There are a range of tools and strategies, including cultural competency self-assessments, communication, and interventions such as the ACCESS model , all aimed at identifying strengths and pinpointing areas where improvements can be made. By focusing on these aspects, nursing professionals and health care organizations can create an environment where all clients, regardless of their cultural or linguistic background, feel understood, respected, and well cared for.
The Promoting Cultural and Linguistic Competency Self-Assessment Checklist for Personnel Providing Primary Health Care Services is a useful resource for improving cultural and linguistic competency in health care settings. It is designed to enhance awareness of and sensitivity to cultural and linguistic diversity and to provide examples of practices that foster an environment of cultural and linguistic competence. Developed by the National Center for Cultural Competence (NCCC) at Georgetown University, the checklist is intended for use by health care personnel in primary care settings (n.d.) and consists of six sections:
Each section is designed to help health care personnel assess their level of cultural and linguistic competence and identify areas for improvement. The checklist provides a list of items to consider and offers examples of best practices for each section. By completing the checklist, health care personnel can gain a better understanding of their cultural and linguistic competencies and take steps to improve the care they provide to clients from diverse backgrounds. For example, in the section on communicating effectively across cultures, the checklist suggests using plain language, avoiding medical jargon, and utilizing an interpreter when necessary.
According to the NCCC, the checklist has been widely used in health care settings and has been shown to be effective in improving cultural and linguistic competence among health care personnel (n.d.).
Visit this link to the National Center for Cultural Competence checklist, complete a self-assessment, and then respond to the following questions.
A welcoming environment in health care refers to a setting that is inclusive, respectful, and culturally sensitive to clients from diverse backgrounds. Such an environment promotes client-centered care and is culturally responsive to clients’ diverse needs—a place where clients feel respected, valued, and included, regardless of their cultural or linguistic backgrounds. By creating a welcoming environment, health care workers can improve the quality of care and promote positive health outcomes for all clients (Figure 24.4). Creating a welcoming environment is part of the NCCC checklist (NCCC, 2013); the following list presents examples of how this may be accomplished:
Figure 24.4 Making clients feel comfortable and welcome goes a long way toward improving health outcomes. In this photo, Ensign Chaquel Shiver places a client at ease while checking them into a Navy hospital ship in Riohacha, Colombia. (credit: “Sailor gives a patient a thumbs-up while checking him” by Kris R. Lindstrom/U.S. Navy/Flickr, CC BY 2.0)
The following is an example of a welcoming environment: The waiting room in a clinic has accessible seating for clients with mobility impairments and clear signage—including signage in Braille —that indicates accessible routes throughout the facility. Clinic staff has received training on how to interact with clients with disabilities in a respectful and inclusive manner. Providing accessible seating, clear signage, and staff training can help create a welcoming environment that is inclusive of all clients, regardless of their physical abilities. By assessing accessibility, health care personnel can identify areas for improvement and take steps to fix them.
In this video from North Western Melbourne Primary Health Network based in Melbourne, Australia, LGBTQIA+ people talk about their experiences accessing health care and offer suggestions to help health care professionals improve their communications and interactions with this population. Although the clients in the video are Australian, much of their comments apply to health care in the United States.
Watch the video, and then respond to the following questions.
For more information on nursing advocacy for LGBTQIA+ populations, read Nursing Advocacy for LGBTQ+ Populations from the American Nurses Association.
Trust provides the foundation for effective communication with clients. Building trust is essential because it lays the groundwork for a strong therapeutic relationship between health care providers and their clients from different backgrounds. When clients trust their health care providers, they are more likely to openly share their concerns, beliefs, and preferences, which enhances diagnostic accuracy and treatment planning. In a culturally diverse health care setting, trust helps overcome potential language and cultural barriers that may otherwise hinder effective communication. By fostering trust, nurses can create an environment where clients feel safe, respected, and valued. Additionally, trust plays a significant role in ensuring client compliance and adherence to treatment plans. Clients are more likely to follow treatment recommendations from health care providers they trust, leading to improved health outcomes.
To build trust, nurses need to demonstrate cultural humility , which involves acknowledging their own biases , being open to learning about different cultures, and actively engaging in respectful and nonjudgmental communication. Nurses should prioritize active listening, empathy, and validating clients’ experiences and perspectives. Additionally, they should be sensitive to cultural differences in communication styles, nonverbal cues, and health beliefs and adapt their approach accordingly. See Culturally and Linguistically Responsive Nursing Care for more information.
