? What attitudes
are necessary to deliver quality care to clients
whose culture is different from yours?
Self-awareness in cultural competence is a deliberate
and conscious cognitive and emotional process of getting
to know yourself: your personality, your values, your
beliefs, your professional knowledge standards, your
ethics, and the impact of these factors on the various roles
you play when interacting with individuals different from
yourself. The ability to understand oneself sets the stage
for integrating new knowledge related to cultural differences into the professional’s knowledge base and perceptions of health interventions.
What have you done in the last 5 to 10 years to
increase your self-awareness? Has increasing your
self-awareness resulted in an increased appreciation for cultural diversity? How might you
increase your knowledge about the diversity in
your community? In your school?
Culture and Essential Terminology
Anthropologists and sociologists have proposed many
definitions of culture. For the purposes of this book, culture is defined as the totality of socially transmitted
behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought
characteristics of a population of people that guide their
worldview and decision making. Health and health-care
beliefs and values are assumed in this definition. These
patterns may be explicit or implicit, are primarily learned
and transmitted within the family, are shared by most
(but not all) members of the culture, and are emergent
phenomena that change in response to global phenomena. Culture, a combined anthropological and social construct, can be seen as having three levels: (1) a tertiary
level that is visible to outsiders, such as things that can be
seen, worn, or otherwise observed; (2) a secondary level,
in which only members know the rules of behavior and
can articulate them; and (3) a primary level that represents the deepest level in which rules are known by all,
observed by all, implicit, and taken for granted (Koffman,
2006). Culture is largely unconscious and has powerful
influences on health and illness. Health-care providers
must recognize, respect, and integrate clients’ cultural
beliefs and practices into health prescriptions.
An important concept to understand is that cultural
beliefs, values, and practices are learned from birth: first
at home, then in the church and other places where
people congregate, and then in educational settings.
Therefore, a 3-month-old male child from Korea adopted
by an African American family and reared in an African
American environment will have an African American
worldview. However, that child’s “race” would be Asian,
and if that child had a tendency toward genetic/hereditary
conditions, they would come from his Korean ancestry,
not from African American genetics.
Who in your family had the most influence in
teaching you cultural values and practices?
Outside the family, where else did you learn about
your cultural values and beliefs? What cultural
practices did you learn in your family that you no
longer practice?
When individuals of dissimilar cultural orientations
meet in a work or a therapeutic environment, the likelihood for developing a mutually satisfying relationship is
improved if both parties attempt to learn about each
other’s culture. Moreover, race and culture are not synonymous and should not be confused. For example, most
people who self-identify as African American have varying degrees of dark skin, but some may have white skin.
However, as a cultural term, African American means that
the person takes pride in having ancestry from both
Africa and the United States; thus, a person with white
skin could self-identify as African American.
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Attitude is a state of mind or feeling about some matter
of a culture. Attitudes are learned; for example, some people think that one culture is better than another. One culture is not better than another; the two are just different,
although many patterns are shared among cultures. A
belief is something that is accepted as true, especially as
a tenet or a body of tenets accepted by people in an ethnocultural group. A belief among some cultures is that if
a pregnant woman craves a particular food substance,
strawberries, for example, and does not satisfy the craving, the baby will be born with a birthmark in the shape
of the craving. Attitudes and beliefs do not have to be
proven; they are unconsciously accepted as truths.
Ideology consists of the thoughts and beliefs that reflect
the social needs and aspirations of an individual or an
ethnocultural group. For example, some people believe
that health care is a right of all people, whereas others see
health care as a privilege.
The literature reports many definitions for the terms
cultural awareness, cultural sensitivity, and cultural competence. Sometimes, these definitions are used interchangeably. However, cultural awareness has more to
do with an appreciation of the external signs of diversity,
such as arts, music, dress, and physical characteristics.
Cultural sensitivity has more to do with personal attitudes and not saying things that might be offensive to
someone from a cultural or ethnic background different
from the health-care provider’s. Cultural competence
in health care is having the knowledge, abilities, and skills
to deliver care congruent with the client’s cultural beliefs
and practices. Increasing one’s consciousness of cultural
diversity improves the possibilities for health-care practitioners to provide culturally competent care.
What activity have you done to increase your cultural awareness and competence? How do you
demonstrate that you are culturally sensitive?
