Valuing Cultural Competence in the
Delivery of Health Care Services
University of South Florida
College of Nursing
Tampa, Florida
October 14, 2009
Time: 9:00am-1:00pm
Managing Cultural Competence in the
Delivery of Health Care
To provide participants from the College of Nursing with experiential and practical applications
that will enable nursing and other health care professionals to bridge existing gaps in crosscultural interactions with ethnically and racially diverse patients and consumers in the USF and
Greater Tampa Bay communities.
What is Cultural Competence?
Why is Cultural Competence necessary in the delivery of
health care?
What are the benefits to be derived from using the case
study method in learning about Cultural Competence?
What Cross Cultural values should drive nursing
Which issues and strategies are research based?
What are the benefits to be derived from the use of a
Cultural Assessment regimen by nurses and health care
© 2009, P.C. Coggins & Associates
Managing Cultural Competence in the
Delivery of Health Care
Understand the concept of Cultural Competence, specifically, the new CDC definitions which include the
following Four Elements: 1) Cultural Diversity Awareness, 2) Culturally Competent Behaviors, 3) Cultural
Sensitivity, and 4) Cultural Assessment (Coggins, CDC).
Apply experiential strategies that will increase the participants’ understanding of the practical
application of:
Culture through semantic mapping (Leahy).
Commonalities vs. Differences through the Venn Diagram (De Anda).
Engage in experimental activities that apply innovative Cultural Assessment methods that are grounded
in Culturally Competent Behaviors and Perspectives.
Review the seven (7) levels of Cultural Competence and their relevance to the delivery of Health Care.
Understand cross-cultural issues with respect to: a) Cultural generalizations about ethnic groups, b)
Being adept to changing generalizations about ethnic groups, and c) Practical strategies to enjoy
responsive interactions with cross-cultural and cross ethnic patients/clients.
Focus on the barriers to Culturally Competent Services.
Build an authentic Cross-Cultural Communication system that supports Cultural Competence in the
Understand the application of validated strategies through the use of relevant case studies that are
appropriate for health care settings.
Other topics agreed on.
Cultural Empowerment
Cultural Proficiency
Culture Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destructiveness
Cultural Competence and Its Implications
for Nursing Education
 Cultural Competence Definitions
 Cultural Destructiveness:
Forced assimilation
 For dominant groups only the
Create uneasiness, disconnect and are destructive to
the cultural group.
Cultural Competence and its Implications for
Nursing Education
 Cultural Incapacity:
inability of systems to respond to the
needs, interests, and preferences of culturally and linguistically
diverse groups.
 Institutional or systemic bias; practices of discrimination
in hiring and promotion; disproportionate allocation of
resources that may benefit one cultural group over
 Subtle messages that some cultural groups
are neither valued nor welcomed;
 Lower
expectations for some cultural, ethnic, or
racial groups.
Cultural Competence and its Implications for
Nursing Education
Cultural Blindness:
 Differences ignored, “treat everyone the same”
 Only meet needs of dominant groups.
 Focus on assimilation ignores cultural strengths
 Blaming the victim
 Little value placed on training and resources that
enhance cultural and linguistic competence.
 Workforce lack diversity are recognition of culture’s
perception and response to disease and illness.
Cultural Competence and its Implications for
Nursing Education
 Cultural Pre-Competence: Refers to the
willingness to explore cultural issues
 Assess needs of organization and individuals
for effective cultural and linguistic resources
 Hiring practices that support diverse
 Token representation on going boards,
administrative positions
 No clear plan to achieve individual and
organizational cultural competence.
Cultural Competence and its Implications for
Nursing Education
 Cultural Competence: Refers to the
organization recognizing individual
and cultural differences
 seek advice from diverse groups, hire
culturally unbiased staff:
Creates a mission statement for focus on
cultural and linguistic competence in all
parts of organization.
Adapts evidence based promising
practices that are culturally and
linguistically competent.
Supports a common definition of cultural
and linguistic competence.
