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Young, S., & Guo, K. L. (2016). Cultural Diversity Training:

CITATION
The Necessity of Cultural Competence for Health Care
Providers and in Nursing Practice. Health Care Manager,
35(2), 94–102. doi: 10.1097/HCM.0000000000000100

AS https://doi.org/10.1097/HCM.0000000000000100
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1
Cultural Diversity Training:
The Necessity of Cultural
Competence for Health Care
Providers and in Nursing
Practice
Young, Susan DHA, MSA, RN; Guo, Kristina L. PhD, MPH

Abstract

The purpose of this article is to discuss the need to provide culturally sensitive care to the growing
number of diverse health care consumers. A literature review of national standards and research on
cultural competency was conducted and specifically focused on the field of nursing. This study supports
the theory that cultural competence is learned over time and is a process of inner reflection and
awareness. The domains of awareness, skill, and knowledge are essential competencies that must be
gained by health care providers and especially for nurses. Although barriers to providing culturally
sensitive care exist, gaining a better understanding of cultural competence is essential to developing
realistic education and training techniques, which will lead to quality professional nursing practice for
increasingly diverse populations.

DEMOGRAPHIC SHIFTS IN the United States are occurring in record proportions.

According to the 2010 US Census, Hispanics/Latinos are the largest minority group
residing in the United States. In addition, it is estimated that by 2050 minorities will
represent more than half of the total population (54%) in the United States (US
Census Bureau, 2010).1 According to the US Census Bureau Population Estimates
Program, 98% of all US residents belong to 1 of 5 single racial groups. Single racial
groups refer to individuals who self-identify as being part of only 1 race. These
include white, black or African American, Asian, American Indian, Alaska Native, and
Pacific Islander populations. The remaining 2% of the total population includes those
who identify with 2 or more single-race categories.1

2
While diversity in populations has steadily increased, so have challenges for health
care providers and recipients of health care. Communication styles, cultural
differences, explanatory styles, and interpreter services are several areas that require
attention in providing care for diversified populations. According to the US Census
Bureau, as of 2007, 20% of people in the United States spoke a language other than
English in the home. Diversity and linguistic challenges have become increasingly
complex. Not only is there lack of understanding of how culture may determine
patients' perspectives of health or illness, but also reviewing details of health or illness
in a culturally appropriate linguistic manner may escape the provider and leave much
to misinterpretation.

The purpose of this article is to discuss the need for cultural diversity training and
competency evaluation. A review of the literature recommends health care providers
and specifically for nurses to demonstrate competencies in cultural assessment
through ongoing education and training to recognize diversity of populations in order
to provide culturally sensitive care to the increasing number of diverse health care
consumers.

BACKGROUND AND THE NEED FOR CULTURAL DIVERSITY TRAINING

Culture is defined as values, beliefs, customs, traditions, patterns of thinking, norms,

and mores of an individual or populations.2 Learned behaviors, ideas, and perceptions
are passed down through generations. Cultural beliefs frame our thinking, decision
making, and perceptions of life. Culture determines where we see ourselves in the
family setting, for example, as sister, brother, eldest, youngest, matriarch, or patriarch.
Along with family order, there are further culturally determined definitions as to
which roles are assumed within the family order. As unique as ethnic cultures may be,
additional cultural norms exist within any given ethnic groups. Generational attributes
define cultures that may be different within the same family. Not all of those within a
single ethnic group may share like customs or religious beliefs. Therefore, the health
care provider may face challenges when treating several members of 1 family
consisting of several generations. The provider needs to be skillful in eliciting a health
history that is accurate and communicate a plan of care in a culturally sensitive way.

Especially in Hawaii, its multicultural setting provides an opportunity to observe the

blend of western and eastern health care practices. There are 9 prominent ethnicities

3
in the state of Hawaii. They include white (25.3%), Hawaiian/part Hawaiian (22%),
mixed (except Hawaiian 19.3%), Japanese (16.5%), Filipino (11.3%), Chinese (3.2%),
Black (0.9%), Samoan/Tongan (0.8%), and Korean (0.6%).3 The challenges of
cultural diversity revolve around linguistic differences, verbal/nonverbal
communication, and multigenerational differences. Superstitions passed down
through families can be as prominent today as in years past. Health care advice given
by someone outside a patient's own culture may be viewed with suspicion. Although
Hawaii has a large Asian population, 32%, each ethnicity within Asian culture is
different in beliefs and lifestyle. Moreover, even within the same cultural group,
responses to and acceptance of health care can vary depending on generation and
environment.3

The US Department of Human Services, Office of Minority Health (OMH),

completed a detailed report named Setting the Agenda for Research on Cultural
Competency in Health Care, with the final version published in August 2004. The
document was developed to examine how cultural competency affects health care
delivery and health outcomes.4

Specifically, cultural competence is defined using the descriptions from the Culturally
and Linguistically Appropriate Services (CLAS) standards and the definition from
Cross.

