The number and scope of cultural competency initiatives in the U.S. healthcare system are increasing due to many factors, including shifting patient demographics, quality improvement and regulatory requirements, new accreditation standards, and ongoing missions to provide care in an equitable manner (Gertner et al., 2010). As the country becomes increasingly diverse, accreditation organizations such as The Joint Commission, the National Quality Forum, and the National Committee on Quality Assurance are developing service standards aimed at providing culturally and linguistically appropriate services (CLAS) for limited English proficiency (LEP) patients (Douglas et al., 2009). These initiatives, according to available literature, are critically important in addressing health disparities across the healthcare system in light of the consideration that about 35 million U.S. residents are foreign-born, 19.7% of the U.S. population speak a language other than English at home, and more than 24 million U.S. citizens speak English less than “very well” and are considered LEP (Wilson, n.d.). The present paper aims to discuss some underlying issues on emerging standards of culturally competent care in an emergency room (ER) setting.
Culturally Competent Care Appropriate in the ER
Gertner et al (2010) define cultural competency in healthcare “…as the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring the delivery of care to meet patients’ social, cultural, and linguistic needs” (p. 191). The ER serves as the first official contact in the continuum of healthcare for many racially diverse and linguistically challenged patients who may end up suffering intense physical, mental, emotional, financial, and social trauma and loss in the absence of culturally competent care initiatives (Jones, 2007). In the U.S., emergency departments are increasingly becoming the source of care for many types of patients, but especially for illegal immigrants, prisoners, the poor, and homeless and underinsured patients (Parker, 2011). Consequently, culturally competent care is fundamental in the ED not only to create the optimal patient-centered experience and effective patient-provider communication (Green-Hernandez et al, 2004) but also to facilitate the delivery of high-quality, evidence-based services (Dreachslin & Myers et al., 2007), as well as the achievement of positive treatment outcomes and high patient/family satisfaction levels (Jones, 2007).
In this light, the culturally competent care appropriate for the ER encompasses the following: 1) an awareness by care providers of existing racial and ethnic health disparities, 2) recruitment by management of diverse staff and volunteers to work in the ER, 3) provision of qualified translators/interpreters and multilingual printed materials, 3) recognition of the incidence and prevalence of health challenges among diverse populations that may present to the ER for care, and 3) provision of adequate skills and expertise not only in identifying and managing racial and ethnic variations in health values, beliefs, attitudes, and behaviors but also in incorporating these variations in healthcare provision strategies with the aim to provide patients with the best care (Green-Hernandez et al., 2004).
Populations Served & Vulnerability
The ER mostly provides care to the Mexican and African American populations residing in the region. Available literature demonstrates that care providers must develop a set of congruent behaviors, attitudes, and policies towards this group of the population not only because of their minority and foreign-born perspectives (Agency for Healthcare Research and Quality, 2003) but also due to noted vulnerabilities, which often prevents them from having equal access and opportunity to receive quality care and medical purchasing efficiency (Dreachslin & Myers et al., 2007). In delineating the issues of population vulnerability, it is evident that most Mexican and African American patients presenting in the ED demonstrate the following vulnerabilities: 1) limited English proficiency, 2) cultural isolation, 3) frail-looking and elderly, 4) poverty-stricken, without resources, or with extremely low income, 5) low literacy skills and, 6) inadequate social support system (Bloch et al., 2011; Jones et al., 2007). As noted by Marquand (2009), these underserved and vulnerable populations “…come to the emergency department because they have no other access to healthcare services” (para. 4). It is therefore imperative to implement and practice culturally competent care initiatives in the ED to eliminate these structural barriers and promote respect for the cultural context of each Mexican or African American individual in the service area.
Standards of Cultural Competence
It has been reported in the literature that the major aim of standards of cultural competence “…is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans” (U.S. Department of Health and Human Services, 2001, p. 3). In this respect, the ED has implemented a number of standards and is in the process of implementing others. This section specifically discusses standards that appear to be met in the ED and any that are not met.
Among the met standards of culturally competent care, it is imperative to mention that the ED has succeeded in ensuring that its care providers receive continuous education and training in culturally and linguistically correct health delivery services (Douglas et al., 2009). The ER has also been able to “…develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services” (U.S. Department of Health and Human Services, 2001, p. 14). However, it is important to note that the department continues to experience some challenges in implementation, in large part due to shortage of funds and an inadequate number of culturally diverse staff, as well as a rapid increase in racially and ethnically diverse populations in the U.S. due to international labor transfers and illegal migrations (Parker, 2011).
The ER has also successfully met the standard that requires healthcare organizations to ensure that information “…on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated” (U.S. Department of Health and Human Services, 2001, p. 15). Consequently, the ER is not only able to adequately identify population groups within its major service area as well as enhance service planning to facilitate access and coordination of care (Douglas et al., 2009) but also ensures appropriate and evidence-based monitoring of patient needs and outcomes (Dreachslin & Myers et al., 2007).
Additionally, the ER has succeeded to meet the standard of maintaining a current demographic, cultural, and epidemiological outline of the Mexican and African American populations residing in the service area, along with a needs and expectations assessment of the communities, with the view to accurately plan for and implement healthcare practices that characteristically respond to the cultural and linguistic aspects of the service area (Douglas et al., 2009). Moving on, it is indeed true that the ER has been successful not only in developing participatory and collaborative partnerships with Mexican and African American populations within the service area but also in exploiting a multiplicity of formal and informal mechanisms to facilitate and reinforce the community’s involvement in culturally and linguistically appropriate services (Dreachslin & Myers et al., 2007; National Center for Cultural Competence, n.d.). Lastly, it is evident that the conflict and grievance resolution strategies employed in the ER are not only culturally and linguistically sensitive to the Mexican and African American populations within the service area, but are also able to identify, prevent, and amicably resolve cross-cultural disputes or grievances from individual patients (Douglas et al., 2009).