Cultural Competence and its Implications for
Nursing Education
Cultural Proficiency: Implement changes to
improve services based upon cultural needs, do
research and teach staff new approaches to being
culturally and linguistically competent.
Cultural Competence is integrated and held as a
core value in the organization.
Develop and publish core values that support
cultural and linguistic competence.
Develop and publish all health promotion
materials and communications that are sensitive
and adapted to the cultural and linguistic needs
of the population served.
© 2009, P.C. Coggins & Associates
The ultimate level is Cultural Empowerment
 Cultural Empowerment is reflected in a
philosophy that the student/staff is a co-equal
partner in the educational and learning process.
 The organization’s Cultural Proficiency is
actualized in intake, assessment, treatment
planning, treatment process and treatment
completion and follow up:
© 2009, P.C. Coggins & Associates
The student/individual is consulted at every phase of
the learning interaction/process.
The individual sees the integration of his/her culture
and linguistic needs and attributes in learning,
advising and social processes.
The individual is empowered to initiate and integrate
cultural concerns in learning, classroom, advisory and
social processes.
The individual respects and actively supports the
infusion of his/her culture and linguistic dimensions
in the learning, advising and social processes.
The interaction is characterized but mutual respect ,
mutual praise, acceptance of differences, recognition
of similarities and mutual striving to achieve one’s
best potentials through empowerment.
Organizations mission, policies and procedures reflect
cultural empowerment
Cultural Competence and its Implications for
Nursing Education
Advocate on behalf of the diverse populations
served by the
University organization.
Maintain partnerships with diverse groups in
education, health,
and community based and racially diverse organization.
Integrates as part of client assessment an assessment of the cultural
background and
dynamics of the client (Coggins & Bell, 2007
Progress in maintaining cultural and linguistic
competence is
discussed at each policy advisory and teaching decision making process.
© 2009, P.C. Coggins & Associates
Cultural Competence and its Implications for
Nursing Education
Institutes cross cultural hiring and staff
development in cultural competence.
Consumers begin to see and feel the
presence of cultural and linguistic
competence through sign (s), publications,
interactions with the staff.
Continuous assessment of infusion of
cultural competence in all operations.
Collect and analyze data using variables
that impact on culturally and linguistically
diverse groups.
The Cultural Competence Continuum in
Nursing and Health Care Practice
*Cultural Empowerment
added by Coggins
(Cross 2002, Coggins 2007)
© 2009, P.C. Coggins & Associates
1. Fold the paper and make four
separate parts.
2. Close your eyes and use only one
piece of paper. Using your Magic
Marker or pen, please draw
yourself with your eyes closed.
3. Now, get a second paper and
draw yourself with your eyes
4. Now, close your eyes once more
and listen for the ethnic group
you are asked to draw.
© 2009, P.C. Coggins & Associates
Exercise 2: What is Culture?
“Culture represents the histories, attitudes, behaviors, languages,
values, beliefs and uniqueness, which distinguishes each racial or
sub-cultural group in a society. Each of us has a historical heritage
and a contemporary heritage that comprises our present culture.”
(Coggins, 2004)
Definition of Culture
Please define in your own words the term of culture and indicate
what values are expressed in the definition.
© 2009, P.C. Coggins & Associates
Exercise 3: Understanding Culture
Let us complete a concept map
 Native American Culture
 Question – By changing the center what happens?
Task 1:
 Using the sheet of paper, map or web the concept of Native American Culture.
 Please put the word Native American Culture in the center of the paper.
 Review your concept map and check to see if you have at least seven elements of the
Task 2:
 Now working in groups, concept map the term Native American Culture by combining
all of the elements and information developed by each member of the group.
Task 3:
 Select a reporter to share the results of the group.
Task 4:
 In the space provided below reflect on what you have learned about the role of
provider with respect to understanding diverse cultures.
© 2009, P.C. Coggins & Associates
Exercise 4: Defining Cultural
Please write your definition of Cultural Competence!
