In exploring the literature relating to cultural competence, it became apparent that the amount of writing related to the topic was quite different among these groups. The Nursing literature is quite vast on this topic. It would appear that the nursing community has taken a leadership role in this area. Physician focused literature was the next largest group, and the other two groups were less well represented in the literature on cultural competence. For that reason, I've chosen to discuss them in that order.

The nursing literature is quite vast on the topic of cultural competence. It explores this topic in quite a comprehensive manner. Articles discussed cultural competence from a global perspective, a group specific viewpoint, and covered the lifespan from pre-term to end of life. The earliest literature using the phrase cultural competence and defining its meaning was provided by nurses just over a decade ago.₂

The American Nurses Association provides a conceptual framework for cultural competence on their web site in the following way: “To meet the needs of culturally diverse groups, health care providers must engage in the process of becoming culturally competent. Cross, Bazron, Dennis, & Isaacs define cultural competence as ‘a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations'⁴ (p. iv). The word competence is used because it implies having the capacity to function effectively.”₃

Rosenjack-Burcham provides additional useful definitions of several attributes of cultural competence. These phrases often are used in place of cultural competence, but have greater meaning as components of cultural competence. Cultural awareness refers to “the developing consciousness of culture and the ways in which culture shapes values and beliefs”.² Cultural knowledge refers to “the continued acquisition of information about different cultures”.² Cultural understanding refers to “the ongoing development of insights related to the influence of culture on the beliefs, values, and behavior of diverse groups of people”.² Cultural sensitivity develops as “one comes to appreciate, respect, and value cultural diversity”.² Cultural interaction refers to the “personal contact, communication, and exchanges that occur between individuals of different cultures”.² And finally, cultural skill begins “with the ability to communicate effectively... and to incorporate the client's beliefs, values, and practices into the provision and planning of care”.² Each of the above terms are components of the concept, cultural competence.

An additional key concept in this area is one of ethnocentrism. It is “woven into the fabric of one's own cultural make-up”.₅ Both health practitioner and patient must acknowledge the potential effect of ethnocentrism on their interactions with each other within a dominant culture.

Further, the concept of “trans-cultural communication” suggests that, “Accepting differences in people and displaying a nonjudgmental attitude are essential for the nurse to communicate successfully across different cultural groups”.₆

The physician-oriented literature on cultural competence was also quite extensive. It seemed to be divided roughly along two lines. One was a body of literature that really was a discussion of health disparities among members of ethnic and cultural minorities. The other literature tended to discuss the need for cultural competence and how it might be achieved. Health disparities are important for clinicians to understand, and to factor into their decision-making process when caring for members of ethnic and cultural minorities.

The American Medical Association web site⁷ includes a relevant quote from James S. Todd, M.D., a past executive vice-president of that organization. He offered the observation: “Give me standard patients and I'll practice standard medicine.” This quote is relevant to the topic of cultural competence, in that the training of healthcare providers at all levels must reflect the population they will serve. Otherwise, their practice will reflect their training and not the needs of the populations they serve.

The AMA working definition of cultural competence is presented by first defining culture and then cultural competence as follows: “Our use of ‘cultural competence' and ‘culturally competent health care' reflects an inclusive definition of the word ‘culture' – any group of people who share experiences, language, and values that permit them to communicate knowledge not shared by those outside the culture... To be culturally competent, ... physicians must be able to provide patient-centered care by adjusting their attitudes and behaviors to the needs and desires of different patients, including accounting for the impact of emotional, cultural, social and psychological issues on the main biomedical ailment. This in turn requires complex integration of knowledge (including knowledge of the effects of culture on others' beliefs and behavior and on one's own beliefs and behavior), attitudes (of the patient as well as the physician) and skills (with communication skills as important as technical skills).”₇

Cultural competence is not yet a part of most medical school curricula. Carrillo, Green, and Betancourt₈ provide guidance for a cross-cultural curriculum. In particular, they caution a need to avoid a “stereotypical” approach to cross-cultural care. They believe that the target audience for such a curriculum should be medical students as well as practicing physicians.

Rush Medical College in Chicago, Illinois developed a “Spanish Language and Cultural Competence Project” composed of three parts. First was Spanish language training, second was a didactic cultural competence component, and the third component was an 8-day international seminar. They spent the 8-days in both urban and rural Mexico in a variety of clinical and non-clinical areas to enhance their cultural understanding and improve their language skills.₉

On a smaller scale, medical educators at Wake Forest University utilized a teaching method that created a “critical incident” to assist students readiness to learn cultural competence by moving them from “unconscious incompetence” to “conscious incompetence” in this area. They are thrust into a clinical scenario where they have medical comfort, but a culturally based incident occurs that affects their ability to diagnose a problem. This incident then makes them more receptive to the cultural competence training to follow.₁₀

Chin and Humikowski make the case that there is a struggle to be culturally competent while avoiding racial stereotyping. They discuss cultural competence curricula and suggest that viewing “the patient within a wider cultural setting can help guide the initial clinical approach, but individualized care is mandatory.”₁₁ They also suggest that cultural norms change over time, making “lifelong learning and flexibility” a necessity.