One progresses from unconscious incompetence (not
being aware that one is lacking knowledge about another
culture), to conscious incompetence (being aware that
one is lacking knowledge about another culture), to conscious competence (learning about the client’s culture,
verifying generalizations about the client’s culture, and
providing cultural specific interventions), and finally, to
unconscious competence (automatically providing culturally congruent care to clients of diverse cultures).
Unconscious competence is difficult to accomplish and
potentially dangerous because individual differences exist
within specific cultural groups. To be even minimally
effective, culturally competent care must have the assurance of continuation after the original impetus is withdrawn; it must be integrated into, and valued by, the culture that is to benefit from the interventions.
Developing mutually satisfying relationships with
diverse cultural groups involves good interpersonal skills
and the application of knowledge and techniques learned
from the physical, biological, and social sciences as well
as the humanities. An understanding of one’s own culture
and personal values and the ability to detach oneself from
“excess baggage” associated with personal views are
essential to cultural competence. Even then, traces of ethnocentrism may unconsciously pervade one’s attitudes
and behavior. Ethnocentrism, the universal tendency
of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural
ways, can be a major barrier to providing culturally competent care. Ethnocentrism, a concept that most people
practice to some degree, perpetuates an attitude in which
beliefs that differ greatly from one’s own are strange,
bizarre, or unenlightened and, therefore, wrong. Values
are principles and standards that are important and have
meaning and worth to an individual, family, group, or
community. For example, the dominant U.S. culture
places high value on youth, technology, and money. The
extent to which one’s cultural values are internalized
influences the tendency toward ethnocentrism. The more
one’s values are internalized, the more difficult it is to
avoid the tendency toward ethnocentrism.
Given that everyone is ethnocentric to some
degree, what do you do to become less ethnocentric? If you were to rate yourself on a scale of 1 to
10, with 1 being less ethnocentric and 10 being
very ethnocentric, what score would you give
yourself? What score would your friends give you?
What score would you give your closest friends?
The Human Genome Project provides evidence that all
human beings share a genetic code that is over 99 percent
identical. However, the controversial term race must still
be addressed when learning about culture. Race is genetic
in origin and includes physical characteristics that are similar among members of the group, such as skin color,
blood type, and hair and eye color. Although there is less
than a 1 percent difference, this difference is significant
when conducting physical assessments and prescribing
medication, as outlined in culturally specific chapters that
follow. People from a given racial group may, but do not
necessarily, share a common culture. Race as a social concept is just as important, and sometimes more important,
than race as a biological concept. Race has social meaning,
assigns status, limits or increases opportunities, and influences interactions between patients and clinicians. Racism
has been described as prejudice combined with power
(Abrums, 2004). The International Convention on the
Elimination of All Forms of Racial Discrimination defines
racism (1965) as “Any distinction, exclusion, restriction,
or preference based on race, colour, descent, or national or
ethnic origin which has the purpose or effect of nullifying
or impairing the recognition, enjoyment, or exercise, on
equal footing, of human rights and fundamental freedoms
in the political, economic, social, cultural, or any other
field of public life.” Racism may be overt or covert. Recent
antidiscrimination laws make racism illegal, but the laws
do not eliminate racist attitudes; thus, people are just less
likely to express racist attitudes openly. Moreover, one
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must remember that even though one might have a racist
attitude, it is not always recognized because it is ingrained
during socialization and leads to ethnocentrism.
How do you define race? What other terms do you
use besides race to describe people? In what category did you classify yourself on the last census?
What categories would you add to the current
census classifications?
Worldview is the way individuals or groups of people
look at the universe to form basic assumptions and values
about their lives and the world around them. Worldview
includes cosmology, relationships with nature, moral and
ethical reasoning, social relationships, magicoreligious
beliefs, and aesthetics.
Any generalization—reducing numerous characteristics of an individual or group of people to a general form
that renders them indistinguishable—made about the
behaviors of any individual or large group of people is
almost certain to be an oversimplification. When a generalization relates less to the actual observed behavior than
to the motives thought to underlie the behavior (i.e., the
why of the behavior), it is likely to be oversimplified.
Thus, generalizations can lead to stereotyping, an oversimplified conception, opinion, or belief about some
aspect of an individual or group. Generalization and
stereotyping are similar, but functionally, they are very
different. Stereotyping is an endpoint; generalization is a
starting point. For example, knowing whether the person
comes from an individualistic versus a collectivistic culture is important. Remember, individualism and collectivism exist to some degree in all cultures, but one pattern
tends to dominate. People identifying with a collectivist
culture, such as most Asians, are more likely to place a
higher value on the family than on the individual,
harmony, and solidarity. However, people who identify
with an individualistic culture, such as the dominant
American and Scandinavian cultures, are more likely to
place a higher value on the individual, independence,
autonomy, and achievement. The health-care provider
must specifically ask questions to determine these values
and avoid stereotypical views of clients.
