Cultural Competency for Nursing Assistants, Home Health Aides, & Medical Assistants

Cultural competency is helpful for working in healthcare. There are eight billion people in the world today (Morse, 2023). They speak over 7,000 languages (Ethnologue, n.d.). More than 50 countries have reported that greater than 15% of their population is made up of immigrants (Kaljee & Stanton, 2011). People around the world are moving more frequently. This movement causes differences to be less clear among traditional language, racial, and ethnic communities.

Cultural competency is the ability to understand the beliefs and values of other people. Culture is how groups of people understand their history, share their values, and engage in similar actions. Culture is not necessarily equal to racial and ethnic groups (Kaljee & Stanton, 2011). It may reflect a similar social group, religion, sexual orientation, or occupation, such as the military culture. People who share a cultural belief are organized into groups. Family, gender, age, or common interests can group them. There can be multiple subcultures. For example, there are different national subgroups within the Latino cultural group, such as Cubans, Venezuelans, Mexicans, and others.

There are other important definitions to know.

Race: This is a term that has been used to group individuals. Examples of race include White, Black or African American, American Indian or Alaskan Native, Asian, and Native Hawaiian or Other Pacific Islander (National Human Genome Research Institute, 2025).

Ethnicity: This refers to the group someone belongs to. It is made of things like shared memories, language, and religion (EBSCO Information Services, 2024).

Equity: This refers to justice and fairness (National Association of Colleges and Employers, n.d.).

Diversity: This means the inclusion of people from different races, backgrounds, sexual orientations, genders, ages, experiences, opinions, etc. (Oxford University Press, 2021; Servaes et al., 2022).

Inclusion: This means to engage with diversity (The George Washington University, n.d.).

Now that culture has been defined, it is time to review specific cultural and personal variables that may be important to patients.

With cultural competency, you can do the following (National Center for Cultural Competence, n.d.):

• Value similarities and differences.
• Understand that people are different.
• Do a cultural self-assessment.
• Respect the beliefs of others.
• Get rid of personal biases.
• Communicate with others.
• Practice cultural competency.
• Support diversity, equity, and inclusion.

Self-awareness is the first step toward culturally competent care. This step starts with knowing your personal values and beliefs. This includes healthcare values and beliefs. Think about how these factors can influence caregiving for patients. This self-awareness helps you understand the beliefs of others. Being aware of your own biases and attitudes allows you to become more appreciative and sensitive to patients' needs. This awareness means that healthcare workers must think about their own attitudes toward different ethnic backgrounds and how those beliefs may cause problems when working with different cultures. Self-awareness is only one component, however. Healthcare workers must be able to develop skills in delivering culturally competent care.

Knowledge is another step in gaining cultural competence. Healthcare workers need to know cultural differences and traditions to provide the best care. Knowledge is not just learning about different cultures. There is a need to understand the patient's worldview. A worldview is how the individual sees the world based on their values and beliefs. This is a part of their culture. Understanding the patient's worldview can help in understanding the behaviors and beliefs that will impact their care. Knowledge also means learning about biological characteristics, variations, and cultural practices. This knowledge will also aid in communication.

Education and training in cultural differences and skills should be included in initial training and continuing education. Healthcare workers need to identify the impact of policies and procedures on patient care and advocate for patients' cultural needs.

Healthcare organizations should provide cultural resources to meet the needs of a diverse population. The organization must focus recruitment and retention on gaining a multicultural workforce. The workforce should be similar to the cultures of people who live in the community where the organization is located.

Different cultures have different ideas about the role of healthcare. Some cultures view healthcare workers as trusted confidants. They expect the worker to provide valuable advice as needed. Other cultures may view workers as an intrusion. So, healthcare workers should adjust their actions based on the patient's background and expectations.

The culture of healthcare has changed. Patients are making their own care decisions. Workers are encouraged to provide services that meet the patient's values.

Being sensitive is a big part of providing culturally competent healthcare. Sensitivity helps workers to appreciate, perceive, and respond to a patient's verbal and nonverbal cues.

