Developing Culturally Sensitive Healthcare Systems

April 6, 2020

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In recent decades, the makeup of the U.S. population has become progressively more diverse, creating new challenges in the healthcare system as providers try to meet patients’ social, cultural, and linguistic needs. Culturally competent healthcare is becoming increasingly important to reduce disparities, provide improved access to medical care and forge better patient-provider relationships.

Nurse reviewing information with patient

Culturally competent healthcare is respectful and responsive to varied health and wellness beliefs and practices, directly meeting patient needs. A lack of cultural competence builds barriers between patients and their healthcare needs.

With the projected growth of multiracial and multiethnic people in the United States, nurses more than ever need to increase cultural competencies and grow diversity within the workforce. The American Association of Colleges of Nursing (AACN) said that Doctor of Nursing Practice (DNP) programs prepare graduates to “synthesize concepts, including psychosocial dimensions and cultural diversity … in developing, implementing and evaluating interventions.” In other words, a DNP education prepares graduates to grow cultural diversity among medical staffs and increase cultural awareness in healthcare systems.

Eric J. Williams, a DNP-prepared nurse and the first male president of the National Black Nurses Association (NBNA), said nurses must embrace cultural competency to create a nurturing and supportive environment where patients will thrive.

“Improving cultural competence requires a conscious effort of individuals, organizations and agencies that provide healthcare,” Williams said in an interview with J&J Nursing Notes. “The United States is ethnically and racially diverse, so cultural competence is essential to providing holistic healthcare services.”

At Duquesne University, students enrolled in the online DNP program embrace cultural awareness by engaging in coursework that takes a close look at vulnerable populations, transcultural care and diverse cultural needs. Through the DNP curriculum, post-graduate students study culturally competent healthcare in accordance with the Institute of Medicine’s (IOM’s) groundbreaking “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” report in 2002.

Uncovering Disparities in Healthcare and Moving Toward Improvements

The report, commissioned by Congress, looked at the differences in the quality and types of healthcare that racial and ethnic minorities in the United States received when compared to non-minorities. It was the first official scientific look at healthcare inequality in the nation.

The IOM found vast disparities across the spectrum of healthcare and minorities that created a culture of mistrust in the healthcare system and a lack of knowledge about how to use healthcare services.

The report also said language barriers, limited access to healthcare services and changes in the nation’s healthcare systems are also hurdles for minority patients. Prejudice and stereotypes are driving healthcare providers to deliver inadequate care, the IOM found.

In response to the findings, the IOM made several recommendations, including promoting the use of evidence-based guidelines, integrating cross-cultural education for providers, and implementing multidisciplinary treatment and preventive care teams.

In 2018, Brian D. Smedley, PhD, who directed the study and report, said in the 16 years since the IOM’s findings and recommendations there has been little progress. Communities of color are continuing to face health threats, including poor access to quality healthcare, an inequitable criminal justice system and community disinvestment.

“We are not making significant progress because we still see evidence of systematic (in)equities in healthcare systems as well as outside of healthcare systems,” Smedley said to The St. Louis American. “The very kinds of structures and systems that helped to create poorer health for many communities of color unfortunately persist.”

Addressing Barriers to Cultural Competency

About the same time the IOM released its “Unequal Treatment” report, the U.S. Department of Health and Human Services’ Office of Minority Health published the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Healthcare. The goal was to advance healthcare equity and improve the quality of services to underserved populations.

In 2013, an updated CLAS was released to reflect the dramatic changes in healthcare in the previous decade, including the advent of the Affordable Care Act. Lawmakers described the National CLAS Standards Enhancement Initiative as a new benchmark “for culturally and linguistically appropriate services to improve the health of all individuals.” Overall, the updated CLAS consists of three themes and 15 standards:

Governance, leadership and workforce
Communication and language assistance
Engagement, continuous improvement and accountability

The principal standard calls for “effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.”

In 2014, the American Nurses Association (ANA) and the Transcultural Nursing Society developed similar standards for culturally competent nursing practice to be universally applied to areas of clinical care, education, administration and research. The 10-point standards include:

Professional nurses should promote universal social justice when related to patients, families, communities and other healthcare professionals. Nurses should advocate for socially just policies.
Nurses should develop a deep understanding of different traditions, values, perspectives and practices of culturally diverse individuals, families and groups.
Healthcare organizations should provide the resources necessary to promote the needs of diverse clients.
Nurse leaders should influence individual and group systems to achieve culturally competent care.
Nurses should promote policy development that will encourage the comprehensive implementation of culturally competent healthcare.