Everyone engages in stereotypical behavior to
some degree. We could not function otherwise. If
someone asked you to think of a nurse, what
image do you have? Is the nurse male or female?
How old is the nurse? How is the nurse dressed? Is
the nurse wearing a hat? How do you distinguish a
stereotype from a generalization?
Even in relatively homogeneous cultures, subcultures
and ethnic groups exist that may not hold all the values
of their dominant culture. Subcultures, ethnic groups,
or ethnocultural populations are groups of people who
have experiences different from those of the dominant
culture. Some of these differences may include socioeconomic status, ethnic background, residence, religion, education, or other factors that functionally unify the group
and act collectively on each member with a conscious
awareness of these differences. Subcultures differ from the
dominant ethnic group and share beliefs according to the
primary and secondary characteristics of culture.
Primary and Secondary
Characteristics of Culture
Great diversity exists within a cultural group. Major
influences that shape peoples’ worldview and the degree
to which they identify with their cultural group of origin
are called the primary and secondary characteristics of
culture. The primary characteristics are things that a
person cannot easily change, but if they do, a stigma may
occur for themselves, their families, or the society in
which they live. The primary characteristics of culture
include nationality, race, color, gender, age, and religious
affiliation. For example, consider two people with these
primary characteristics: one is a 75-year-old devout Islamic
female from Saudi Arabia; the other is a 19-year-old
African American fundamentalist Baptist male from
Louisiana. Obviously, the two do not look alike, and they
probably have very different worldviews and beliefs,
many of which come from their religious tenets and
country of origin.
What are your primary characteristics of culture?
How has each one influenced you and your worldview? How has your worldview changed as your
primary characteristics have changed? How is
each of these a subculture?
The secondary characteristics include educational
status, socioeconomic status, occupation, military experience, political beliefs, urban versus rural residence,
enclave identity, marital status, parental status, physical
characteristics, sexual orientation, gender issues, reason
for migration (sojourner, immigrant, or undocumented
status), and length of time away from the country of origin. For example, the secondary cultural characteristics of
being a single transsexual urban business executive will
most likely evolve into a different worldview from that of
a married heterosexual rural secretary who has two
teenagers. In another case, a migrant farm worker from
the highlands of Guatemala, who has an undocumented
status, has a different perspective than an immigrant
from Mexico who has lived in New York City for 10 years.
People who live in ethnic enclaves and get their work,
shopping, and business needs met without learning the
language and customs of their host country may be more
traditional than people in their home country. Such was
the case for a Japanese man who lived in a Japanese ethnic enclave in San Francisco. When he returned to Japan
after 20 years to visit relatives, he was criticized for being
too traditional. Japanese society had changed, while he
had not.
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What are your secondary characteristics of culture? How has each one influenced you and your
worldview? How has your worldview changed as
your secondary characteristics have changed?
How is each of these a subculture?
Immigration status influences a person’s worldview.
For example, people who voluntarily migrate generally
acculturate more willingly; that is, they have given up
most traits from the culture of origin as a result of contact
with another culture. A number of acculturation scales
exist; some are generic for any population, whereas others
are specific to a particular culture such as Chinese,
Korean, or Filipino. Yet, others are specific to an age group
such as teenagers and older people. More traditional people adhere, and sometimes tenaciously, to most of the
traits of their culture of origin. Similarly, assimilation is
gradually adopting and incorporating the majority of the
characteristics of the prevailing culture. Many people
who migrate become bicultural; they are able to function
equally well in their dominant and their host cultures.
Marginalized people seem to have few traits from their
dominant or host culture. People who voluntarily immigrate assimilate and acculturate more easily than people
who immigrate unwillingly or as sojourners. Sojourners,
who immigrate with the intention of remaining in their
new homeland only a short time, or refugees, who think
they may return to their home country, may not identify
a need to acculturate or assimilate. In addition, undocumented individuals (illegal aliens) may have a different
worldview from those who have arrived legally with work
visas or as “legal immigrants.”