Equally, there exist some unmet standards in the ER. For instance, due to an inadequate culturally diverse workforce, the department is yet to ensure that patients receive from care providers “…effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language” (U.S. Department of Health and Human Services, 2001, p. 7). The limited number of culturally diverse care providers at the ED not only hinders the consideration of values, preferences, and expressed needs of Mexican and African American patients, but also impinges on the nurses’ capacity to recognize and respond to health-related beliefs and cultural values of this group of the population (Douglas et al., 2009).
Explicitly tied to the above unmet need, it is indeed clear that the ER has also not adequately met the requirement to recruit, retain, and promote a diverse workforce and leadership that is representative of the demographic distinctiveness of the Mexican and African American populations that constitute the majority in the ER service area. It is highlighted in the literature that “…the diversity of an organization’s staff is a necessary, but not sufficient, condition for providing culturally and linguistically appropriate healthcare services” (U.S. Department of Health and Human Services, 2001, p. 8). So far, the ER has failed to hire adequate bilingual staff from the Mexican and African American cultural orientations to provide emergency care to the predominant populations in the service area.
Third, the ER is yet to develop the capacity to provide full-time language assistance services to Mexican and African American patients with limited English proficiency as demanded in the provisions of culturally competent care. The standards dealing with language proficiency are categorical that language services “…must be made available to each individual with limited English proficiency who seeks services, regardless of the size of the individual’s language group in that community” (U.S. Department of Health and Human Services, 2001, p. 10). Available literature demonstrates that care organizations should always strive to provide bilingual staff and interpreter services at no extra cost to vulnerable members of the community to ensure equitable access to healthcare services (Douglas et al., 2009).However, this is yet to be achieved at the ER due to lack of adequate funding for translator and interpreter services (Agency for Healthcare Research and Quality, 2003).
Additionally, and directly related to the incapacity to provide full-time language assistance services, the ER is yet to develop the capacity to provide to Mexican and African American patients in their preferred native language both verbal offers and written notices informing them of their inherit right to access language assistance services. This standard, according to the U.S. Department of Health and Human Services (2001), is one of the most fundamental as it acts to inform LEP individuals – in a language the can readily identify with – that they have the right to free translator or interpreter services, and that such services are readily available. However, verbal offers and written notices are yet to be adequately availed in the ER, primarily due to shortage of bilingual staff and lack of sufficient funding (Griffiths & Daly, 2008).
Equally unmet is the standard that the ER should at all times assure the competence of language assistance provided to Mexican and African American patients by the facility’s limited interpreters and bilingual members of staff. The ER is also yet to meet the standard of making “available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area” (U.S. Department of Health and Human Services, 2001). Again, this challenge is closely linked to the issue of adequate funding towards translating available health materials into the local dialects of the Mexican and African American populations in the ER service area.
Influence on the Delivery of Nursing Care
Extant literature demonstrates that meeting the standards of culturally competent care results in effective service care delivery (Griffiths & Daly, 2008), positive patient outcomes, including appropriate preventive healthcare services for vulnerable populations, accurate diagnosis and treatment, and improved health status for communities residing in service areas (Parker, 2011), as well as breaking down of cultural and linguistic barriers to avail better quality care in emergency settings (Marquand, 2009). However, non-compliance with these standards has serious ramifications for patients as well as healthcare organizations and departments (Wilson, n.d.). For instance, patients become increasingly anxious and stressed when they are introduced to an environment that is not culturally and linguistically conducive to them (Douglas et al., 2009), leading to poor treatment procedures, exposure to medical errors, diminished level of patient satisfaction and trust, lack of understanding of treatment needs and requirements, as well as potential for civil or criminal liability on the part of care providers (Gertner et al., 2010). Indeed, Marquand (2009) rightly points out that non-compliance with the set standards of culturally competent care adversely impact all aspects of care.
Recommendations for Practice
To remedy the apparent lack of adequate culturally diverse staff in the ER, it is recommended to involve a patient advocate, case administrator, or ombudsperson with adequate experience in cross-cultural communication so that the Mexican and African American communities within the service area benefit from appropriate care. Equally, the management should employ proactive initiatives, including incentives, mentoring programs, and partnerships with local institutions, to develop the capability for workforce diversity (U.S. Department of Health and Human Services, 2001). In the absence of language assistance services, it is highly recommended that the ER should use trained members of staff to provide face-to-face interpretation or employ the services of a telephone interpreter.
Additionally, in informing patients about language assistance services, the ER should employ language identification or post and maintain clear signs in frequently encountered dialects within the department’s points of entry. The ER should also consider including briefs about the services available and the inherent right to free language assistance services in mostly used local dialects and place such information in brochures, booklets, flyers, and other materials that are regularly distributed to the public within the service area. Moving on, it is strongly suggested to use a trained interpreter rather than a family member or a friend to assure the competence of language assistance as such a move will always facilitate the delivery of complete, accurate, impartial, and confidential communication (Douglas et al., 2009). Lastly, it is highly recommended for the ER to develop policies, routines and procedures that will enhance the development of quality non-English signage and patient-oriented materials that are suitable for the Mexican and African American populations residing within the service context.
References
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