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homework Diversity and Cultural Competency in Health Care Jean Gordon, RN, DBA LEARNING OUTCOMES After completing this chapter, the student should be able to: ☛ Define diversity. ☛ Define cultural competency. ☛ Define diversity management. ☛ Understand why changes in U.S. demographics affect the health care industry. OVERVIEW Demographics of the U.S. population have changed dramatically in the past three decades. These changes directly impact the health care indus- try in regard to the patients we serve and our workforce. By 2050, the term “minority” will take on a new meaning. According to the U.S. Census Bureau, by midcentury the white, non-Hispanic population will comprise less than 50 percent of the nation’s population. As such, the health care industry needs to change and adopt new ways to meet the diverse needs of our current and future patients and employees. The American Heritage Dictionary of the English Language (4th ed.) defines diversity as: “(1) the fact or quality of being diverse; difference, and (2) a point in which things differ.” Dreachslin (1998) provided us with a more specific def- inition of diversity. She defined diversity as “the full range of human similari- ties and differences in group affiliation including gender, race/ethnicity, social class, role within an organization, age, religion, sexual orientation, physi- cal ability, and other group identities” (p. 813). For our discussions, we will focus on the following diversity characteristics: (1) race/ethnicity, (2) age, and (3) gender. This chapter is presented in three parts. First, we discuss the chang- ing demographics of the nation’s population. Second, we examine how these changes are affecting the delivery of health services from both the patient’s and employee’s perspectives. Because diversity challenges faced by the health care industry are not limited to quality-of-care and access-to-care issues, in part three of our discussions we explore how these changes will affect the health services workforce, and more specifically the current and future leader- ship within the industry. 15 CHAPTER 2 9781284087062_CH02_PASS02.indd 15 17/02/15 6:10 PM CHANGING UNITED STATES POPULATION There is no doubt that the demographic profile of the U.S. population has undergone significant changes within the past 10 years regarding age, gender, and ethnicity (see Table 2–1 ). Data from the 2010 Census provide insights to our racially and ethnically diverse nation (Humes, Jones, & Ramirez, 2011). According to the 2010 Cen- sus, 308.7 million people resided in the United States on April 1, 2010—an increase of 27.3 million people, or 9.7 percent, between 2000 and 2010. The vast majority of the growth in the total population came from increases in those who reported their race(s) as something other than White alone and those who reported their ethnicity as Hispanic or Latino. For the first time in the 2000 Census, individuals were presented with the option to self-identify with more than one race, and this continued with the 2010 Census. Using the five race categories (White, Black/African American, American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islander) required by fed- eral agencies, there are 57 possible multiple race combinations that could have been selected by individuals in addition to “some other race.” In fact, over 7 million or 2 percent of the U.S. population did so in the 2010 Census by identifying with and choosing “some other race” or “two or more races.” It is predicted that the number of Americans reporting themselves or their chil- dren as multiracial will increase in the future. In addition to the changing eth- nic and racial composition of America, another issue is the aging population. Table 2–1 Population of the United States by Age, Gender, and Race/Ethnicity a 2000 2010 Number Percent Number Percent Total population 281,421,906 100.0 308,745,538 100.0 Under age 19 80,473,255 25.7 83,267,556 26.9 Ages 19 to 64 165,956,888 61.9 185,209,998 60.0 Ages 65 and over 34,991,753 12.4 40,267,984 13.0 Males 138,053,563 49.1 151,781,326 49.2 Females 142,368,343 50.9 156,964,212 50.8 White 211,460,626 75.1 196,817,552 63.7 Black 34,658,190 12.3 37,685,848 12.2 Hispanic 35,305,818 12.5 50,477,594 16.3 Asian 10,242,998 3.6 14,465,124 4.7 American Indian 2,475,956 0.9 2,247,098 0.7 Some other race 15,359,073 0.5 1,085,841 0.1 Two or more races 6,826,228 0.2 5,966,481 0.2 a Percentages do not add up to 100 percent due to rounding and because Hispanics may be of any race and are therefore counted under more than one category. Data from U.S. Census Bureau, 2010 Census. DP-1 - United States: Profile of General Population and Housing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data as shown in the 2009 Population Estimates table; U.S. Census Bureau: National Population Estimates; Decennial Census. 