Learning Outcomes
By the end of this section, you should be able to:
- 24.2.1 Describe the Promoting Cultural and Linguistic Competency Self-Assessment Checklist for Personnel Providing Primary Health Care Services.
- 24.2.2 Identify the components of the ACCESS model.
- 24.2.3 Use the ACCESS model as a framework to deliver transcultural nursing care.
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.
Promoting Cultural and Linguistic Competency Self-Assessment Checklist
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:
- Creating a welcoming environment
- Communicating effectively across cultures
- Conducting a cultural self-assessment
- Understanding and applying cultural knowledge
- Engaging in cross-cultural interactions
- Advocating for culturally and linguistically competent practices
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.).
Promoting Cultural and Linguistic Competency Self-Assessment Checklist
Visit this link to the National Center for Cultural Competence checklist, complete a self-assessment, and then respond to the following questions.
- How has this self-assessment influenced your understanding of cultural differences? Can you identify any specific insights you gained?
- What additional tools or resources do you think could complement this assessment?
- Have you uncovered any preconceptions or biases that you were previously unaware of? How will you address these in your professional development?
- In what ways have you identified areas for personal growth regarding cultural and linguistic competency? What steps do you plan to take to improve in these areas?
Creating a Welcoming Environment
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:
- Introducing oneself and asking how the client prefers to be addressed, including name and pronouns
- Using professional interpreters or language services to communicate effectively with clients who have LEP or speak a different language
- Displaying posters, brochures, and other materials that represent the diversity of the client population
- Providing information about the client’s rights and responsibilities in multiple languages and formats
- Asking about the client’s cultural beliefs, practices, and values related to health and illness
- Providing accommodations that meet the client’s specific cultural and linguistic needs, such as dietary restrictions or prayer times
- Avoiding assumptions or stereotypes based on the client’s race, ethnicity, or cultural background
- Being aware of one’s own cultural biases and seeking to understand the client’s perspective
- Creating a safe and supportive environment that promotes trust and open communication between the client and health care provider
- Assessing if the physical environment is welcoming and accessible to all clients, including those with disabilities
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.
LGBTQIA+ People Talk About Their Experiences Accessing Health Care
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.
- What are some reasons individuals who identify as a member of a LGBTQIA+ group, including transgender people, might not be accessing health care?
- When a health care professional misgenders a client, what does it communicate to that client?
- As a nurse, how can you create a welcoming environment for transgender clients?
- What trainings do you think would help nurses provide culturally safe care to LGBTQIA+ clients?
For more information on nursing advocacy for LGBTQIA+ populations, read Nursing Advocacy for LGBTQ+ Populations from the American Nurses Association.
Communicating Effectively Across Cultures
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.
Being a “cultural broker”
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.
- How would you define the role of a cultural broker?
- How does this role contribute to effective communication between different cultural backgrounds?
- Can you think of a situation in your own life where a cultural broker might have been helpful? How might the outcome have been different with a cultural broker involved?
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).
Conversations About Culture
Culture, Language, and Health Literacy
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.
- Why is effective communication as important to health care as clinical skills?
- How does cultural competence contribute to health equity?
Conducting a Cultural Self-Assessment
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:
- Values and Belief Systems
- Cultural Aspects of Epidemiology
- Clinical Decision-Making
- Life Cycle Events
- Cross-Cultural Communication
- Empowerment/Health Management
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.
Understanding and Applying Cultural Knowledge
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.
Case Reflection
Applying Cultural Knowledge
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.
- How did Emily’s actions in understanding Korean cultural norms and beliefs align with the CLAS standards for culturally responsive care?
- Why is it beneficial to actively involve family members, like Nari, in the care plan of a client from a different cultural background? How does this contribute to providing culturally responsive care?
- Discuss the importance of maintaining respect for client preferences, such as modesty, during physical assessments when providing culturally responsive care.
Advocating for Culturally and Linguistically Responsive Practices
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:
- Provide training and education to nurses and other health care providers: Health care organizations can provide cultural competency training and education to their staff to increase their understanding of different cultures, values, beliefs, and practices. This can include training on how to communicate effectively with clients who have LEP, as well as education on cultural diversity and sensitivity.
- Use interpreters: Health care organizations can ensure that clients with LEP have access to qualified interpreters. This can include in-person interpreters, telephone interpreters, or video interpreters, depending on the needs of the client.
- Use translated materials: Health care organizations can provide translated materials in languages commonly spoken by the client population they serve. This can include client education materials, consent forms, and other important documents.
- Engage with community organizations: Health care organizations can partner with community organizations to better understand the health care needs of their client population. This can include collaborating with community leaders to develop culturally appropriate outreach and education programs.
- Collect and analyze data: Health care organizations can collect and analyze data on the cultural and linguistic needs of their client population. This can help identify areas where improvements can be made and inform targeted interventions to address disparities.
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.
The Roots of Health Inequities
The Cultural Roots of Health Inequities
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
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.
Components of the ACCESS Model
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:
- Communication is a critical component of delivering transcultural care. Nurses must be aware of and use the cultural communication norms of the client, both verbal and nonverbal, to ensure effective communication.
- Cultural negotiation and compromise involve being aware of cultural differences and understanding how the client perceives the health care issue. This can help nurses and other health care providers tailor care plans that are respectful of the client’s beliefs and values.
- Establishing respect and rapport is vital for clients to maintain their dignity. When health care providers show respect for the client’s culture and beliefs, the client is more likely to have trust in the health care provider, especially during times of crisis.
- Sensitivity involves demonstrating sensitivity toward clients during interactions with health care providers. This includes using terms that clients understand to explain their health situation and trying to understand their needs pertaining to their culture and beliefs.
- Safety is the idea that health care providers should not engage in any action that disrespects the client’s culture, which could cause the client to feel culturally unsafe. This component emphasizes the importance of cultural sensitivity and respect in delivering effective health care services.
Using the ACCESS Model as a Framework to Deliver Transcultural Nursing Care
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. |
Case Reflection
Applying the ACCESS Model
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.
- How did Emily’s approach to establishing mutual goals with Hyeon’s family align with the CLAS standards for culturally responsive care? Provide at least one specific example to illustrate your answer.
- What specific aspects of Hyeon’s needs might be included in Emily’s comprehensive assessment, and how did this assessment contribute to providing culturally responsive care?
- Explain the role of trust building and rapport in providing effective, culturally responsive care for clients like Hyeon, and provide specific examples of how Emily’s approach helped to build trust and rapport with Hyeon.