Physician Assistants (PAs) utilize the medical (physician) literature quite extensively in their training and on-going practice. However, they do have a smaller body of literature that explores the concept of cultural competence.

The American Academy of Physician Assistants¹² officially addresses cultural competence as a diversity issue as follows: “The AAPA is committed to a policy that respects the ethnic and cultural diversity of all people. The Academy's commitment to diversity is a belief in the value and worth of each individual, and a recognition that when differences in cultures and ethnic groups are understood and respected everyone in society benefits. Accepting diversity is not an attempt to eliminate or dilute the rich heritage that exists in all peoples. Accepting diversity does require an understanding and respect for the differences that exist among all physician assistants and the patients they serve.”₁₂

PA training programs have explored ways of incorporating cultural competence training. One method described in a paper by Miller and Morton-Rias¹³ involved a component of the humanities course. They describe the utilization of a written and verbal requirement for PA students to examine their own cultural roots. They shared their “cultural portrait” with their classmates to include their racial and ethnic roots, socioeconomic profile, general values and beliefs, artifacts, and traditions regarding health care. This allowed the students to enhance their understanding of their own cultural background as well as improving the knowledge and understanding of their peers.

Another PA educator has created a model for small groups of PA's to confront their own cultural biases employing panel presentations, lectures, a field experience, and videotaped interviews.¹⁴

Yet another group of PA educators performed a study using a survey instrument testing their students “multicultural sensitivity” at four points during and immediately following a 30-month PA program. The greatest improvement in scores followed their clerkship rotations where they had encountered low-income patients of racial and ethnic backgrounds that were different from their own.₁₅ They suggested that increasing PA training in these settings would enhance multicultural sensitivity.

The literature representing healthcare administrators and executives is less extensive than that of the other groups. The importance of cultural competence to this vital group in the delivery of healthcare in America should be readily apparent. On reviewing the available literature, they seemed to focus on the skills needed to practice in a diverse environment, how to improve diversity among their ranks, and how diversity impacts the business of healthcare.

The American College of Healthcare Executives (ACHE) web site₁₆ was reviewed for references to cultural competence or diversity issues. A search of the site only revealed a need to encourage and promote minorities in the health management field. “Our country's increasingly diverse communities result in a more diverse patient population. Studies suggest that diversity in healthcare management can enhance quality of care, quality of life in the workplace, community relations, and the ability to affect community health status. Achieving diversity in senior management will involve a commitment to awareness of diversity issues, hiring practices that attract diverse staff, development and mentoring in educational programs and organizations, and organization-wide diversity training.” This group supports a newer group called the Association of Hispanic Healthcare Executives,₁₇ whose goals are to assist in the professional development of Hispanics in the U.S., promote public awareness of the healthcare needs of Hispanics, serve as a resource to improve access to care for Hispanics, and advocate for greater Hispanic representation in medical and health related academia. References to other minority advocacy groups were not made on the ACHE web site.

A project funded by the Robert Wood Johnson Foundation convened focus groups to determine how prepared public health administrators seemed to be. These groups identified forces that they believed influenced their competencies, determining that “recognition of the importance of cultural diversity” and acquiring skills in cultural competence were of primary importance. They also identified the barriers and incentives to acquiring these skills, citing limited time for training as a major barrier and improved effectiveness and pride in personal growth as important incentives.₁₈

Brach and Fraser make a “business case for culturally competent health care”.₁₉ They cite four interrelated financial incentives for providing culturally competent care: increasing their appeal to minority consumers, competing for private purchaser business, responding to public purchaser demands, and improving cost effectiveness. However, they acknowledge that while healthcare organizations may have some financial incentives to increase cultural competence, the incentives remain fairly weak and are often negated by cost constraints. It would appear, from their article, that the incentives would vary according to the market served. Interestingly, our course readings included a similar article making the case for physicians as small business men and women to embrace cultural competence as a means of practice building.

For the purposes of this paper, the associations above were assumed to present the current prevailing views and interests of the represented groups. In addition, the individual papers cited were assumed to represent at least a portion of the group to which the authors belonged and not just represent the views of the authors alone.

There is a vast literature on the topic of cultural competence or sensitivity. The scope of this paper does not allow an exhaustive review of that literature. While many viewpoints were represented in the literature, those presented here seemed to predominate. Also, the professions researched are not equally represented in the literature. The Nursing literature is vast on cultural sensitivity and competence. The numbers of articles were fewer for physicians, PA's, and fewest for healthcare executives and administrators.