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and

policies that come together in a system, agency, or among professionals that enables
effective work in cross-cultural situations. "Culture refers to integrated patterns of
human behavior that include the language, thoughts, communications, actions,
customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
"Competence" implies having the capacity to function effectively as an individual and
an organization within the context of the cultural beliefs, behaviors, and needs
presented by consumers and their communities.5

Leininger and McFarland6 define cultural diversity as variables or differences in care

beliefs, meanings, patterns, values, symbols, and life ways. These variables exist
between individuals and cultures. This array of variables can increase the chances for
miscommunication between providers and patients. Salimbene7 emphasizes that
health care providers need to be knowledgeable of different health care perceptions,

4
including an awareness of their own perceptions, as well as those of their patient
populations.

Governmental agencies have recognized the need for cultural diversity education
within the health care field. The US Department of Health and Human Services
through the Office of Public Health and Science and the OMH has partnered with the
Agency for Health care Research and Quality to examine cultural diversity and
competence. The project Setting the Agenda for Research and Cultural Competency
in Health Care was initiated to examine components of cultural competence, to
determine what is accomplished by being culturally competent, and to measure the
impact of this competence on the delivery of health care and health outcomes.5

In 1998, the OMH sponsored the development of the National Standards on CLAS.
There are 14 standards divided into 3 major themes, Culturally Competent Care,
Language Access Services, and Organizational Supports for Cultural Competence.4
The need to provide culturally and linguistically appropriate services was apparent to
the OMH. Existing guidelines were incomplete and fragmented. Without
comprehensive guidelines, health care providers did not have a direction on the best
way to treat culturally diverse patients and ensure the best outcomes. Recognition of
the need for national standards prompted development of a national focus for CLAS
standards. The final form was published in the Federal Register in 2000 with
recommendations for all stakeholders including health care organizations, health
communities, and health care providers.4

The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care (2003) directs attention to minorities and quality of care.
The report states that minorities receive lower quality of care even when controlling
for insurance, comorbidity, education, and socioeconomic status. The report further
recognizes that disparities are complex within health care systems.8

A follow-up report One Size Does Not Fit All: Meeting the Health Care Needs of
Diverse Populations was published in 2008 by Wilson-Stronks et al.9 The goal of this
report was to further explore procedures and references for hospitals to meet the
needs of diverse populations with attention to their own facilities. Wilkes-Stronks et al
8 report there is no-one-size-fits-all solution, and the complexity of the problem
requires all health care stakeholders' attention.

5
A common theme exists for hospitals and health care providers to move forward in
becoming culturally competent. Understanding the overall complexity of diverse
cultures and ongoing training is essential. Although there is not a one-size-fits-all
answer to increasing diversity and increasing cultural competence, themes relating to
self-assessment, learning, and acceptance of cultural similarities and differences have
been addressed by many experts in the field of health care and anthropology such as
William Harvey from the University of Virginia, Dr Madeline Leininger, and Dr
Yolanda Moses from the University of California. Guo and Castillo 10 developed a
framework for guiding health care organizations and professionals by establishing a
set of culturally competent strategies to improve quality of care and patient outcomes
for diverse populations. They identified communication and monitoring and feedback
as key components in the provision of culturally competent care.

The American Medical Association and American Nurses Association have joined the
Institute of Medicine and The Joint Commission in recognizing the need for cultural
diversity and competency training for health care professionals.11 Cultural and
linguistic competence is not only required of the seasoned professional. There has
been a specific undertaking by the US Department of Health and Human Services to
build upon the present curricula in nursing and medical schools. Although training in
areas of cultural competency, diversity, race relations, and ethnic sensitivities has been
in existence for 30+ years, the renewed emphasis has targeted institutions of
education such as medical and nursing schools. The requirements, expectations, and
prospects of curricula devoted to cultural diversity vary greatly.12-14 This will be further
discussed in the literature review to show various definitions, theories, and
recommended frameworks are needed to educate health care workers so that they can
become more culturally competent.

LITERATURE REVIEW

The literature review included scholarly books, journal articles, research documents,
governmental publications, and research documents. Specifically, Internet research
databases such as Ovid, CINAHL, Ovid MEDLINE, PubMed, and ERIC were
searched. The literature is abundant with recommendations for educating health care
workers on becoming culturally competent. There is a common theme among the
theories. Cultural competency begins with knowing oneself first before building upon
acceptance of others. In addition, the literature recognizes that cultural competency is

6
more than learning terms and observing different cultures. To be congruent with
differing cultures, knowledge and acceptance, as well as openness to lifelong learning,
must be included.