The debate regarding the precise definition and differences among the terms transcultural, cross-cultural, and
intercultural continues. Many authors and texts define the
terms differently. This book uses the terms interchangeably to mean “crossing,” “spanning,” or “interacting”
with a culture other than one’s own. When people interact
with individuals whose cultures are different from their
own, they are engaged in cultural diversity. Awareness of
the differences and similarities among ethnocultural
groups results in a broadened multicultural worldview.
Ethics Across Cultures
As globalization grows and population diversity with
nations increases, health-care providers are increasingly
confronted with ethical issues related to cultural diversity.
At the extremes stand those who favor multiculturalism
and postmodernism versus those who favor humanism.
Internationally, multiculturalism asserts that no common moral principles are shared by all cultures; postmodernism asserts a similar claim against all universal
standards, both moral and nonmoral. Postmodernism
holds the stance that everything is social construction,
which leads to the contention that context is allimportant (Baker, 1998). The concern is that universal
standards provide a disguise whereas dominant cultures
destroy or eradicate traditional cultures.
Humanism asserts that all human beings are equal in
worth, that they have common resources and problems,
and that they are alike in fundamental ways (Macklin,
1999). Humanism does not put aside the many circumstances that make individuals’ lives different around the
world. Many similarities exist as to what people need to
live well. Humanism says that there are human rights that
should not be violated. Macklin (1998) asserts that universal applicability of moral principles is required, not
universal acceptability. Beaucamp (1998) concurs that
fundamental principles of morality and human rights
allow for cross-cultural judgments of immoral conduct.
Of course, there is a middle ground.
Throughout the world, practices are claimed to be cultural, traditional, and beneficial, even when they are
exploitive and harmful. For example, the practice of
female circumcision, a traditional cultural practice, is
seen by some as exploiting women. In many cases, the
practice is harmful and can even lead to death. Whereas
empirical anthropological research has shown that different cultures and historical eras contain different moral
beliefs and practices, it is far from certain that what is
right or wrong can be determined only by the beliefs and
practices within a particular culture or subculture. Slavery
and apartheid are examples of civil rights violations.
Accordingly, codes of ethics are open to interpretation
and are not value-free. Furthermore, ethics belong to the
society, not to professional groups. Ethics and ethical
decision making are culturally bound. The Western
ethical principles of patient autonomy, self-determination, justice, do no harm, truth telling, and promise
keeping are not interpreted or shared by some nonWestern societies. In the dominant American culture,
truth telling, promise keeping, and not cheating on
examinations are highly valued. However, not all cultures
place such high regard on these values. For example, in
Russia, the truth is optional, people are expected to break
their promise, and most students cheat on examinations.
Cheating on a business deal is not necessarily dishonorable (Birch, 2006).
In health organizations in the United States, advance
directives give patients the opportunity to decide about
their care, and staff members are required to ask patients
about this upon admission to a health-care facility.
Western ethics, with its stress on individualism, asks this
question directly of the patient. However, in collectivist
societies, such as among ethnic Chinese and Japanese, the
preferred person to ask may be a family member. In most
collectivist societies, a person does not stand alone, but
rather is defined in relation to another unit, such as the
family or work group. In addition, translating these forms
into another language can be troublesome because a
direct translation can be confusing. For example,
“informed consent” may be translated to mean that the
person relinquishes his or her right to decision making.
How do you perceive truth telling? Do you always
tell the truth? Do you always tell the whole truth?
If a female colleague asks you how you like her
new hairstyle, are you completely truthful or are
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you likely to be a little less than completely truthful and tell her what you think she wants to hear?
If a patient asks you how he is doing and if he is
going to get better, do you tell him that everything
is okay, even if you know he is not?
Some cultural situations occur that raise legal issues.
For instance, in Western societies, a competent person
(or an alternative such as the spouse, if the person is
married) is supposed to sign her or his own consent for
medical procedures. However, in some cultures, the
eldest son is expected to sign consent forms, not the
spouse. In this case, both the organization and the family can be satisfied if both the spouse and the son sign the
informed consent.
Instead of Western ethics prevailing, some authorities
advocate for universal ethics. Each culture has its own definition of what is right or wrong and what is good or bad.
Accordingly, some health-care providers encourage international codes of ethics, such as those developed by the
International Council of Nurses. These codes are intended
to reflect the patient’s culture and whether the value is
placed on individualism or collectivism. Most Western
codes of ethics have interpretative statements based on
the Western value of individualism. International codes of
ethics do not contain interpretative statements, but rather
let each society interpret them according to its culture. As
our multicultural society increases its diversity, health-care
providers need to rely upon ethics committees that
include members from the cultures they serve.