• Then! Join a group of six individuals and come up with a group definition of
Cultural Competence.
• Post your group’s Definition on the news print and be prepared to share your
definitions with the group.
Group’s Definition of Cultural Competence
© 2009, P.C. Coggins & Associates
Exercise 5: Assessing Your
Cultural Competence
Model Your Commitment to Culturally Competence By:
1. Including Ethnic Content in the Nursing School Curriculum?
2. Teaching about major Cultures across the Nursing
3. Having Celebrations that include all Cultures?
4. Using Diverse Language in all Nursing School
communication ?
5. Focus of Cultural Competence in the policies and
procedures of the College of Nursing.
6. Retention focuses on relevant culture issues of patients/
7. Has in place and monitors a mechanism for resolving
interracial and intergroup complaints and conflicts.
Subtotal =
© 2009, P.C. Coggins & Associates
Exercise 6: Group Questions
1. What key concepts should be considered in
enhancing the Cultural competence of the Nursing
Educator/Nursing Professional?
2. What key concepts and words can be used in the
development of an assessment instrument in
“Cultural Competence?”
© 2009, P.C. Coggins & Associates
Exercise 7: Developing an Assessment
Instrument for Cultural Competence
Task 1: Working in your groups of 6 and using the information you
have learned thus far, please develop five questions that you would ask
to get deeper into the culture of the patient/student.
Task 2: List Questions that you would include in assessment of the
Activity 1: Be prepared to post your questions on the newsprint.
2: Select a member of your group to share the information
with the entire group.
© 2009, P.C. Coggins & Associates
Exercise 8: Practical Application of the
Assessment Process
Task 1:
Now that you have developed an instrument with
questions that you believe are relevant and
valuable, now move to the next task.
Task 2:
Role play by selecting one person being the a)
Nurse/Professional, b) One person the
Task 3:
The remaining members of the group must keep
time and provide feedback on how long the role
players took to cover the assessment questions.
Task 4:
The other group members should take turns to
experience the assessment process as either a)
Nurse/Professional b) Patient/Client/Student.
© 2009, P.C. Coggins & Associates
Facilitator’s Processing of
Assessment Play
The Facilitators will explore the following Questions/issues:
1. How long did it take to complete each role pay using the
five questions?
2. What was the shortest time recorded?
3. What did each participant learn about assessing the deep
culture of an individual?
4. Any other comment and feedback from the participants.
Final Note from Facilitator
The ultimate goal is to develop the habit of assessing and
knowing the student’s (staff’s) cultural background.
 Rationale: Dr. Coggins taught a student for one (1)
semester after which he assessed the students culture and
discovered she was a “Seneca Indian member”. The
student said, “It would have been nice if I knew that fact
and included her culture in the content of the class”. For
example, the inclusion of the Iroquois Nation’s contributions
towards our US Constitution.
© 2009, P.C. Coggins & Associates
Summary of Components Which
Comprise the Definitions
1. Cultural Diversity Awareness – Acquisition of knowledge of
the history and cultural characteristics of diverse groups
(your patient/client/student).
2. Cultural Competent Behaviors – Habit of exhibiting
appropriate behaviors with diverse individuals/groups.
Always relevant and positive actions – Just Do It – Beyond
Saying it.
3. Cultural Sensitivity – Be flexible, kind, non-harsh, non
discriminatory- driven by genuine respect for the
patient/client/student. (Feeling a sense of being cared for)
4. Cultural Assessment – To assess cultural needs of the
client/student by asking appropriate questions, using data to
enhance the treatment and services of patients/clients.