Effective communication across cultures is a cornerstone of inclusive and compassionate nursing care, encompassing differences not only in ethnicity and language but also in sexual orientation, gender identity, and relationships. For example, recognizing and respecting the unique needs of LGBTQIA+ individuals is vital in fostering trust and understanding. One tangible step is to include nonbinary choices on intake forms, allowing clients to identify themselves in a way that feels most authentic. This sends a strong message of acceptance and can significantly impact the client’s comfort and willingness to engage in care. Additionally, environmental factors such as displaying LGBTQIA+ inclusive symbols, offering gender-neutral restrooms, and displaying inclusive signage can further promote an inclusive atmosphere. Collaborating with LGBTQIA+ advocacy groups and implementing these best practices can help ensure that health care providers are meeting the diverse needs of all clients, demonstrating a commitment to care that respects and honors individual identity and cultural background.
In many cultures, concepts of health and illness are deeply connected to spiritual or religious beliefs. For example, some clients may believe that an illness is caused by a lack of balance between the body, mind, and spirit. To communicate effectively with these clients, health care providers can ask about their spiritual or religious beliefs and how they relate to their health. They can also provide information about spiritual or religious resources that may be available, such as chaplains, clergy, or prayer groups.
Another example of effective communication across cultures is the use of professional interpreters or language services. Clients who have LEP or speak a different language may struggle to communicate their health concerns or understand medical instructions. By using interpreters or language services, health care providers can ensure that clients receive accurate and appropriate care. Interpreters can also help health care providers to understand cultural nuances and provide culturally responsive care.
Finally, health care providers can use visual aids or other materials to communicate effectively with clients from diverse cultural backgrounds. For example, providing information in multiple languages or using pictures or diagrams to explain medical procedures can help to overcome language and cultural barriers . Health care providers can also use cultural brokers or community health workers to help clients navigate the health care system and understand their health needs. Cultural brokers are individuals who act as intermediaries or go-betweens among different cultures. They use their knowledge and understanding of different cultures to help facilitate communication, understanding, and advocacy on behalf of an individual or group. The concept of cultural brokering has evolved and permeated many aspects of U.S. society, including health care, education, and child welfare programs. Cultural brokers can come from various backgrounds and may receive extensive training in cultural humility and community partnerships to better serve their role.
Cultural brokers play an indispensable role in bridging the gap between different cultures, especially in diverse settings like health care, education, and community services. Acting as intermediaries, they facilitate communication and understanding by interpreting cultural norms, values, and languages, ensuring that individuals from various backgrounds can effectively interact and collaborate. This video explores the vital function of cultural brokers, their skills, and the impact they have on creating more inclusive and empathetic environments.
Watch the video, and then respond to the following questions.
Effective communication with individuals from diverse backgrounds is critical in health care settings. Research has shown that culture is central to effective messaging for community engagement in health care and that cultural respect is critical for accuracy in medical research (Tse et al., 2020). Interprofessional collaboration—actively partnering with professionals from diverse backgrounds with distinctive professional cultures—is also essential for meeting the needs of diverse populations in health care settings (Kline et al., 2019).
To improve individual health and build healthy communities, nurses and other health care providers need to recognize and address the unique culture, language, and health literacy of diverse consumers and communities as presented in this Health Resources and Services Administration video.
Watch the video, and then respond to the following questions.
Organizations and nurses working in the field of population health are uniquely positioned to understand and meet the diverse cultural needs of the communities they serve. Assessment tools are available to evaluate and enhance the cultural competence of nurses and their practice. For example, diversity, equity, and inclusion (DEI) organizational assessment tools can be utilized as a benchmark, specifically tailored for nursing environments, to guide quality improvement and recognize cultural competence as an ongoing, adaptive process. As introduced previously, institutions like Georgetown University’s NCCC also offer tools such as the Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPA), designed to assess nurses’ cultural awareness and responsiveness. Additionally, frameworks like “Becoming a Culturally Competent Nurse in Population Health” provide guidelines and strategies for nursing professionals to develop, implement, and sustain culturally competent care within their practice. These resources emphasize the essential role nurses play in delivering care that is not only clinically effective but also culturally sensitive, ultimately contributing to the overall well-being and health of diverse populations.
Although the CLCHPA is an individual assessment for health practitioners, having culturally competent providers within an organization enhances the organization’s cultural competence as a whole. The CCHPA is based on three assumptions: (1) cultural competence is a developmental process at both the individual and organizational levels; (2) with appropriate support, individuals can enhance their cultural awareness, knowledge, and skills over time; and (3) cultural strengths exist within organizations or networks of professionals but often go unnoticed and untapped (NCCC, 2006).
The CLCHPA has six subscales:
The NCCC believes that self-assessment is a process based on an organizations strengths. Upon completion of the CLCHPA, response fields identify awareness, knowledge, or skill level for each of the six subscales. Depending on the response pattern, a listing of resources such as web-based journals, textbooks, multimedia materials, and suggested learning experiences should be provided.