16 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE 9781284087062_CH02_PASS02.indd 16 17/02/15 6:10 PM According to the 2010 Census, 40 million people (13 percent of the U.S. popu- lation) are 65 years of age or older. This is 12.3 million more people than in 2000 (see Figure 2–1 ). During the past decade, the population aged 65 and over grew at a faster rate (15.1 percent) than the population under age 45. This trend was expected as the Baby Boomers (those born between 1946 and 1964) began reaching age 65 in 2011 (see Figure 2–2 ). In addition to the increasingly older population, there is a declining number of young people in America. From 1940 to 2010, the percentage of the Ameri- can population under the age of 18 fell from 31 percent to 24 percent (U.S. Census Bureau, 2012). This decline in America’s younger population will have a direct effect on the industry’s ability to recruit health care professionals to provide sufficient services in the future. Young people of all ethnicities must be attracted to the health care industry as a career choice in order to meet the health care needs of the country’s growing population. Males and females are almost evenly divided for the total population, rep- resenting 49.2 percent and 50.8 percent, respectively; however, in the pop- ulation under 25 years, males dominate females, with 105 males for every 100 females. Among older adults, the male–female ratio reverses, with women outnumbering men. However, there was an interesting change in the male– female ratios for the population aged 60 and older between 2000 and 2010 (Howden & Meyer, 2011). A greater increase in the male population relative to the female population for these age groups was noted. Males aged 60 to 0 65 to 74 years 2000 2010 2000 2010 2000 2010 75 to 84 years 85 years and over 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 Women Men Figure 2–1 Population 65 Years and Over by Age and Sex, 2000 and 2010 (numbers in thousands) Data from U.S. Census Bureau, 2010 Census. DP-1 - United States: Profile of General Population and Housing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data as shown in the 2009 Population Estimates table. Changing United States Population 17 9781284087062_CH02_PASS02.indd 17 17/02/15 6:10 PM 74 increased by 35.2 percent, while their female counterparts increased by 29.2 percent. A narrowing of the mortality gap between men and women at older ages in part accounts for this difference. Race/Ethnicity The U.S. population has continued to diversify during the past 10 years, as minority populations continue to increase at a faster rate than the White population. Although the White population still represents the largest group (63.7 percent) of the U.S. population, this is down from 75.1 percent in 2000 (see Table 2–1 ). In 2010, the Hispanic population represented the largest minority in the United States, 16.3 percent of the population. This is up from 4.5 percent in 1970, the first census in which Hispanic origin was identified. The remain- ing population is composed of 12 percent Black, 5 percent Asian and Pacific Islanders, 1 percent American Indians and Alaska Natives, and 3 percent those who identified themselves as belonging to another or more than one race (see Table 2–1 ). The Asian population in the United States is increasing rapidly as a per- centage of the total population. From 2000 to 2010, the population of those Figure 2–2 Projected Population of the United States by Age, 2000–2050 (Numbers in thousands) Data from Population Division, U.S. Census Bureau. 0 2010 2020 2030 2040 2050 50,000 100,000 150,000 200,000 250,000 Years 0–18 19–64 65 and over 18 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE 9781284087062_CH02_PASS02.indd 18 17/02/15 6:10 PM people who identified themselves as being Asian (either alone or in combina- tion with another race) grew 43.3 percent, while the total population grew only 9.7 percent (see Table 2–1 ) Aging Population The world’s population is aging. According to the United Nations (2013), slow population growth brought about by reductions in fertility leads to popu- lation aging; that is, it produces populations where the proportion of older per- sons increases while that of younger persons decreases. Globally, the number of persons aged 60 and over is expected to more than triple by 2100, which will represent 34 percent of the world’s population, or more than 3 billion indi- viduals. Of this group, the number of persons aged 80 and over is projected to increase almost sevenfold by 2100, representing just under one-third of the world’s population aged 60 and over. The United States is experiencing the same as the world’s aging popula- tion. As reported by Howden and Meyer (2011), the 2010 Census reflects that the number of people under age 18 was 74.2 million (24.0 percent of the total population). The younger working-age population, ages 18 to 44, represented 112.8 million persons (36.5 percent). The older working-age population, ages 45 to 64, made up 81.5 million persons (26.4 percent). Finally, the 65 and over population was 40.3 million persons (13.0 percent). Between 2000 and 2010, the population under the age of 18 grew at a rate of 2.6 percent. The growth rate was even slower for those aged 18 to 44 (0.6 percent). On the opposite side, the country is experiencing substantially faster growth rates for older ages. For example, the population aged 45 to 64 grew at a rate of 31.5 percent. The large growth in this age group is primarily attributable to the aging of the Baby Boom population. As noted previously, the growth rate (15.1 percent) of the 65 and over population was faster than the population under age 45. One of the most striking characteristics of the older population is the change in the ratio of men to women as people age. As Howden and Meyer (2011, p. 3) point out, this is a result of differences in mortality for men and women, where women tend to live longer than men. As such, there are more females then males at older ages. However, over the past decade an increase in the male population relative to the female population has been noted. For exam- ple, in 2010, there were 96.7 males per 100 females, representing