© 2009, P.C. Coggins & Associates
Exercise 9: Culturally Related
Please answer the questions as briefly and concisely as possible by jotting down areas,
concepts, or topics. “I would consider myself as a ‘Culturally Competent’ person
because I…”
Supervisor/individuals/nurses and University staff could increase their “Cultural
Competence” by developing or enhancing the following skills:
The College of Nursing in the University I work for can ensure Cultural Competence
between supervisors and workers, and with patients/clients/students by:
© 2009, P.C. Coggins & Associates
The Mulatto: What are the
Jane, who is a very smart and friendly 20-year-old woman was experiencing
severe depression, pains in her chest, and anxiety. She was told by her
supervisor to, “stop acting up and take time off to straighten out her
behavior... no more outbursts will be tolerated!” So her mother encouraged
her to go to the hospital for help. Upon arriving at the hospital, Jane was
asked by the nurse, “in case of an emergency, who should we contact?”
Jane said, “my mother who is standing right here next to me.” The nurse
said, “are you sure this is your mother? She is black and darker than you.”
Upon hearing the nurse’s comment, the mother was annoyed and
demanded to see the supervisor or the doctor. The doctor came out and
inquired about what was going on. The doctor shouted, “can’t you people
conduct yourself properly?” Jane blurted, “we are fine, the problem is with
this clerk who refuses to take down the information I provided about my
mother!” Sensing a problem, the doctor said, “take the woman’s information
down, okay?” The nurse did, and Jane’s mother strolled off to the waiting
© 2009, P.C. Coggins & Associates
The Mulatto: What are the
Answer the following questions:
1. What were the cultural competence issues that were raised in this case?
2. What were the cultural needs of Jane and her mother?
3. What behaviors would have been more culturally sensitive and
appropriate for caregivers?
© 2009, P.C. Coggins & Associates
How to Heal
You are a caregiver. A middle-aged Korean woman with chronic back
problems is admitted into your hospital. She speaks little English. Her
husband speaks English and translates for her. When the husband is present,
the patient denies pain. when the husband leaves the room, the patient
admits to having pain.
You believe that the husband has little faith in the U.S. medical community.
The husband says that he believes that pain medications interfere with the
patient’s body’s “natural healing process” and he places the pain medication
out of the patient’s reach. Instead, he provided his wife with herbal teas to
help her “heal.”
You want to help the patient be more comfortable, but can’t get her to
acknowledge the pain in her husband’s presence. You feel that the husband
has no clinical experience to dictate how his wife should handle her pain.
© 2009, P.C. Coggins & Associates
How to Heal: Questions
1. What are the issues from the patient’s perspective? From the husband’s
2. What are the possible “cultural” issues in this case?
3. Brainstorm how you could handle this situation more effectively.
4. How does the use of the husband as an interpreter impact the situation?
A 19-year-old Hmong Male
A 19-year-old, English-speaking, Hmong college student,
born and raised in the United States to Hmong immigrant
parents, developed progressive liver failure requiring a
liver transplant. He agreed to be placed on the transplant
waiting list, but his family members, when presented with
this information, rejected his decision, saying, “If you
have this transplant, you will no longer be our son!”
© 2009, P.C. Coggins & Associates
A 19-year-old Hmong Male
Answer the following questions:
1. What is your first reaction to this scenario?
2. Think about how you would proceed with this patient. What would you
recommend in this case?
© 2009, P.C. Coggins & Associates
Exercise 10: Processing the
Case Studies
Basic Cultural Competence Principles
 1. One size does not fit all.
 2. Focus on Differentiated Cultural Interventions.
 3. Assessing the Cultural Background to Find out the root causes and perception of
 4. Using Best Practices to determine
 5. Any other observations and comments.
Facilitator’s Note: The College of Nursing is encouraged to Build Cultural Competence among staff by
using the “Case Method” to discuss and explore common solution to creating a culturally competent
school and clinic.
© 2009, P.C. Coggins & Associates
Exercise 11: Examination of the Racial/Ethnic Gap
Between Minority and Majority Groups
Why does this gap exist among ethnic groups in the USA in our
nursing schools/departments/colleges?
Note: Culture is everything; we need to understand that
humans have commonalities as well as differences. Avoid
focusing on only differences. Also recognize the
commonalities we share as humans.
© 2009, P.C. Coggins & Associates

Valuing Cultural Competence in the Delivery of Health Care