As the globalization of health-care services increases,
providers must also address very crucial issues such as cultural imperialism, cultural relativism, and cultural imposition. Cultural imperialism is the practice of extending the policies and practices of one group (usually the
dominant one) to disenfranchised and minority groups.
An example is the U.S. government’s forced migration of
Native American tribes to reservations with individual
allotments of lands instead of group ownership as well as
forced attendance of their children at white people’s
boarding schools. Proponents of cultural imperialism
appeal to universal human rights values and standards.
Cultural relativism is the belief that the behaviors
and practices of people should be judged only from the
context of their cultural system. Proponents of cultural
relativism argue that issues such as abortion, euthanasia,
female circumcision, and physical punishment in child
rearing should be accepted as cultural values without
judgment from the outside world. Opponents argue that
cultural relativism may undermine condemnation of
human rights violations, and family violence cannot be
justified or excused on a cultural basis.
Cultural imposition is the intrusive application of
the majority group’s cultural view upon individuals and
families (Universal Declaration of Human Rights, 2001).
Prescription of special diets without regard to clients’
cultures and limiting visitors to immediate family, a
practice of many acute-care facilities, border on cultural
What practices have you seen that might be
considered a cultural imposition?
What practices have you seen that might be
considered cultural imperialism?
What practices have you seen that might be considered cultural relativism?
What have you done to address them when you
have seen them occurring?
Health-care professionals must be cautious about
forcefully imposing their values regarding genetic testing
and counseling. No group is spared from genetic disease.
Ashkenazi Jews have been tested for Tay-Sachs disease for
many years. Advances in technology and genetics have
found that many diseases such as Huntington’s chorea
have a genetic basis. Some forms of breast and colon cancers, adult-onset diabetes, Alzheimer’s disease, and hypertension are some of the newest additions. Currently, only
the well-to-do can afford broad testing. Advances in technology will provide the means for access to screening that
will challenge genetic testing and counseling. The relationship of genetics to disability, disabled individuals,
and the potentially disabled will create moral dilemmas
of new complexity and magnitude.
Many questions surround genetic testing. Should
health-care providers encourage genetic testing? What is,
or should be, done with the results? How do we approach
testing for genes that lead to disease or disability? How do
we maximize health and well-being without creating a
eugenic devaluation of those who are disabled? Should
employers and third-party payers be allowed to discriminate based on genetic potential for illness? What is the
purpose of prenatal screening and genetic testing? What
are the assumptions for state-mandated testing programs?
Should parents and individuals be allowed to “opt out” of
testing? What if the individual does not want to know the
results? What if the results could have a deleterious outcome to the infant or the mother? What if the results got
into the hands of insurance companies that then denied
payment or refused to provide coverage? Should public
policy support genetic testing, which may improve health
and health care for the masses of society? Should multiple
births from fertility drugs be restricted because of the burden of cost, education, and health of the family? Should
public policy encourage limiting family size in the contexts of the mother’s health, religious and personal preferences, and the availability of sufficient natural resources
(such as water and food) for future survival? What effect
do these issues have on a nation with an aging population, a decrease in family size, and decreases in the numbers and percentages of younger people? What effect will
these issues have on the ability of countries to provide
health care for their citizens? Health-care providers must
understand these three concepts and the ethical issues
involved because they will increasingly encounter situations in which they must balance the client’s cultural
practices and behaviors with health promotion and
wellness as well as illness, disease, and injury prevention
activities for the good of the client, the family, and
society. Other international issues that may be less
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10 • CHAPTER 1
controversial include sustainable environments, pacification, and poverty (Purnell, 2001).
Individual Cultural Competence
Much has been debated, especially since the early 1990s,
about objectively measuring individual competence.
Most tools for measuring cultural competence are selfreported and subjective in nature. A number of tools have
been developed to assess individual and organizational
cultural competence. Some have been validated and are
specific to a discipline or area of practice, whereas others
are more general in nature. To select one that more specifically meets your needs, go to the Internet search engine
www.scholar.google.com and type “cultural competence
measurement” or “cultural competence assessment tools”
in the search field. The Office of Minority Health also
has a document on Cultural Competence Standards
(www.omhrc.gov). In general, cultural competence is a
journey involving the willingness and ability of an individual to deliver culturally congruent and acceptable
health and nursing care to the clients to whom one provides care. To these authors, individual cultural competence can be arbitrarily divided among cultural general
approaches, the clinical encounter, and language.
