Clinical Scholarship
Cultural Competence Among Ontario and Michigan Healthcare Providers Stephanie Myers Schim, Ardith Z. Doorenbos, Nagesh N. Borse Purpose: To examine variables associated with cultural competence among urban, hospitalbased healthcare providers in Ontario (Canada) and Michigan (US). Design and Sample: A cross-sectional descriptive design with a convenience sample of hospital-based providers was used. The sample was 145 providers (n=71 Ontario; n=74 Michigan). Methods: Providers completed a survey which included the Cultural Competence Assessment (CCA) instrument. Regression analysis was used to examine associations. Findings: Providers with diversity training and higher levels of educational attainment scored significantly higher on cultural awareness and sensitivity and on cultural competence behaviors. Conclusions: Variables significantly associated with cultural competence included prior training in cultural competency and higher educational attainment among both Ontario and Michigan healthcare providers. C 2005 SIGMA THETA TAU INTERNATIONAL. JOURNAL OF NURSING SCHOLARSHIP, 2005; 37:4, 354-360.
[Key words: cultural competence, nurses, healthcare providers, Michigan, Ontario] *
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ncreasing cultural diversity, a phenomenon in both Canada and the United States, creates the need for culturally competent healthcare. Recently noted increases in the numbers and types of different cultural groups in North America have occurred primarily by immigration. The resulting international connections at personal level, with the creation of a “global village” through rapid travel and expanding global technology, have ensured a growing interest in diverse cultures in North America. Demographic and cultural changes require that healthcare providers manage complex differences in communication styles, attitudes, expectations, and world views, as well as multiple languages (Fortier & Bishop, 2003). Beyond traditional considerations of racial and ethnic differences, issues of culturally competent care for people of different socioeconomic class, gender, or sexual orientation have become equally important (Abrums & Leppa, 2001). Providing culturally competent care has been associated with improved provider-client communications, improved compliance with medical regimens, greater satisfaction with care, and better health outcomes (Fortier & Bishop, 2003). The purpose of this study was to examine variables associated with cultural competence among urban, hospital-based health care providers in Ontario (Canada) and Michigan (US).
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Background Culturally congruent care occurs when providers and recipients of health services come together with an attitude of cultural humility and respect. They can then negotiate mutually satisfactory strategies to address health promotion, disease prevention, restoration of health, or a “good death,” as defined by the person needing care. For culturally congruent care to occur, providers need a knowledge base, attitudinal framework, and skill set to appreciate, accommodate, and negotiate cultural and individual variations in beliefs, values, lifestyles, education, and the myriad elements that comprise cultural context.
Stephanie Myers Schim, RN, PhD, Lambda, Assistant Professor, College of Nursing, Wayne State University, Detroit, MI; Ardith Z. Doorenbos, RN, PhD, Kappa Iota, Postdoctoral Fellow, College of Nursing, Michigan State University, East Lansing, MI. Nagesh N. Borse, BPharm, MS, International Health Doctoral Candidate, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. The authors thank Karyn Huenemann for her careful review of this manuscript, and Cathy Gretch and Debra Amaro for their assistance with data collection. Correspondence to Dr. Schim, College of Nursing, 240 Cohn Building, Wayne State University, Detroit, MI, 48202. E-mail:
[email protected] Accepted for publication May 31, 2005.
Cultural Competence
Assessment of nurses and other providers across the international border is useful, in part, because of the similarities and differences between Canada and the US. The state of Michigan and the province of Ontario are integrally connected by economic interdependence, exchange of goods and services, and cross-border employment patterns. However, many observable differences exist in approaches to such issues as diversity and cultural competence. The Canadian policy of multiculturalism supports integration by which both cultural heritage maintenance and full participation in the larger society are promoted (Berry, 2003). In contrast, the US has a more assimilationist approach (Taylor & Lambert, 1996). Many societal characteristics are shared, and yet the health systems in Canada and the US have evolved in very different directions. Canada has a predominantly publicly financed healthcare system which is provincially administered, comprehensive, universal, portable, and accessible to Canadians regardless of age, health status, socioeconomic status, or physical ability (Health Canada, 2002). In contrast to the Canadian “single payer” model, the US has a complex health care system that has at its core an employer-driven insurance system, operating in a context of competition and free enterprise (Robinson, 2004). Access to health services in the US is provided for those who can afford to pay, those who work in jobs that provide health benefits, those who rely on state assistance for low-income households or people with disabilities, and those who can otherwise negotiate access. In spite of the different systems for health care financing, the two countries have similar systems for health professional education and licensure, similar practice standards, and similar programs of health research. A constant and dynamic flow of both patients and providers is observed between Canada and the US across what is known as the longest unguarded border in the world. Responses to expanding diversity on the part of healthcare providers, organizations, and even federal governments have differed between the two nations. In 1982, the Canadian government passed the Canadian Charter of Rights and Freedoms, which formally recognized the equality of all Canadians, irrespective of race, ethnicity, language, or religion. In 1988, Canada became the first country to articulate a position on diversity in the form of national legislation. The Canadian Multiculturalism Act (CMA) is aimed at providing all citizens with equal access and opportunities to ensure that needs associated with culture are considered in decision-making processes (CMA, 1985; Majumdar, Browne, Roberts, & Carpio, 2004). In the US, the Joint Commission on Accreditation of Healthcare Organizations (JCHCO, 1994) requires healthcare providers to be “culturally competent.” The U.S. government also has presented recommendations for national standards and an outcomes-focused research agenda to assure cultural competence in health care (Office of Minority Health, 2001). Such requirements have spurred interest in increasing cultural competence among nurses and other providers.