A cultural assessment should be done for every person. It is often performed by nurses and providers. It is important to know about. Cultural information that is important to the care of the patient should be reviewed. Asking open-ended questions is important. Asking the patient what they think about the illness or injury and how it will impact their lives can reveal more about their culture. The healthcare provider can decrease fears and form a partnership with the patient. This could enhance the outcome.

A cultural assessment includes the following. This list is not all-inclusive (Narayan & Mallinson, 2022):

• Basic demographics
• Cultural identity and background
• Preferred language
• Communication style
• Family role and structure
• Beliefs and practices
• Food and drink preferences
• Social determinants of health
• Social and community involvement

Scenario/situation/patient description

Amina is a 68-year-old female. She recently immigrated from Ethiopia. She came to her appointment complaining of headaches, dizziness, and tiredness. She did not speak English well. Her daughter, Sarah, came to her appointment with her. She acted as her interpreter, as she spoke English well. Amina did not make a lot of eye contact when talking. This is especially true if the staff were males. Her responses were very brief. She would nod slightly to answer a question.

It was found out that Amina does not always take her medication that was prescribed for high blood pressure. Her medical records mention missed follow-up appointments. Her previous provider mentioned noncompliance. Sarah has been the interpreter during each visit.

The nurse practitioner, Ama, has been working on her cultural competency skills. Instead of relying on Sarah to be the interpreter, Ama requested that a certified interpreter be present. While waiting, Ama decided to look into medical practices and cultures in Ethiopia.

The interpreter found that Amina speaks Amharic fluently. She let the interpreter know that she does not understand her diagnosis. She discussed her diagnosis with a family member in Ethiopia. After, she began using herbal remedies instead of taking her prescribed medication. She also mentioned being extremely uncomfortable talking about personal medical conditions with males. Now that Ama has a more holistic view, it is clear that noncompliance is actually a language barrier.

Intervention/strategies

There are many different interventions and strategies that can be used. A professional interpreter makes sure there is effective communication. Documents that are printed will be in the English version for Sarah. They will also be in the language that Amina speaks. A teach-back method should be used to make sure that Amina and Sarah understand more about high blood pressure.

A cultural assessment should be performed. This would look at language, roles of the family, decision-making, beliefs about her diagnosis, illness, and healing. These are only some of the topics that will be covered. A cultural assessment was done with Amina. It showed that she prefers to involve only Sarah in her medical discussions, she prefers female providers, and likes traditional and holistic practices.

Collaborative care planning should also be used. The provider should use traditional and holistic measures if possible. This can be done by talking about herbal remedies that would not interfere with prescribed medications. This provider should also make sure the patient feels safe. They could sit at the patient's eye level, not asking questions too quickly, discussing the challenges of immigrating to America, and giving enough time to answer questions. If possible, a female provider, nurse, or nursing assistant could care for Amina.

Discussion of outcomes

At her follow-up, Amina's high blood pressure got better over the last three months. She was able to take her medication routinely. She also followed Ama's advice about which herbal remedies she could take. Her headaches, tiredness, and dizziness improved. She came to more scheduled appointments. Amina was more satisfied with her ability to talk about her high blood pressure. The interpreter played a significant role in this. Amina now kept a blood pressure log. She felt confident in managing her high blood pressure. At her follow-up appointment, she said she felt respected and heard.

Strengths and weaknesses

There were many strengths and weaknesses associated with this case study. Strengths included the following:

• Effective communication with the interpreter. This made the patient feel safe. It also decreased reliance on Sarah for information.
• A cultural assessment was performed.
• Patient-centered collaboration.
• There was an increase in patient satisfaction.
• System-level awareness.

There are also weaknesses associated with this case study, and they include the following:

• Late recognition of the language barriers.
• Systemic gaps related to barriers.
• Previous providers used family members as interpreters.

Communication is very important in cultural competence. Communication within a culture is socially based and often complicated. Misunderstandings can lead to stereotyping, prejudice, and issues with cultural boundaries. It is important to remember the culture's normal actions when communicating. The differences that exist when two cultures communicate can confuse the meanings of the messages sent and how they are understood. The communication between two different cultures is called cross-cultural communication (Hegazi & Pakianathan, 2018).