an increase from 2000, when the ratio was 96.3 males per 100 females (Howden & Meyer, 2011). This lowering of male mortality may be attributible to technological advances, more preventive screening, and healthier lifestyles. While the elderly population is not as racially and ethnically diverse as the younger generations, it is projected to increase in its racial and ethnical makeup over the next four decades. As in the past, the highest proportion of the U.S. population aged 60 and over is White (78.8 percent). However, within the racial composition of the older population, White is projected to decrease by 10 percent by 2050, and all other race groups will increase in their own populations. This change is already being seen. In 2000, the aged White population was 82.5 percent, a 7 percent decrease compared with 2010. The remaining makeup of this population group is 8.8 percent Black, 7.3 percent Changing United States Population 19 9781284087062_CH02_PASS02.indd 19 17/02/15 6:10 PM Hispanic, and 3.6 percent Asian, with other races forming the remainder. As noted, this population group’s racial composition will continue to change over the next 40 years. Gender As previously noted, according to the U.S. Census Bureau, in 2010, 50.8 percent of the U.S. population was female, and 49.2 percent was male— almost identical to the 2000 Census. That translates to 96 men for every 100 women. However, the ratio of men to women varies significantly by age group. There were about 105 males for every 100 females under 25 in 2010, reflecting the fact that more boys than girls are born every year and that boys continue to outnumber girls through early childhood and young adulthood. However, the male–female ratio declines as people age. For men and women aged 25 to 54, the number of men for each 100 women in 2010 was 99. Among older adults, the male–female ratio continued to fall as women increasingly out- numbered men. For people 55 to 64, the male–female ratio was 93 to 100, but for those 85 and older, there were only 48 men for every 100 women. These male–female ratios reflect a new trend that has been occurring since 1980. From 1900 to 1940, there were more males. Beginning in 1950, there were increasingly more females due to reduced female mortality rates. This trend reversed between 1980 and 1990 as male death rates declined faster than female rates and as more men immigrated to the United States than women (United States Department of Commerce, 2003). When we look at education, it appears that females are outpacing men. Among the population aged 25 and older, 88 percent of both men and women were high school graduates. But of this group, 39 percent of men had gradu- ated from college, as compared with 61 percent of women. However, even with college degrees, only a high minority (44 percent) of women are employed in management or professional positions. IMPLICATIONS FOR THE HEALTH CARE INDUSTRY The changing demographics of America’s population affect the health care industry twofold. First, health care professionals and organizations need to have cultural and linguistic competence to provide effective and efficient health services to diverse patient populations. However, before we continue our discussion, we need to define what is meant by cultural and linguistic competence. Over the years, cultural competence has been defined in many ways, such as “ongoing commitment or institutionalism of appropriate prac- tice and policies for diverse populations” (Brach & Fraser, 2000; Weech- Maldonado et al., 2002; see Hofstede’s Cultural Dimensions, Exhibit 2–1 ). Linguistic competence has been defined as “the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not liter- ate, and individuals with disabilities” (Goode & Jones, 2004). For our discus- sions we adopted the definition used by the Office of Minority Health (OMH) 20 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE 9781284087062_CH02_PASS02.indd 20 17/02/15 6:10 PM Exhibit 2–1 Hofstede’s Cultural Dimensions One of the most extensive cross-cultural surveys ever conducted is Hofstede’s (1983) study of the influence of national culture on organizational and managerial behaviors. National culture is deemed to be central to organizational studies, because national cultures incorporate political, sociological, and psychological components. Hofstede’s research was conducted over an 11-year period, with more than 116,000 respondents in more than 40 countries. The researcher collected data about “values” from the employees of a multinational corporation located in more than 50 countries. On the basis of his findings, Hofstede proposed that there are four dimensions of national culture, within which countries could be positioned, that are independent of one another. Hofstede’s (1983, pp. 78–85) four dimensions of national culture were labeled and described as: • Individualism–Collectivism: Individualism–collectivism measures culture along a self- interest versus group-interest scale. Individualism stands for a preference for a loosely knit social framework in society wherein individuals are supposed to take care of them- selves and their immediate families only. Its opposite, collectivism, stands for a prefer- ence for a tightly knit social framework in which individuals can expect their relatives, clan, or other in-group to look after them in exchange for unquestioning loyalty. Hofstede (1983) suggested that self-interested cultures (e.g., individualism) are positively related to the wealth of a nation. • Power Distance: Power Distance is the