Factors related to cultural competence in these two national systems indicates important areas of similarities and differences, and as well as possible directions for enhancement of practice, education, and research. This project was an examination of cultural competence among health providers in neighboring communities across the Canada– U.S. border.
Cultural Competence Model The cultural competence model has been described with the analogy of a jigsaw puzzle, with pieces representing important provider elements (Doorenbos & Schim, 2004.) Culture is “that complex whole which includes knowledge, belief, arts, morals, law, custom, and many other capabilities and habits acquired by man as a member of society” (Tylor, 1871/1958, p. 1). This definition is focused on attributes acquired through living in or experiencing a particular society, rather than through biological inheritance (Kottak, 2004). Leininger further defined culture as “the learned and transmitted values, beliefs, and practices that provided a critical means to establish culture-care patterns from the people” (1991, p. 36). The fusion of these definitions leads to an understanding of cultural competence as the demonstration of knowledge, attitudes, and behaviors based on diverse, relevant, cultural experiences. The four components of this model are: (a) cultural diversity, (b) cultural awareness, (c) cultural sensitivity, and (d) cultural competence behaviors. Healthcare providers are not expected to achieve complete cultural competence, but, rather, that they strive to match their competencies to the specific populations, subgroups, and individuals with whom they work. Cultural diversity is a fact in Canada and the US today. According to recent Canadian estimates, about 4.3 million people—19% of those aged 15 and older—reported being of European origin, in addition to the dominant British or French heritage. People of non-European descent accounted for 2.9 million, or about 13%. “First generation” Canadians, those who are themselves foreign-born, account for almost one-quarter (23%) of the population; not since 1931 has the proportion of population born outside Canada been this high (Statistics Canada, 2003). In the US, nonWhite groups and those of Hispanic or Latino heritage continue to gain proportionally. As of the last national census, Blacks/African Americans were counted at 34 million or 12.3% of the population; people of Asian descent accounted for roughly 2.5 million or 3.6%; and an estimated 12.5% of U.S. Census participants reported being of Hispanic or Latino origin regardless of racial background (U.S. Census, 2000). Cultural diversity is not, however, limited to differences in race and ethnicity. Both Canadians and Americans have growing awareness of the effects of differences in language, religion, gender, sexual orientation, ability and disability, and access to technology on provider-patient interactions (Fortier & Bishop, 2003). Even when a provider and patient share the same ethnic or racial heritage, other aspects of diversity remain to be addressed. Journal of Nursing Scholarship
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Cultural Competence
Cultural awareness is based on knowledge and therefore it is closely linked to education. Many efforts have been focused on incorporating cultural knowledge into healthcare curricula (Morell, Sharp, & Crandall, 2002; Warner, 2002), and increases in cultural knowledge have been reported in response to educational interventions in various practice settings (Browne, Braun, Makuau, & McLaughlin, 2002; Smith, 2001). Cultural sensitivity requires the recognition of personal attitudes, values, beliefs, and practices within one’s own culture and insight into the effect of self on others. Communication skills are reflective of a speaker’s sensitivity and require the willingness to develop and use listening skills. A sensitive speaker is also attuned to nonverbal communication (body language), careful use of silence and touch, respect for conversational distance, and appropriate tone of voice. Sensitivity influences the effective use of translators or interpreters and the handling of personal emotional issues that arise when third parties interact in healthcare situations (Purnell & Paulanka, 2003). Sensitivity toward coworkers in an increasingly diverse healthcare workforce is also important for cultural awareness and to enhance team functioning through open and respectful dialogue. Cultural competence is the incorporation of personal experience with cultural diversity (fact), awareness (knowledge), and sensitivity (attitude) into everyday practice behaviors. Competence behaviors are learned from personal exposure and experience with people from diverse groups, awareness of individual and group similarities and differences, and sensitivity to self and others. Taking action to adapt health advice and interventions to the specific needs of clients is basic to effective care.