To apply cultural knowledge, health care providers should use culturally competent communication skills to understand their clients’ cultural backgrounds and how that might affect their health beliefs, behaviors, and preferences. According to Campinha-Bacote (2002), culturally competent communication involves being aware of one’s own cultural biases and assumptions—using appropriate language and nonverbal communication—and actively listening to clients to understand their unique perspectives. Providers can tailor their care to meet the individual needs of each client.
Health care providers should also be aware of the impact of organizational culture on health care quality. Health care organizations with a strong culture of safety and quality are more likely to provide high-quality care and improve client outcomes. Providers can use their knowledge of organizational culture to identify areas for improvement and drive change within their organizations to improve quality and eliminate health care disparities. Applying cultural knowledge in health care involves understanding and respecting the cultural beliefs and values of individual clients while also recognizing the impact of organizational culture on health care quality. By doing so, nurses can improve client outcomes and provide more equitable care to all clients.
Read the scenario, and then respond to the questions that follow.
This scenario continues to follow Emily's work with Hyeon Lee. After completing a cultural assessment with Hyeon, Emily takes time to understand Korean cultural norms and beliefs that may influence Hyeon’s care and maintains respect for her preferences, including modesty during physical assessments. With Hyeon’s permission, Emily actively involves members of the family, such as Nari, in Hyeon’s care plan and connects her client with local Korean community centers that may provide support. Emily gives careful attention to explaining Hyeon’s medication regimen, utilizing visual aids when necessary.
Health care organizations can advocate for culturally and linguistically responsive practices by implementing policies and procedures that prioritize DEI. Here are some specific ways that health care organizations can advocate for culturally and linguistically responsive practices:
By implementing these strategies, health care organizations can advocate for culturally and linguistically sensitive practices and improve health outcomes for all clients, regardless of their background or language proficiency.
Cultural behaviors have been shown to have important implications for human health. Culture—a socially transmitted system of shared knowledge, beliefs, and practices that varies across groups—has been a critical mode of adaptation throughout the history of our species. Socioeconomic status, gender, religion, and moral beliefs are among the cultural factors that have been shown to affect health outcomes.
Racial and cultural minority groups have documented disparities across a number of health indicators, including Black Americans, Native Americans, and Latino Americans. Some evidence suggests that particular groups may receive poorer standards of care due to biased beliefs or attitudes held by health professionals.
Researchers have also found a clear pattern of disparities in health, which was first observed in the 1970s. These disparities are attributed to a range of factors, including cultural and social determinants, access to care, and individual behaviors.
Cultural factors have been shown to play an important role in the development and persistence of health inequities. Identifying and addressing these factors is essential to achieving health equity for all individuals and communities.
(See Hatzenbuehler et al., 2013; Latif, 2020; Lavizzo-Mourey et al., 2021; Rural Health Information Hub, 2022.)
The ACCESS model is a comprehensive approach to promoting cultural competence in health care services. It emphasizes the importance of awareness, knowledge, and skills in providing effective care for diverse populations. By understanding the unique cultural perspectives and experiences of clients, health care providers can work to build trust, reduce disparities, and improve health outcomes.
Nurses and other health care providers can use the ACCESS model to deliver culturally responsive care by first assessing clients’ cultural background and beliefs and then adapting their communication style and negotiating a care plan that is respectful of the client’s beliefs and values. Nurses can also establish a trusting relationship with clients by demonstrating sensitivity to nonverbal cues and ensuring that the client feels safe and comfortable in the health care setting.
The ACCESS model is a framework that health care providers can use to deliver culturally competent care to clients from diverse backgrounds. The model consists of six key components: assessment, communication, cultural negotiation and compromise, establishing respect and rapport, sensitivity, and safety (Narayanansamy, 2002). Assessment involves evaluating a client’s cultural background , including their health beliefs and practices. Additionally, understanding the client’s previous interaction with the health care system, such as LGBTQIA+ clients, is needed. This information can help nurses and other health care providers tailor care plans to meet the unique needs of each client:
The ACCESS model provides nurses with a comprehensive framework for delivering transcultural nursing care. As discussed in Transcultural Nursing, transcultural nursing seeks to provide culturally sensitive and competent care to individuals from diverse cultural backgrounds. By assessing cultural backgrounds, communicating effectively, acquiring cultural knowledge, establishing supportive care environments, and seeking client feedback, nurses can enhance their cultural competence and deliver care that is sensitive, respectful, and culturally responsive.
The first step of the ACCESS model involves assessing the cultural background of individuals and understanding how it shapes their health beliefs and behaviors. This supports the development of a culturally sensitive care plan tailored to their specific needs. According to Romem et al. (2021), by conducting a comprehensive assessment, nurses can identify cultural factors that may influence health practices and beliefs, facilitating the delivery of client-centered and culturally responsive care.
Effective communication is pivotal to transcultural nursing care. It involves using inclusive language, avoiding assumptions, and ensuring cultural nuances are acknowledged. The ACCESS model emphasizes the importance of clear communication and understanding clients’ preferences. Effective communication involves active listening, being respectful, and acknowledging cultural differences, which can foster trust and enhance client-provider rapport (Narayanasamy, 2002).
