A dear friend, who is a veteran nurse, recently told me about her husband's post-operative experience. The surgery itself went well; immediately after his return to the nursing unit, he was appropriately asked by his nurse, "How is your pain?" Using the almost-universal pain scale, she asked him to rate his pain from zero (being no pain at all) to 10 (being the worst pain you've ever experienced).

She said that her husband didn't know how to answer the nurse's question because, in her words, "He didn't have anything to compare it to." He struggled to honestly answer her, and the nurse patiently persisted in trying to establish some baseline benchmark for his pain, using more descriptive and colorful adjectives.

Quite simply, understanding where this man was coming from was critical to providing appropriate care which would ultimately result in a better outcome (pain relief). These skills - learning to ask questions sensitively, listening carefully to the answers and appreciating the other person's perspective can be described as cultural competency.

Certainly, cultural competency is a term that is not specific to nursing or to health care organizations. HR/benefits professionals know full well that cultural competency requires flexibility, adapting to different cultural beliefs and practices, and having a respect for other points of view.

In the 1989 book, "Towards a Culturally Competent System of Care," the authors listed five essential elements that contribute to an institution's or agency's ability to become more culturally competent:

1. Valuing diversity.

2. Having the capacity for cultural self-assessment.

3. Being conscious of the dynamics inherent when cultures interact.

4. Having institutionalized cultural knowledge.

5. Having developed adaptations of service delivery reflecting an understanding of cultural diversity.

These five elements should manifest themselves at every level of an organization, including policymaking, administration and practice, regardless of the industry. Additionally, these elements should be reflected in the attitudes, structures, policies and services. In other words, they should become the organizational "culture."

But in health care, in direct service provider facilities, not only should that culture be appreciative of its employees, but also of the patients and families it serves.

Much has been reviewed about the distinct challenges for health care providers to provide culturally competent care. The most obvious, perhaps, is the challenge of recognizing basic clinical differences among people of different ethnic and racial groups. High blood pressure, for instance, is known to occur more commonly among African-American groups.

As in any relationship, the most significant challenge lies in communication. Clearly, this could be said for a lot of issues, but pragmatically in health care it's referring to the need, directly, for interpretation and, more subtly, the need for understanding nuances of words in different languages. My mother used to tell me to "never talk about sex, politics or religion" at parties. Many patients, not raised by my mother, are reluctant to talk about personal matters such as sexual activity or chemical use. So, how does a clinical resource deal with that?

Another challenge is ethics and acknowledging the belief systems of other people. While we may like to think that the American health care system has all the answers, that is mightily presumptuous. Despite all of the financial wealth and resources that we have, our health care system does not have the best clinical outcomes. Respect for the belief systems of other cultures and the effects of those beliefs on patients' well-being are critically important.

The last challenge is trust. For some individuals meeting our health care system for the first time, their ability to trust a physician or someone in an authority position might be very difficult. We may not know all of their history - perhaps they are new to this country and are mistrusting of caregivers and authority figures.

These challenges can be applied to any HR/benefits department. As health care reform moves forward and our nation becomes more diverse, thanks to increased immigration, providers, patients and employers will be affected. It's best to look again at your policies, practices and procedures to ensure that you, too, are delivering culturally competent services.

But know that just as in my friend's husband's post-op experience, there is no one right answer, no one correct template. Developing culturally competent programs is an ongoing process and requires continual evaluation to make sure that you are doing the best thing for your employee, your patient and your organization.

Contributing Editor Betty Long is a registered nurse and founder of Guardian Nurses Healthcare Advocates, a health care advocacy firm that has helped thousands of patients navigate the health care system and saved millions of dollars in health care costs.

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