Cross-cultural communication includes:

• Respect and appreciation for another language
• Ability to communicate without judgment
• Recognize cultural barriers
• Encourage expression
• Speak slowly and clearly without slang
• Show empathy
• Ability to correct misunderstandings

Good communication skills include:

• Actively listening
• Pay attention to non-verbal cues
• Pay attention to perceptions of time, space, touch, expressions, and silence
• Understand how the patient perceives the situation and health treatments

Health organizations that receive federal funding are required to meet standards that improve communication. Some of the standards are:

• Care should be correct for different cultures. This includes health beliefs, actions, languages, health knowledge, and other communication needs.
• Workers should have the correct culture and language for the people in the service area.
• Educate employees on culture and language, as well as correct policies and actions.
• Offer language assistance to patients for free.
• Inform all patients about language assistance in their preferred language. This should be done verbally and in writing.
• Make sure those who are providing language assistance are capable of doing so. Avoid using untrained individuals or family members/minors as interpreters.
• Provide easy-to-understand print material and signs in the languages commonly used by the people in the service area.

Sometimes, an interpreter is needed. Family members should not be used as interpreters. This can interfere with privacy and lead to bias. Once communication barriers are understood and overcome, the conversation about care is clear. Using the patient's own language and terms shows respect and caring.

Healthcare workers' nonverbal communication impacts patient satisfaction. If healthcare workers were attentive to the patient's needs, appeared interested, and made eye contact during care, a healthcare worker's race did not matter in the patients' evaluations (Hegazi & Pakianathan, 2018).

Cross-cultural communication is also called intercultural communication. It involves basic elements of communication. This includes specific language, openness, and awareness. It promotes inclusion and breaks down barriers. The goal is to change how language is delivered across various backgrounds (Aririguzoh, 2022).

Effective cross-cultural communication can lead to increased cultural competence. Many healthcare providers can use the LEARN model to increase competence, enhance communication, and improve the quality of care.

Listen: Assess the patient's understanding of health and disease.

Explain: Discuss health without bias and be open-minded to others' understanding of health.

Acknowledge: Respect the differences in views and perspectives.

Recommend: Make a care plan through understanding and collaboration.

Negotiate: Work together with the patient (Ladha et al., 2018).

There are different models of care used to guide cultural competence.

Leininger's Cultural Care Diversity and Universality Theory and the Sunrise Model

This is focused on the idea that cultural heritage and customs are important to each group. The Sunrise Model uses this theory to focus on patient care in a global environment. It includes the different parts of culture and their relationships (Leininger, 2002).

Giger and Davidhizar's Transcultural Assessment Model

This model is based on six areas (Giger & Haddad, 2021). It focuses on the idea that although many cultures are different, they share important factors.

• Communication: What language is spoken? How is silence used? What non-verbal forms of communication are used?
• Space: What is personal space? Notice body movements during conversations.
• Social Organization: Look at gender, geography, socioeconomic status, ethnicity, family role, religion, age, and life cycle status.
• Time: How is time used? How important is time? Is there more focus on the past, present, or future?
• Environmental controls: What are current health practices? What is the definition of health and illness?
• Biological variations: Risk of disease, food and drink preferences, support, and coping.
• Cultural uniqueness: Place of birth, race, and length of time in the country.

The Purnell Model for Cultural Competence

This is an assessment tool used in many areas of care. The model has its roots in many different domains (Purnell, 2002). It is drawn as a circle. Society is the outer ring, community is the second ring, family is the third ring, and the inner ring is the person. There are 12 domains used as guides in the assessment. These are (Purnell, 2002):

1. Heritage: Origin, residence, politics, education, and occupation.
2. Communication: Language, time, names, touch, facial expression, body language, and eye contact.
3. Family role and organization: Structure, gender, and roles.
4. Workforce: Language barriers, dominant culture, and secondary culture.
5. Biocultural ecology: Biological and physical characteristics.
6. High-risk behaviors: Safety, alcohol, and drug use.
7. Nutrition: Common foods and rituals.
8. Pregnancy and child-rearing: Fertility practices, views on pregnancy, and birthing.
9. Death: Rituals and grief.
10. Spirituality: Religion, the meaning of life, and prayer.
11. Healthcare practices: Traditions, beliefs, and barriers.
12. Healthcare practitioner: Perceptions, gender, and healthcare status.