Campinha-Bacote 15 originally identified 4 domains for her model of cultural

competence. They included cultural awareness, cultural knowledge, cultural skill, and
cultural encounters. A fifth construct, cultural desire, was later included in the model.
The first construct, cultural awareness, refers to understanding oneself and how
culture is influential and how the world is viewed and biases developed. The second,
cultural knowledge, incorporates understanding another's situation and belief system.
Campinha-Bacote 15 refers to this as seeking knowledge of differing word views and
becoming knowledgeable of biological ethnic differences. Differences can influence
how medication is absorbed and reactions to different medications and herbs. Other
biological attributes that are specific to ethnicity include genetics and hereditary
conditions such as Mediterranean or thalassemia anemia.

Campinha-Bacote 15,16 describes cultural skill as the ability to collect cultural data that
is applicable and significant for that particular patient. Perceptions of health and
illness are viewed differently by each individual. She recommends that health care
providers select assessment tools that gather information on the patient's beliefs and
values. Understanding a patient's perception of their illness and beliefs surrounding
treatment needs to be approached in a sensitive manner.15,16 Cultural encounters and
cultural desire are the last 2 constructs in Campinha-Bacote's 16 model. She believes
there is more variation among groups than across groups. Realizing this becomes
important when reviewing what is known or thought to be known for different
cultural groups. She explains that health care providers should have varied encounters
to help prevent stereotyping. Finally, Campinha-Bacote et al describe 17 cultural desire
as wanting to engage in the process of cultural competence. As the most recently
added construct to Campinha-Bacote's model, cultural desire is described as
motivation and the desire to work with diverse populations. Most importantly,
Campinha-Bacote et al 16-18 promote the concept of genuine caring that can be
transferred to a patient from the health care provider. Without cultural desire, the
other constructs of skill, awareness, knowledge, and encounters remain incomplete in
the journey toward cultural competence.

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Giger et al 19 further explain that structures for each cultural group have different
importance and play a role in decision making regarding health care. Health care
providers need to be aware that family members in cultures such as Mexican, Samoan,
and Hawaiian actively participate in the care of the patient. With many family
members at the bedside, this cultural trait can often upset hospital personnel. Nuclear
families may be expanded to include nieces, nephews, and cousins. The matriarch or
the patriarch (mother, father, grandmother, or grandfather) may well be the decision
maker on health issues and communication, not the actual patient.19 Campinha-Bacote
et al 16,17 stress that cultural assessments need to be done for everyone, not only for
those cultures unknown to the health care provider. All patients deserve to be treated
and assessed in a culturally sensitive manner. Eliason and Macy 20 warn against
stereotyping and grouping such as cultures. Social groups may be structured in several
ways. Cultures can vary within cultures by gender, age, and religion.

Purnell and Paulanka 21 believe respect and acceptance do not happen immediately
but rather constitute a process of becoming culturally aware. The range of awareness
may be classified in a number of categories: unconscious incompetence (lack of
awareness of cultural differences), conscious incompetence (aware of knowledge
deficit for cultural competence), conscious competence (health care worker
consciously seeks information regarding a patient's culture but is not comfortable
caring for diverse patients), and unconsciously competent (ability to automatically
provide culturally congruent care).21

Cross-cultural encounters and immersion programs are suggested as paths to develop

awareness, knowledge, and desire to become culturally competent. A component in
cross-cultural interactions is the integration of language. Jones et al 22 studied a
cultural immersion project with American health care workers and a Mexican
population. The project included living with Mexican families and learning Spanish.
Although the project lasted only 1 week, the authors believed the immersion provided
valuable knowledge and communication skills for the health care personnel. Subtleties
in cultural communication styles such as gestures, engaging in small talk, tone of
voice, and eye contact can influence how providers receive and distribute information
to patients. An example includes that of the Hawaiian culture, where "talking story"
asking about the family and small talk prior to conducting a health assessment is
expected in engaging open communication.22 Another example is asking where the
health care provider is from, which is not intended as a physical location inquiry. A

8
culturally correct answer would be to describe where your parents live, including
uncles and aunts, as the question is not about where you live but instead about your
family and background. Awareness of the intent of the communication can greatly
assist providers in obtaining and giving health information.

