Diversity and Cultural Competence in Health Care

A Systems Approach

Janice L. Dreachslin, M. Jean Gilbert, Beverly Malone

• Publisher: Jossey-Bass
• Year: 2012
• ISBN:
  9781118282168
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Major changes are occurring in the United States population and the nation's health care institutions and delivery systems. Significant disparities in health status exist across population groups. But the health care enterprise, with all its integrated and disparate parts, has been slow to respond. Written by three nationally known scholars and experts, Diversity and Cultural Competence in Health Care: A Systems Approach is designed to provide health care students and professionals with a clear understanding of foundations, philosophies, and processes that strengthen diversity management, inclusion, and culturally competent care delivery.

Focusing on current practice and health care policy, including the recently passed Patient Protection and Affordable Care Act of 2010 (ACA), this textbook integrates strategic diversity management, self-reflective leadership, and the personal change process with culturally and linguistically appropriate care into a cohesive systems-oriented approach for health care professionals. The essentials of cultural competence and diversity management covered in this text will be helpful to a wide variety of students because they encompass principles and practices that can be realistically incorporated into the ongoing work of any health care field or organization.

Each chapter contains learning objectives, summary, key terms, and review questions and activities designed to allow students to understand and explore concepts and practices identified throughout the text.

PART ONE

THE DIVERSITY IMPERATIVE

The chapters in Part One provide background and context for the systems approach to cultural competence and diversity management in health care. They supply a rationale for health care services designed to meet the needs of a diverse population. In Chapter One, “Systems Approach to Cultural Competence,” we explain the unifying systems concept as it is applied to health care. The authors see cultural competence and diversity management, integrated into a systems approach, as critical to meeting the health care challenges of the nation’s diverse population. Although the United States rightly considers itself one people, there is significant diversity within the population, and this diversity has implications that affect the way health care is structured and delivered. We discuss several important dimensions of diversity and address the unfortunate reality that there are serious disparities in health care access and status that divide the nation’s diverse groups. Major changes in how health care services are conceptualized and delivered are taking place, and we briefly point out how cultural competence and diversity management integrate these changes.

In Chapter Two, “Systematic Attention to Health Care Disparities,” the term disparities is clarified. In-depth attention is then given to the kinds and degrees of health care disparities that are visible throughout segments of the nation’s population. After a long period of inattention to the nature of these disparities and their consequences, the health care establishment, private philanthropy, and government agencies are gearing up to address them with data, legislation, and new strategies of care. We discuss how collecting data on the characteristics and health of patient populations is important for all health care organizations and emphasize its use as a driver for changing health care approaches. Organizations that are implementing data-driven strategies are described, as are some of the tools that have been developed for collecting and using data about diverse groups.

A diversifying population means a diversifying labor force, and Chapter Three, “Workforce Demographics,” addresses significant changes in the nation’s workforce as minorities become majorities in many parts of the country. The health care workforce is a major sector of the US labor force, and its complex structure of many different kinds of professionals, support, and service staff is reviewed in this chapter. Majority and minority groups are integrated differently in health care’s hierarchical workforce structure, and the reasons for and implications of this are significant when it comes to the nation’s being able to provide culturally appropriate care and reduce health disparities. Additionally, we point out that such a diverse workforce, with its many occupational specialties and levels as well as its racial, ethnic, age, and gender composition, offers many performance challenges to management. Group identity has important social meaning for persons inside and outside groups, and these meanings are reflected in constructive and destructive workplace behavior. We make clear that the need for informed diversity management, with its emphasis on inclusion, opportunity, and equity, is critical.

CHAPTER 1

SYSTEMS APPROACH TO CULTURAL COMPETENCE

LEARNING OBJECTIVES

• To clarify what is meant by a systems approach
• To define key terms including diversity, cultural competence, disparities, and strategic diversity management
• To describe the dimensions of diversity that will be discussed throughout this text
• To gain an understanding of health care disparities in the United States
• To become familiar with essential systems approaches to cultural competence and reducing disparities
• To characterize the relationship between strategic diversity management and culturally competent health care delivery

Fundamentally, a system is a structure of interconnected people, policies, and practices designed to work in concert to achieve a common goal. The systems approach is the process of considering how different parts of the whole structure influence and integrate with each other and viewing problems in a system as affecting the system overall. Component parts of a system can best be understood in the context of their relationships with each other. In a well-integrated, smoothly functioning system, each part contributes to the achievement of the goals for which the system was put into place. In the case of the health care system in the United States, the goal is a high level of health within the nation’s population. Thus, this system can be said to be a preventive and curative system. It is also, most important, a major employment system and a key business system. The health care system is an “open system”; that is, elements from outside the system in its environment are constantly affecting and being admitted to the system. In other words, there are transactions across the external and internal boundaries of the system. As this occurs, a well-designed system includes feedback mechanisms so that those operating the system can assess, evaluate, and readjust its structure and processes, enabling it to continue to meet its goals. In this book, we view diversity within the population and disparities in health care access and treatment as factors with which the US health care system must successfully adjust in order to meet its goal of good health for the overall population rather than just segments of the population.