Healthcare leaders have also constructed models of cultural competence for a foundation to help nurses understand cultural beliefs and differences during the delivery of healthcare services. Some of the more significant models showcase the predominant themes of empathy and tolerance:

Leininger’s Sunrise Model

In the 1950s, Dr. Madeleine Leininger recognized that cultural care was missing from nursing and developed the transcultural nursing theory, also called the culture care theory. The theory involves knowing and understanding different cultures and care practices, beliefs and values. Leininger’s Sunrise Model demonstrated the three modes of transcultural nursing care: cultural care preservation (helping patients maintain their culture while undergoing medical treatment), cultural care accommodation (supporting a patient’s culture for a beneficial health outcome) and culture care repatterning (helping a patient change harmful cultural practices to see healthy benefits).

Transcultural Assessment Model

Developed in 1988, the Transcultural Assessment Model provides a framework for patient assessment and nurse education. The model looks at the cultural differences between individuals through six cultural dimensions: communication, time, space, social organization, environmental control and biological variations. It is used to design and deliver culturally sensitive patient care.

Purnell Model for Cultural Competence

The Purnell model consists of 12 domains that intersect to create individual and group culture and provide a foundation for cultural awareness to be used in team-oriented healthcare environments. The 12 domains, which include heritage, bicultural ecology, nutrition, death rituals and healthcare practices, are intended to help providers better understand cultures and their characteristics.

Model of Cultural Competence in Healthcare Delivery

Created in 1998 and revised in 2002, this model considers cultural competence a process in which nurses endeavor to work effectively in culturally diverse environments. To achieve cultural competence, nurses must be cognizant of cultural awareness, knowledge, skill, encounters and desire.

DNPs Establishing Culturally Competent Healthcare

In developing a culturally sensitive healthcare operation, the AACN said nursing students must move from “thoughtful action” to “critical reflection.” A DNP curriculum provides a venue for APRNs to increase their leadership capacity to eliminate transcultural disparities, the AACN said. The organization, which represents more than 800 schools of nursing including Duquesne University, said the nursing leadership role in regard to cultural competency encompasses the following:

An understanding of the complex causes of disparities
Implementing culturally aware and competent nursing care
Advocating for patients and policies that align with healthcare decisions
Developing competency to collaborate with patients and other healthcare stakeholders
Undergoing personal transformation
Contributing to culturally competent scholarship

The AACN also said strengthening knowledge and skill in some areas provides a foundation for transcultural leadership. The organization developed cultural competency guidelines for doctoral nurse education programs:

Prioritize social and cultural factors that impact healthcare delivery.
Construct socially and empirically derived cultural knowledge to guide research and practice.
Assume leadership roles in creating, implementing and evaluating culturally competent nursing.
Transform healthcare systems to address social justice and health inequalities.
Provide across-the-board leadership to develop and continue cultural competence.
Conduct transcultural teaching, research and practice that can be utilized in healthcare systems.

The AACN and other large healthcare organizations look to DNP-prepared nurses as a conduit to culturally competent healthcare. Online DNP programs allow APRNs to study and practice cultural competence while continuing a career path.

At Duquesne University, the DNP coursework takes students on a cross-cultural exploration of knowledge and skill. The Transcultural Care and Global Health Perspectives course explores the impact of global interconnectivity in healthcare on individuals, families and populations, with an eye on developing culturally competent healthcare systems. Social Justice and Vulnerable Populations examines vulnerability through the lens of social justice and determinants of health.

About Duquesne University’s Online DNP Program

Duquesne University’s online DNP program prepares graduates to build culturally competent healthcare systems and assume leadership roles to make a positive impact on individuals, families and populations. The university’s DNP curriculum builds on existing knowledge for a comprehensive education to boost leadership skills.

The DNP program, which is 100 percent online, provides an opportunity for APRNs to study abroad to expand transcultural experiences while studying at Duquesne University’s Rome or Dublin campuses. For more information, visit the university’s online DNP program website.