Whose values and beliefs should come first—
yours, the organization’s, or the client’s?
11. Accepting responsibility for one’s own education in cultural competence by attending conferences, reading literature, and observing cultural practices.
12. Promoting respect for individuals by discouraging racial and ethnic slurs among coworkers.
13. Intervening with staff behavior that is insensitive, lacks cultural understanding, or reflects
14. Having a cultural general framework for assessment as well as having cultural specific knowledge about the clients to whom care is provided.
1. Adapting care to be congruent with the client’s
2. Responding respectively to all clients and their
families (includes addressing clients and family
members as they prefer, formally or informally).
3. Collecting cultural data on assessments.
4. Forming generalizations as a method for formulating questions rather than stereotyping.
5. Recognizing culturally based health-care beliefs
and practices.
6. Knowing the most common diseases and illnesses affecting the unique population to
whom care is provided.
7. Individualizing care plans to be consistent with
the client’s cultural beliefs.
1. Developing an awareness of one’s own existence, sensations, thoughts, and environment
without letting it have an undue influence on
those from other backgrounds.
8. Having knowledge of the communication
styles of clients to whom you provide care.
2. Continuing to learn cultures of clients to whom
one provides care.
10. Having a working knowledge of the religious
and spirituality practices of clients to whom
you provide care.
3. Demonstrating knowledge and understanding
of the client’s culture, health-related needs, and
meanings of health and illness.
4. Accepting and respecting cultural differences in
a manner that facilitates the client’s and the
family’s ability to make decisions to meet their
needs and beliefs.
5. Recognizing that the health-care provider’s beliefs
and values may not be the same as the client’s.
6. Resisting judgmental attitudes such as “different is not as good.”
7. Being open to new cultural encounters.
8. Recognizing that the primary and secondary
characteristics of culture determine the degree
to which clients adhere to the beliefs, values,
and practices of their dominant culture.
9. Accepting varied gender roles and childrearing
practices from clients to whom you provide care.
11. Having an understanding of the family dynamics of clients to whom you provide care.
12. Using faces and language pain scales in the ethnicity and preferred languages of the clients.
13. Recognizing and accepting traditional, complementary, and alternative practices of clients to
whom you provide care.
14. Incorporating client’s cultural food choices and
dietary practices into care plans.
15. Incorporating client’s health literacy into care
plans and health education initiatives.
9. Having contact and experience with the communities from which clients come.
1. Developing skills and using interpreters
(includes sign language) with clients and families who have limited English proficiency.
10. Being willing to work with clients of diverse
cultures and subcultures.
2. Providing clients with educational documents
that are translated into their preferred language.
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3. Providing discharge instructions at a level the
client and the family understand and in the language the client and the family prefer.
12. The organization is willing to support a mentoring program to entice recruitment into the
health professions.
4. Providing medication and treatment instruction
in the language the client prefers.
13. Data collected include race, ethnicity, culture, and
language preferences of the staff and client base.
5. Using pain scales in the preferred language of the
14. Patient rights documents are in the major languages served by the community.
Look at the list of activities that promote individual cultural competence. Which of these activities
have you used to increase your cultural competence? Which ones can you easily add to increase
your cultural competence? Which ones are the
most difficult for you to incorporate?
15. Cultural and Linguistic Appropriate Services
(CLAS) Standards are adhered to.
16. Fiscal resources are available for interpretation.
17. The strategic plan reflects the needs of the community.
18. Input on research priorities is sought from consumers.
19. Researchers are reflective of the staff, clients,
and community.
Organizational Cultural Competence
Individual cultural competence is not sufficient for culturally competent care. The organization in which the
care is delivered must also demonstrate a commitment to
cultural competence. Several things must be in place if an
organization is to demonstrate cultural competence. A list
of attributes of culturally competent organizations, organized arbitrarily by governance and administration, education and orientation, and language follows:
1. The organization must have a mission statement and policies that address diversity.
2. The Board of Governance must include members of the ethnicity of the community it serves.
3. A committee for cultural competence exists and
includes staff, managers, administrators, chaplains, and members representative of the community.
4. The organization engages in community diversity fairs.
5. The organization seeks resources from federal,
state, and private agencies to continually upgrade
and integrate cultural competence into care.