measure of how a society deals with physical and intellectual inequalities, and how the culture applies power and wealth relative to its inequalities. People in large Power Distance societies accept hierarchical order in which everybody has a place, which needs no further justification. People in small Power Dis- tance societies strive for power equalization and demand justification for power inequali- ties. Hofstede (1983) indicated that group-interest cultures (e.g., Collectivism) have large Power Distance. • Uncertainty Avoidance: Uncertainty Avoidance reflects the degree to which members of a society feel uncomfortable with uncertainty and ambiguity. The scale runs from tolerance of different behaviors (i.e., a society in which there is a natural tendency to feel secure) to one in which the society creates institutions to create security and minimize risk. Strong Uncertainty Avoidance societies maintain rigid codes of belief and behavior and are intol- erant toward deviant personalities and ideas. • Weak Uncertainty: Avoidance societies maintain a more relaxed atmosphere in which practice counts more than principles and deviance is more easily tolerated. • Masculinity Versus Femininity: Masculinity versus femininity measures the division of roles between the genders. The masculine side of the scale is a society in which the gen- der differences are maximized (e.g., need for achievement, heroism, assertiveness, and material success). Feminine societies are ones in which there are preferences for relation- ships, modesty, caring for the weak, and the quality of life. Hofstede proposed that the most important dimensions for organizational leadership are Individualism/Collectivism and Power Distance, and the most important for decision-making are Power Distance and Uncertainty Avoidance. Uncertainty Avoidance plays an integral part in a country’s culture regarding change. For example, Nahavandi and Malekzadeh (1999, pp. 495–496) point out that countries such as Greece, Portugal, and Japan have national cul- tures that do not easily tolerate uncertainty and ambiguity. Therefore, the resultant behavior emphasizes the issue avoidance or the importance of planned and well-managed activities. Other countries, such as Sweden, Canada, and the United States, are able to tolerate change because of the potential for new opportunities that may come with change. The question frequently asked is whether Hofstede’s (1983) cultural dimensions are still applicable today. Patel (2003) found that the characteristics of Chinese, Indian, and Austra- lian cultures corroborated Hofstede’s study results. Patel’s study of the relationship between business goals and culture, measured by correlating the relative importance attached to the (continues) Implications for the Health Care Industry 21 9781284087062_CH02_PASS02.indd 21 17/02/15 6:10 PM of the U.S. Department of Health and Human Services, which defines “cul- tural and linguistic competence as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and that enables effective work in cross-cultural situations.” (United States Department of Health and Human Services, 2013). Second, because of the changing demographics of the nation’s population, the health care industry needs to ensure that the health care workforce mir- rors the patient population it serves, both clinically and managerially. As noted by Weech-Maldonado et al. (2002), health care organizations must develop policies and practices aimed at recruiting, retaining, and managing a diverse workforce in order to provide both culturally appropriate care and improved access to care for racial/ethnic minorities. DIVERSITY ISSUES WITHIN THE CLINICAL SETTING Consider the following: Scenario One: An insulin-dependent, indigent black non-Hispanic male was treated at a predominantly Hispanic border clinic. Later, he was brought back to the clinic in a diabetic coma. When he awoke, the nurse who had counseled him asked whether he had been follow- ing her instructions. “Exactly!” he replied. When the nurse asked him to show her, the monolingual Spanish-speaking nurse was startled when the patient proceeded to inject an orange and eat it. Scenario Two: As Maria (an elderly, monolingual Hispanic female) was being prepared for surgery, which was not why she came to the hospital, her designated interpreter (a young female relative) was told by an English-speaking nurse to tell Maria that the surgeon was the best in his field and she’d get through this fine. The young inter- preter translated, “the nurse says the doctor does best when he’s in the field, and when it’s over you’ll have to pay a fine!” These may seem rather humorous misunderstandings, but real-life experi- ences such as these happen every day in the United States (Howard, Andrade, various business goals with the national culture dimension scores from Hofstede’s study, found that although the four cultural dimension scores were nearly 20 years old, they were validated in this large, cross-national survey. In a study that measured 1,800 managers and professionals in 15 countries, statistically significant correlations with the Hofstede indices validated the applicability of the first study’s cultural dimension findings (Hofstede et al., 2002). The findings from these studies suggest that Hofstede’s cultural dimensions continue to be robust and are still applicable measure components of national culture differences. NOTE: Hofstede (1991) subsequently included an additional dimension based on Chinese values referred to “Confucian dynamism.” Hofstede renamed