Campinha-Bacote Model of Cultural Competence in Healthcare Delivery

The five constructs associated with this model are important to define and incorporate into practice (Campinha-Bacote, 2002).

• Cultural awareness: This involves self-examination of one's own professional and cultural background.
• Cultural knowledge: This is getting information and education about diverse ethnic and cultural groups.
• Cultural skill: This is the ability to gather information about a patient's symptoms or problem. This also means being able to do a physical assessment.
• Cultural encounters: This is where the provider takes part in interactions that are cross-cultural with people from diverse cultural backgrounds.
• Cultural desire: This is the motivation to want to engage in cultural awareness, knowledge, skills, and encounters.

There are many other models that providers can use for guidance or incorporate into care.

Providers should make a safe environment for patients to feel comfortable. There have been reports of negative experiences by the LGBTQ+ community. It has mostly involved unequal treatment and homophobia.

LGBTQ+ is commonly used to represent all gender or sexual minorities. This can include asexual or intersexual subgroups (Pakianathan et al., 2016).

The LGBTQ+ meaning has changed. Providers should keep up with the newer terms. The following are definitions of terms (Human Rights Campaign Foundation, 2023):

• Asexual: This is a complete or partial lack of sexual attraction or lack of interest in sexual activity.
• Bisexual: Someone who is attracted to both genders.
• Cisgender: This person recognizes their gender as the same gender they had assigned at birth.
• Homosexual or gay: Someone who is attracted to the same gender.
• Intersex: Someone who is born with variations in sex characteristics that do not fall into the typical description of a male or female body. This refers to someone whose anatomy is not exclusively female or male.
• Lesbian: This refers to a woman who is attracted to another woman.
• Pansexual: A person who is attracted to people of any gender or sexual orientation.
• Questioning: This refers to someone who is questioning their gender or sexual orientation.
• Transgender: This refers to someone whose gender differs from the gender at birth.
• Transitioning: A series of processes that some patients who are transgender may undergo to live more fully as their true gender. This typically includes social transition, such as names and pronouns; medical transition, which may consist of hormone therapy or surgeries; and legal transition, which mainly includes changing the legal name and sex on documents.

LGBTQ+ communities face inequalities in healthcare delivery. This includes sexual health, mental health, and substance use. Providers who are competent in cultural awareness are critical to bridge the gaps in care (Pakianathan et al., 2016).

Sexual health is very intricate in the lives of the LGBTQ+ community. Until 1990, homosexuality was considered a mental illness. Then, it was declassified by the WHO (Hegazi & Pakianathan, 2018).

People in the LGBTQ+ community may fear talking about their sexual orientation. This can lead to higher rates of sexually transmitted diseases (STDs) (Hegazi & Pakianathan, 2018). Some people in the LGBTQ+ community still get attacked if they display affection publicly. There is still bullying and poor access to healthcare among the LGBTQ+ communities. This is especially true in poorer countries (Hegazi & Pakianathan, 2018).

People who are LGBTQ+ have higher rates of suicide, anxiety, depression, and drug or alcohol use (Hegazi & Pakianathan, 2018). The cause of the increased health disparities is very complex.

Our Nation is a vessel for many ethnic nationalities. They each have their own subculture and ideas on healthcare. Providers have a responsibility to care for various individuals with different ethnic backgrounds and cultural beliefs. Cultural competence is important in healthcare. It is an ongoing process of learning, advocating, and understanding. Conflicts need to be identified, as well as an awareness of how one's own ideas can impact care. Providers should seek out resources to better understand how to care for a diverse patient population.

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