Methods Design and Procedures A cross-sectional descriptive study was conducted to examine variables associated with cultural competence among health providers employed at three urban hospitals in Ontario and four urban hospitals in Michigan. Participants were recruited with convenience sampling. Each potential participant was approached while off-duty, at the beginning or end of a work shift, in face-to-face contact. A research assistant familiar with each of the hospitals asked that providers complete the paper-and-pencil survey and return it an unmarked envelope. To assure anonymity, participants were asked not to put names or other identifying marks on the survey forms. They were advised that participation was completely voluntary and the survey would take approximately 20 to 30 minutes to complete. An information sheet on the front of the survey indicated the study purpose and that providers could withdraw or stop at any time. Completion and return of the survey constituted informed consent. Approval for the study was granted by the university human investigation committee. Of the 231 surveys distributed, 153 were returned, 356
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for an overall response rate of 66%. Eight were eliminated for having more than 10% missing data. The final analyses were conducted on 145 surveys (Ontario, n=71; Michigan, n=74). Instruments The Cultural Competence Assessment (CCA) tool is a 26item instrument designed to measure cultural diversity experience, awareness and sensitivity, and competence behaviors. Cultural diversity experience is assessed with a single item on which respondents identify whether they have cared for people of various cultural groups in the past 12 months. The item score is a simple count of the number of groups selected, with higher numbers indicating greater diversity of experience. The combined subscale (CAS) for cultural awareness (knowledge) and sensitivity (attitude) is based on a 5-point, Likert-like response set from strongly agree (5) to no opinion (1).” The subscale for cultural competence behavior (CCB) has response categories of “always, often, at times, never, and not sure.” The items are summed for each subscale score; higher scores indicate higher levels of knowledge and more positive attitudes, and greater self-reported frequency of competence behaviors. Internal consistency reliability for the CCA has been reported in previous work at over .80, and construct, content, and face validity and test-retest reliability have been established (Schim, Doorenbos, Miller, & Benkert, 2003; Doorenbos, Schim, Benkert, & Borse, in press). In the current study, overall internal consistency reliability for the CCA was .89. The CAS subscale reliability was .76, and the CCB subscale reliability was .93. Demographic items on the CCA included questions about age, years of hospital experience, prior cultural diversity training, self-identified race or ethnicity, level of educational attainment (high school, associate, bachelors, graduate degrees), and provider discipline. Sex was not identified in this study to avoid the possibility that unique combinations of other demographic variables when combined with sex might reveal identity of participants. Analysis All analyses were done with SPSS for Windows 12.0. Level of significance was set at .05. Any case with more than 10% missing values was excluded from analysis. Maximum likelihood was used to replace random missing values (Little & Rubin, 2002). Descriptive analyses were conducted to identify participant characteristics and to evaluate assumptions for regression analysis. T tests were used to determine differences between Michigan and Ontario providers. Two regression analyses were conducted. Standard multiple regression was used to determine the amount of variance accounted for by the independent variables of (a) age, (b) years of hospital experience, (c) cultural competency training, (d) educational attainment, (e) number of diverse groups cared for in the last 12 months, (f) self-identified race or ethnicity, (g) discipline, and (h) state or province on the CAS
Cultural Competence
and CCB subscales respectively. For a medium-sized relationship, assuming an α of .05 and a β of .20, a sample size of 114 is sufficient for a regression analysis with eight independent variables (Tabachnick & Fidell, 2001). Thus the sample of 145 was deemed adequate to support the regression analyses conducted. All possible interaction terms were tested, but only significant interaction terms are reported.
Findings Descriptive analysis indicated a profile of the characteristics of the sample drawn from Ontario and Michigan providers (Table). Mean age of the Canadian respondents was 39 (SD 11.98); the U.S. respondents were slightly older (41; SD 9.19). The majority of respondents were White but included Hispanic/Latino, Black/African American, Native Indian, Asian, and Arab. The Canadian sample had greater racial or ethnic diversity; 22% were non-White compared to 15% non-White respondents in the US. A variety of health care disciplines were represented among the respondents. The majority of respondents from each side of the border were nurses: 71% in Canada and 77% in the US. Other healthcare disciplines represented were clerical workers, nutritionists, occupational and physical therapists, and others, including administrators and physicians. For purposes of analysis, discipline categories were combined to nursing and
Table. Demographic Characteristics of Respondents in Ontario and Michigan
Years in health care Age Race or ethnicity White Hispanic/Latino Black/African American Asian Other Education High school Associate degree Bachelors degree Graduate degree Missing data Occupation Nurse Clerical worker Nutritionist Therapist (occupational or physical) Other
Ontario providers n=71
Michigan providers n=74
Range 1 to 35 Mean 13 ± 10.1 Range 22 to 65 Mean 39 ± 12 n (%) 55 (78) 1 (1) 4 (6) 4 (6) 7 (9) n (%) 19 (27) 10 (14) 14 (20) 26 (37) 2 n (%) 50 (71) 4 (6) 2 (3) 3 (4) 12 (16)
Range 1 to 40 Mean 17 ± 10.2 Range 20 to 63 Mean 41 ± 9 n (%) 63 (85) 2 (3) 4 (5) 3 (4) 2 (3) n (%) 5 (7) 16 (21) 37 (51) 16 (21) n (%) 58 (77) 2 (3) 3 (4) 4 (5) 7 (11)
non-nursing, and race or ethnicity was combined to White and non-White. The two groups of respondents differed significantly in years of experience: the Michigan respondents reported an average of 4 more years of healthcare experience than did those in Canada (t(142)=2.11, p=.037). They also differed significantly in prior cultural competence training: 58% of Michigan respondents reported diversity or cultural competence training, but only 23% of Ontario respondents reported having had such training (t(141)=4.50, p