6. The organization partners with diverse community agencies.
7. The organization networks with diverse community leaders.
8. Administrators, managers, and staff are encouraged to be active in public policy for the client
base to whom they deliver care.
9. Policy statements include efforts to eliminate
the bias and prejudice of clients and staff.
20. Human Resources recruitment and hiring activities reflect the diversity of the community.
21. The job analysis procedure includes scoring for
ethnocultural and language ability.
22. Position descriptions and evaluation practices
reflect cultural competence.
23. Conflict and grievance procedures reflect the
language of the staff.
24. The organization demonstrates active recruitment of bilingual staff.
25. The staff is compensated for bilingual ability
and certification.
26. The ethics committee has members reflective of
the staff and clients.
27. Hours of operation of clinics are adjusted to
meet the needs of the community.
28. Pictures and posters are reflective of the client
29. Food choices are reflective of the client and staff.
30. The holiday calendar represents the client population base.
31. Intake forms reflect cultural assessment.
32. Pain scales are in diverse languages of the population served.
33. Culturally appropriate toys
(Hispanic Santa, black dolls).
34. If staff is used or interpretation is available, a
plan is in effect to address their job duties while
interpreting for patients and staff (also a Joint
Commission on Accreditation of Healthcare
Organizations [ JCAHO] requirement).
10. Programs reflect the needs of the diversity of
the community.
1. Diversity must be addressed as part of new employees’ orientation, in-service, and continuingeducation programs.
11. The organization’s programs are advertised in
community newspapers and on the radio and
television in the languages of the community.
2. Nursing care delivery systems, the U.S. system
of insurance reimbursement, and issues related
to culture and autonomy are discussed.
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12 • CHAPTER 1
3. Mentoring programs exist for diverse student
and staff populations.
16. Satisfaction surveys are in the languages of the
4. Diversity of the health professions is included
in orientation.
17. Staff surveys are in the languages of the
5. All employees must be offered cultural general
topics and cultural specific needs of populations for whom they provide care.
18. Audiovisual materials for staff and clients are in
their preferred languages.
6. Cultural celebrations are reflective of the staff
and clients.
7. Resources are available to staff on the unit and
in the library.
8. The staff is trained in language interpretation.
9. Health classes are offered to clients the community serves.
10. Certification in culture for staff is offered at various levels.
19. Wellness and health promotion classes are
offered in the languages of the client base.
Look at the list of activities that promote organizational cultural competence. Which of these activities
have you used to increase the organization’s cultural
competence? Which ones can you easily add to
increase the organization’s cultural competence?
Which ones are the most difficult to accomplish?
11. Pharmacists, nurses, and physicians are educated in ethnopharmacology.
12. A lunch and learn series that supports the ongoing development of cultural competence can be
1. Mechanisms must be in place for translation of
written materials in the preferred language of
the client.
2. Policies must address interpretation services.
3. Resources are available for translation of educational materials and discharge instructions in
the languages of the client population.
4. The organization engages in activities that
address health literacy of the population it
5. Written documents undergo a cultural sensitivity review.
6. Consent and procedure forms are translated
into the languages of the population served.
7. English-as-a-second language classes exist for
8. Language classes are offered to clients and family (English and language of the population
9. Waiting areas have literature in the language of
the population served.
10. Directions to referral facilities are in the languages of the client base.
11. Videos are in the language of the client and
have pictures of the client base.
12. Diverse language includes sign language.
13. Need for interpreters is determined ahead of
14. Telephone system is in the languages of the
15. Television programs are in the languages of the
Evidence-Based Practice:
Developing Individual and
Organizational Culture
Section written by Susan Salmond
The mandate for evidence-based practice (EBP) to reduce
the “know-do” gap (Antes, Sauerland, & Seiter, 2006)
between known science and implementation in practice
is being driven by the demand for improved safety and
quality outcomes for clients. Although a laudable goal, it
will require a culture shift. The prevailing culture in
health care is an “opinion-based culture” grounded in
intuition, clinical experience/expertise, and pathophysiological rationale (DiCenso, Guyatt, & Ciliska, 2005). A
culture of EBP calls for the conscientious, explicit, and
judicious use of current best evidence in making decisions
about the care of individuals or groups of patients.