this dimension as a long-term versus short-term orientation in life. Exhibit 2–1 (Continued) 22 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE 9781284087062_CH02_PASS02.indd 22 17/02/15 6:10 PM & Byrd, 2001). For example, a survey by the Commonwealth Fund (2002) found that black non-Hispanics, Asian Americans, and Hispanics are more likely than white non-Hispanics to experience difficulty communicating with their physician, to feel that they are treated with disrespect when receiving health care, to experience barriers to access to care, such as lack of insur- ance or not having a regular physician, and to feel they would receive better care if they were of a different race or ethnicity. In addition, the survey found that Hispanics were more than twice as likely as white non-Hispanics (33 per- cent versus 16 percent) to cite one or more communication problems, such as not understanding the physician, not being listened to by the physician, or not asking questions they needed to ask. Twenty-seven percent of Asian Ameri- cans and 23 percent of black non-Hispanics experience similar communication difficulties. Cultural differences between providers and patients affect the provider– patient relationship. For example, Fadiman (1998) related a true and poignant story of cultural misunderstanding within the health care profession. Fadi- man described the story of a young female epileptic Hmong immigrant whose parents believed that their daughter’s condition was caused by spirits called “dabs,” which had caught her and made her fall down, hence the name of Fadi- man’s book The Spirit Catches You and You Fall Down . The patient’s parents struggled to understand the prescribed medical care that only recognized the scientific necessities, but ignored their personal belief about the spirituality of one’s soul in relationship to the universe. From a unique perspective, Fadiman examined the roles of the caregivers (physicians, nurses, and social workers) in the treatment of ill children. She studied the way the medical care system responded to its own perceptions that the family was refusing to comply with medical orders without understanding the meaning of those orders in the con- text of the Hmong culture, language, and beliefs. Because of our increasingly diverse population, health care professionals need to be concerned about their cultural competency, which is more than just cultural awareness or sensitivity. Although formal cultural training has been found to improve the cultural competence of health care practitioners, Kund- hal (2003) reported that only 8 percent of U.S. medical schools and no Cana- dian medical schools had formal courses on cultural issues. However, changes are occurring within the industry (see Exhibit 2–2 ) to assist health care prac- titioners in the developing of their cultural competences as they encounter more diverse patients. For example, in 2000 the Liaison Committee on Medi- cal Education (LCME), the accrediting body of medical schools, introduced the following accreditation standard for cultural competence: The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, dis- eases, and treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in healthcare delivery, while considering first the health of the patient. This standard has given added impetus and emphasis to medical schools to introduce education in cultural competence into the undergraduate medical curriculum (Association of American Medical Colleges, 2005, p. 1). In addition, Diversity Issues within the Clinical Setting 23 9781284087062_CH02_PASS02.indd 23 17/02/15 6:10 PM The Joint Commission has implemented patient-centered communication accreditation standards, which require hospitals to meet certain mandates related to qualifications for language interpreters and translators, identify- ing and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and nondiscrimination in care (The Joint Commission, 2014). Over the past decade, the Commonwealth Fund has been a leader in the effort “to eliminate the cultural and linguistic barriers between health care providers and patients, which can interfere with the effective delivery of health services” (Beach, Saha, & Cooper, 2006, p. vi). The Commonwealth Fund (2003), in addition to funding initiatives regarding quality of care for under- served populations, has also initiated an educational program that assists health care practitioners in understanding the importance of communication between culturally diverse patients and their physicians, the tensions between modern medicine and cultural beliefs, and the ongoing problems of racial and ethnic discrimination. The goals of this program are for clinicians to: 1. Understand that patients and health care professionals often have dif- ferent perspectives, values, and beliefs about health and illness that can lead to conflict, especially when communication is limited by language and cultural barriers. 2. Become familiar with the types of issues and challenges that are partic- ularly important in caring for patients of different cultural backgrounds. 3. Think about each patient as an individual, with many different social, cultural, and personal influences, rather than using general stereotypes about cultural groups. Exhibit 2–2 Unequal Treatment A study in 2002 by the Institute of Medicine, entitled Unequal Treatment: Confront- ing Racial and Ethnic Disparities in Health Care, found that a consistent body of research demonstrates significant variation in the rates of medical procedures by race, even when …