Cultural competence is a major strategy for helping the system successfully meet the challenges of diversity and disparities. From its initial conceptualization in health care, cultural competence was seen as an essential systems component. Cross, Barzon, Dennis, and Issacs (1989) defined it as “a set of congruent behaviors, attitudes and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” (p. 2). Another excellent definition of cultural competence put forth by the National Quality Forum (2008) is “the ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient and family centered, evidence based and equitable” (p. 3). Cultural competence incorporates all of the strategies and practices needed to work effectively with patients from diverse groups based on an understanding of their beliefs, values, and social milieu. We take the position in this book that by systematically integrating the philosophy and practices of cultural competence and diversity management into the processes, transactions, and structures of the health care system, appropriate care for diverse groups and the elimination of disparities could better be accomplished and the goal of good health care across the nation more completely realized.

Figure 1.1 is a visual representation of the authors’ overall conceptualization of a systematic approach to the development of cultural competence and diversity in health care, moving from a rationale for the development of cultural competence in health care, to the adoptions of appropriate attitudes, skills, and knowledge, then to an application of those capabilities in service delivery, and finally to the use of organizational leadership and strategic diversity management to create well-functioning, diverse organizations able to provide appropriate health care to all populations.

FIGURE 1.1 Systematic Approach to Development of Cultural Competence

This first chapter provides an overview of the seven key dimensions of diversity that will be considered in this book as well as the roots of diversity in the United States. In this text, the term diversity refers to differences that make each person or group unique when compared with other persons or groups. Our individual uniqueness is driven by the groups we are identified with, such as race and ethnicity, socioeconomic status, gender, age and generation, sexual orientation, and religious preference, and also by what our identity groups mean to others and ourselves. Diversity is important in health care because what patients, caregivers, families, and health care organizations believe about key diversity dimensions affects how patient care is structured and delivered and how the health care work force is managed. And the United States is changing: not only are we becoming more diverse across multiple dimensions of diversity but our attitudes toward diversity are also evolving. In this chapter we review the diversity demographic trends for the seven key dimensions of diversity that have special implications for health care and are referenced throughout this text: race and ethnicity, gender, sexual orientation, age, language, socioeconomic status, and religion (see Table 1.1). The first three dimensions of diversity are personal, almost immutable, qualities of personhood; the last four are important social variables that create diversity among people, crosscutting the immutable dimensions and contributing to diversity within them. A moment’s reflection also will tell us that these dimensions of diversity frequently overlap and interact with each other and intersect with the health care system in many complex ways. This complexity will be addressed in this book many times over.

TABLE 1.1 The Seven Dimensions of Diversity

Immutable Dimensions of Diversity	Crosscutting Dimensions of Diversity
Race and ethnicity	Age
Gender	Language
Sexual orientation	Socioeconomic status
	Religion

This chapter next introduces the critical issue of health care disparities across diverse population groups in the United States. The glaring disparities in access to health care and levels of treatment quality experienced by different groups in the United States is a significant societal problem that can be addressed only through careful assessment of diverse needs and the structuring of appropriate and systematic health care delivery.

Several new approaches to the creation of health care delivery systems that require culturally competent care will be briefly introduced, including evidence-based care, medical homes, person-centered health care, and interdisciplinary professional teams. Cultural competence is seen as an important factor in needs assessment and the creation of appropriate personalized care.

Finally, it is clear that the changes needed to create and implement more systematic and culturally competent health care policies and practices will not take place without the informed management and leadership of health care professionals and policy makers. The chapter ends by urging students to take up the challenge of leadership in the creation of health care systems and organizations that truly meet the needs of all the nation’s residents.

DIMENSIONS OF DIVERSITY

The following section examines each of the dimensions of diversity in depth so that when the terms are used throughout the book, the reader will understand exactly what is meant by each term.

Ethnicity and Race

The growing attention to diversity and cultural competence in health care has been in great part driven by the United States’ increasing racial and ethnic diversity and by the fact that health care access and quality of care differ substantially across diverse groups, resulting in critical differences in health status (Smedley, Stith, & Nelson, 2002). The 2010 Census confirmed that, by the middle of this century, the United States will be a majority minority nation; less than half of the population will be non-Hispanic white (Mather, Pollard, & Jacobsen, 2011). Cultural or ethnic groups are not the same as racial groups, though culture and race are both aspects of human diversity. An ethnic group is defined by its culture; it is a group of people whose members identify with each other through a common language, behavioral norms, worldview, history, and ancestry. Culture, like language, is learned, not biologically inherited. An ethnic group is also generally...