However, evidence alone does not constitute EBP but
requires the integration of this evidence with clinical
expertise, patient values and preferences, and the clinical
context of care (Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996). The achievement of best patient outcomes is not assumed but is continuously evaluated
though measurement of outcomes and patient safety
(Coopey, Nix, & Clancy, 2006). This evidence is fed back
into the system for consideration, and improvement
changes at the individual, group, and system levels.
Figure 1–1 portrays the components of EBP process, and
Table 1–1 examines the components of EBP and the
change/resources needed to facilitate its implementation.
The best evidence is usually found in clinically relevant
research that has been conducted using sound methodology (Sackett, 2000). With more than 1500 new articles per
day and 55 new clinical trials per day, individual clinicians cannot hope to locate and read even a small portion
of the relevant research published each year to assure best
practices (Cilaska, Pinelli, DiCenso, & Cullum, 2001). The
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Best Patient
FIGURE 1–1 Components of evidence-based practice.
EBP process presents a more focused way of searching for
information. Rather than routinely reviewing the contents of journals for interesting articles, the EBP process
targets issues related to specific patient problems and provides clinicians with a set of skills for developing clinical
questions related to these problems, searching current
databases to keep current with the literature, and appraising the validity of the research on the topic of interest. In
this process, the abstract exercise of reading and critically
appraising the literature is converted into a pragmatic
process of using the literature to benefit individual
patients while simultaneously expanding the clinician’s
knowledge base (Bordley, 1997).
Within EBP, not all evidence is the same. The EBP clinician must know the nature and strength of the evidence
found and, therefore, the accompanying degree of certainty/uncertainty with which to make decisions about
whether the evidence should be applied to practice
(Bhandari, 2003). Because much of research has been
focused on the evaluation of “intervention effectiveness,”
in the evidence pyramid, the gold standard has been the
randomized controlled trial followed by cohort studies,
case-controlled studies, case series, and qualitative studies
(Fig. 1–2). Yet, much of nursing practice and the majority
T A B L E 1.1 The Evidence-Based Practice Process
Identify best evidence
Resources/Change Needed
Clinical inquiry: What knowledge is needed?
Informed skepticism: Why are we doing it this
way? Is there a better way to do it? What is
the evidence for what we do? Would doing
this be as effective as doing that?
(Salmond, 2007)
• Shift from “know how” and doing to “know why”
• Reflect on what information is needed to provide
“best” care
• Generate questions about practice and care
• Role model clinical inquiry at report, rounds, conferences
• Use interdisciplinary case reviews to evaluate
actual care
• Include clinical librarians as members of teams
participating in clinical rounds and conferences
• Differentiate between background and foreground
• Consider recurring clinical issues, need for information, negative incidents/events as sources for
questions or information needs
• Identify clinical issues sensitive to nursing interventions
• Narrow broad clinical issues/questions into searchable, focused questions
• Use the mnemonic PICO to frame questions
• Use evidence-searching skills to target relevant
focused evidence
• Access evidence databases ideally at the point of
• Understand evidence pyramids
• Databases available include pre-appraised literature sources for point-of-care answers regarding
• Search strategies: key terms, multiple databases,
point-of-care data
• Use assistance of clinical librarian
Convert information needs from practice into
focused, searchable questions (patientintervention-comparison-outcome [PICO]
Search databases for highest level of evidence
in a timely manner
(Continued on following page)
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14 • CHAPTER 1
T A B L E 1.1 The Evidence-Based Practice Process (Continued)
Resources/Change Needed
Use critical appraisal process to determine
strength and validity of evidence and
relevance to one’s practice
• Clinical Practice Guidelines available at
• Preappraised sources such as Critically Appraised
Topics (CATs)
• Demonstrate knowledge of research design
• Demonstrate knowledge of statistics
• Use critical appraisal tools to guide process of
research critique
• Utilize journal clubs
• Summarize findings from evaluation, resolving
conflicting evidence
• Consider evidence in relation to own patient population
• Consider cost-benefit ratio
• Consider multidimensionality of patient and clinical situation in relation to evidence that is often
• Understand culture-general and culture-specific
knowledge to guide interactions with client
• Use interview skills to avoid culture imposition
and seek client’s true preferences
• Communicate evidence and treatment options
considering patient values and preferences
• Involve client and family in both information giving and decision making
Clinical experience
and expertise
Use clinical expertise to determine how to use
evidence in care of patient and how to
manage patient in absence of evidence or
presence of conflicting evidence
Patient values and
Demonstrate ability to perform a culture
assessment and identify client preferences…
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