Nursing and cultural competence

Literature on research studies that examined cultural competence in nursing, nursing
education, medicine, medical education, demographics, and transcultural nursing was
reviewed for this study. There are several nursing scholars who have devoted their
research to the field of nursing and anthropology, focusing on cultural diversity and
competence. Transcultural nursing was first identified and named by Leininger 23 in
1950. Leininger 23 developed the Theory of Cultural Care Diversity and Universality,
the first among culturally centered nursing theories. She argued that the key to
providing good care is to individualize care to converge with the patient's cultural
beliefs. The theory emphasizes discovery of what is universal, or commonalities, and
what is diverse regarding human care beliefs. Leininger 23 predicted that minority
groups would continue to increase and that culturally specific care would become an
expectation for each health care encounter. As a leader in the field, she recognized
and identified the challenges that exist in educating culturally competent health care
professionals. Leininger 23 noted nurses were not able to provide culturally competent
care because they lacked such education in their curricula because of inadequate
faculty expertise in this area. Ryan et al 24 conducted a study of transcultural nursing
concepts and practices in nursing curricula across the United States. A descriptive
survey was sent to all baccalaureate and higher-degree National League of Nursing
schools.24 Six hundred ten surveys were sent with 217 or a 36% response rate. The
surveys were sent to deans and directors of the nursing schools. The respondents
indicated that incorporation of educational modules has been and is occurring.
However, many schools did not have the expert resources available. In order to
educate culturally competent student nurses, there needs to be consensus among
nursing educators and leaders as to appropriate curriculum content and how best to
ensure nursing educators can provide instruction to students.24

Transcultural nursing has provided guidance and definition to the importance of

culture and its role in health care. The Transcultural Nursing Society, founded in
1974, declares in its mission statement "[horizontal ellipsis]The mission of

9
Transcultural Nursing Society is to enhance the quality of culturally congruent,
competent, and equitable care that results in improved health and well-being for
people worldwide."25 In 1988, the first issue of the Journal of Transcultural Nursing
was published, with Leininger as the editor.

Ryan et al 26 conducted a study on the effect of cultural immersion as an experiment

with 9 nursing students. The intent was to investigate how the experience would
enrich their culture experience, to provide feedback on the experience, and to
examine the social interactions that occurred during it. The study revealed students
identified early the resources needed for support, such as faculty and other group
members, which helped them to properly prepare for the experience. Increased
communication, thinking differently, adaptation, and an improved awareness of the
importance of cultural awareness and competence were major findings.26 The authors
asserted that cultural immersion experiences can provide an important component in
nursing curricula. The hands-on experience affords a clear view into other cultures
that cannot be acquired by only reading about backgrounds different from the
students' own.26

Jeffreys 27 describes her model of Cultural Competence and Confidence as the

interrelating of concepts that influence or predict the learning of cultural competence.
She further explains a leading factor is the construct of transcultural self-efficacy
(TSE) or confidence. Transcultural self-efficacy is differentiated from cultural
competence in that TSE is perceived confidence in transcultural nursing skills. The
learning process is key. The TSE is inclusive of cognitive, practical, and affective
descriptions, which are not stagnant and can change over time.27 Formal education,
training, and experience contribute to any changes that may occur.

Jeffreys 27 refers to Bandura's 28 social cognitive theory, in which learning and

motivation are influenced by self-efficacy perceptions. Those with strong self-efficacy
perceptions think and act differently from those considered inefficacious or overly
confident. Jeffreys 27 advises that use of the Transcultural Self-efficacy Tool can be
helpful in differentiating these 2 groups. She cautions that self-efficacy as a predictor
of cultural competence can be difficult to verify. This is due to self-reporting, which
can have errors in verification. She recommends using a valid measurement tool to
measure competence so that interpretation errors may be avoided.27

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Papadopoulos et al 29 published the PTT (named after the authors) model for
developing cultural competence. The model begins with cultural awareness in which
the practitioner examines personal beliefs and values. The next stage, cultural
knowledge, is necessary to bridge the gap of understanding variations and similarities
of cultures in order to avoid stereotyping. Cultural sensitivity, in which the
development of trust, respect, and empathy are fostered, leads to the final stage,
cultural competence. This final stage is identified by assessment and diagnostic and
clinically focused culturally competent care. Papadopoulos et al 29 further recommend
that nurses be required to challenge discrimination and inequalities in health care
actively as part of increasing cultural competence.

Some researchers suggest that cultural competence is a process rather than an

outcome. While in-service and workshops are valuable, becoming culturally
competent is an ongoing process and based on self-reflection of one's many
experiences.30

DISCUSSION

The literature shows that to provide appropriate care for diverse populations in the
United States patient care providers need knowledge, skill, culturally diverse
experiences, and ongoing education. The education should begin in nursing and
medical schools and continue throughout professional practice.