Cultural knowledge is essential for providing quality care to culturally diverse clients. The ACCESS model promotes cultural competence by encouraging nurses to continually update and broaden their knowledge of diverse cultures and communities. Sharifi et al. (2019) emphasize the importance of nurses familiarizing themselves with the customs, beliefs, values, and practices of various cultures to provide culturally sensitive care.
A supportive care environment is crucial for promoting positive health outcomes among clients from diverse cultural backgrounds. The ACCESS model suggests displaying visual cues such as posters or brochures that show support for different cultures. Providing a welcoming environment that respects clients’ unique backgrounds and values is associated with improved client satisfaction and better health outcomes (Medina-Martínez et al., 2021).
The final step of the ACCESS model involves seeking client feedback and continuously evaluating the effectiveness of care. By actively involving clients in their care and soliciting their feedback, nurses can identify areas for improvement and adjust accordingly. Medina-Martínez et al. (2021) highlighted the importance of client feedback in identifying areas of cultural insensitivity within health care settings, which underscores the need for ongoing evaluation to provide quality, person-centered care. Table 24.3 provides an example of using the ACCESS model with a client.
| Assessment | Assess the client’s cultural background, and understand how it influences their health beliefs and expectations. Inquire about the client’s gender identity, pronouns, and how they want to be addressed. |
| Communication | Use inclusive language, and avoid heteronormative assumptions or reinforcing stereotypes. Provide clear explanations, and discuss the need for sensitive exams, respecting the client’s comfort level. Familiarize yourself with legal protections, discrimination laws, and organizational policies related to LGBTQIA+ individuals. |
| Cultural negotiation and compromise | Continuously update knowledge about LGBTQIA+ culture and communities. Stay informed about new information and resources supporting LGBTQIA+ health. Talk with the client to understand their concerns, and work with them to find an alternative treatment plan that is respectful of their values and beliefs. |
| Establishing respect and rapport | A nurse is working with a client who has experienced discrimination in the past due to their race, ethnicity, sexual orientation, or gender identity. The nurse shows respect for their experiences, helping to build trust and rapport. |
| Sensitivity | Create an environment that is supportive and affirming of LGBTQIA+ clients. Display posters or brochures in waiting areas that show support for LGBTQIA+ individuals Take the time to understand the client’s concerns, and use language that is respectful and sensitive to their background when discussing their diagnosis and treatment. |
| Safety | A nurse is working with a client who identifies as transgender and has experienced trauma related to their identity. The nurse takes care not to engage in any actions or language that could trigger traumatic memories or cause the client to feel unsafe or disrespected. |
Read the scenario, and then respond to the questions that follow.
This scenario continues to follow Emily's work with Hyeon Lee. Working with the interpreter, Emily helps schedule regular follow-up visits and establishes clear communication channels for any questions or concerns between visits. Hyeon’s recovery proceeds smoothly, and her cultural and linguistic needs are met, leading to a positive client experience and adherence to the care plan.
The home care nurse can also use the ACCESS model as a framework for this scenario:
A—Assessment: Emily begins with a comprehensive assessment of Hyeon’s needs, including her language proficiency, cultural background, family dynamics, and medical condition. Emily’s recognition that using a family member as an interpreter is not best practice is part of this initial assessment.
C—Communication: Emily ensures that communication is clear and effective by engaging a professional interpreter. Although Hyeon’s daughter speaks English well, Emily opts for professional services to maintain objectivity and accuracy in conveying medical information.
C—Cultural Competence: Emily actively seeks to understand Korean cultural norms and beliefs that may influence Hyeon’s care. This includes respecting preferences such as modesty during physical assessments and considering cultural attitudes toward health, illness, and family roles.
E—Establishment of Mutual Goals: Emily involves Hyeon’s family in the care plan and sets recovery goals that align with Hyeon’s cultural values and expectations. By involving the family, she ensures that the care plan is acceptable and tailored to Hyeon’s individual needs.
S—Sensitivity: Emily exhibits sensitivity to Hyeon’s cultural background, recognizing that care practices must be adapted to meet her unique needs. This includes connecting Hyeon with Korean community centers and being mindful of dietary preferences and other culturally specific aspects of care.
S—Support: Regular follow-up visits and clear communication channels support Hyeon’s ongoing care. Emily’s approach facilitates a smooth recovery process, ensures adherence to the care plan, and leads to a positive client experience.
By utilizing the ACCESS model, Emily is able to deliver care that is culturally sensitive, respectful, and effective. Emily works to understand and respect Hyeon’s cultural background, beliefs, and values while also ensuring her safety and comfort. This helps to build trust and rapport, which is essential for providing effective care.