Just as important for patients to have a clear understanding of their health condition,
nurses from different cultures may have differing beliefs surrounding health and
health care. These differences can result in conflict with fellow health providers as
well as patients. At present, there is not a consensus on how best to provide an
educational strategy for cultural competence. Experts, however, do agree on the
importance and value that a culturally competent health care worker can bring in
providing quality of care and positive outcomes. The Joint Commission identifies
patient safety as a priority in health care settings. Patients will not follow health care
recommendations if time and patience have not been used in explaining the need for
the treatment or medication. It may take additional time to explain to culturally
diverse patients and family members why certain medications are ordered and how to
administer medications. Many cultures will use traditional healing techniques advised

11
by their elders. This may include herbal remedies and practices that could cause
serious interactions with current Western treatments.

The US Department of Health and Human Services OMH continues to recommend

development and updating of cultural competence standards.4 The Liaison Committee
on Medical Education has recommended development of culturally competent
medical education standards. The American Academy of Nursing and the American
Association of Colleges of Nursing offer direction for schools of nursing to
incorporate culturally competent curricular development.19 For instance, Cueller et al
31 developed "Blueprint for Integration of Cultural Competence in the Curriculum"
for undergraduate nursing curriculum, where they outlined a number of learning
objectives that focused on cultural competence for each year in the nursing program.
In freshman year, nursing students should have foundation knowledge of diversity. By
sophomore year, students are expected to understand the theme of health disparities.
At the end of junior year, students gain comparative knowledge of national health
disparities and special, at-risk populations. By senior year, nursing students should be
able to analyze cultural diversity issues and synthesize knowledge and skills needed as
practicing nurses. They recommended the use of case studies, discussions, role play,
community panels, and debates as teaching strategies for incorporating cultural
diversity in the nursing curriculum. Nevertheless, they agree that it is extremely
challenging to incorporate content related to cultural competence in an already very
full nursing curriculum.31 In fact, many nursing educators do not feel confident or
comfortable teaching cultural competence content.32 Thus, the need to transform
nursing education is imperative. Currently, there is a huge gap between what is being
taught and what needs to be learned. As diversity increases, making cultural
competence a priority relies on expanded roles of leaders in nursing schools to be
willing to take risks and develop a strategic plan that integrates cultural diversity in the
nursing school curriculum.33

Recommendations for further study

Based on the literature review, this study supports the theory that cultural competence
is learned over time and is a process of inner reflection and awareness. The domains
of awareness, skill, and knowledge are essential competencies that must be gained by
health care providers to provide care to diverse populations.18 Health care providers
must develop sensitivities to a diverse cultural community and demonstrate

12
competency. However, there are many challenges to providing culturally competent
care. These include inadequate diversity in workforce and poor communication with
health professionals and patients.10 Furthermore, health care employers often lack
resources to provide culturally and linguistically appropriate services. Some of these
include not having enough interpreters for diverse patient populations and inadequate
understanding of health literacy and cultural norms essential for the populations
served.34 As a result, miscommunication often occurs between providers and patients
that lead to patient dissatisfaction and poorer health outcomes.35

While the federal government and nursing and medical school programs have
provided guidelines to advance education and training, there still remains inadequate
attention, knowledge, and consistency to improving various educational programs.
Although this study has shown the importance of cultural competence and the
necessary training techniques that are important for providing culturally competent
care, this is only the first of several qualitative and quantitative studies to better
understand cultural competency in nursing programs. Specifically, recommendations
for nursing faculty will be made to help health professionals acquire expertise and
embrace the value of cultural diversity and skills necessary to providing quality and
culturally competent care. Additional studies are necessary to investigate the levels of
cultural education needed in nursing programs and strategies to evaluate changes in
cultural competence. This will aid in future curriculum development and evaluation of
nursing programs so that nursing graduates will be trained to fully understand the
needs of diverse patients and be able to provide culturally competent care.

CONCLUSION

Understanding cultural competence is more than just knowing the concept or its
definitions. For health care professionals to be culturally competent, this means
having the knowledge, skills, and tools to practice, as well as being dedicated and
committed to the ongoing process of providing culturally competence care. This is
especially so for nurses who may be the first health professional encountered by
patients. Currently, many challenges exist because of the static nature of health care,
diversity in patient populations, and uniqueness of various cultures. Although these
barriers to providing culturally sensitive care exist, gaining a better understanding of
cultural competence is essential to developing realistic education and training

13
techniques, which will lead to quality professional nursing practice for increasingly
diverse populations.

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