Cultural Diversity in Healthcare: Strategies for Culturally Appropriate Patient Care

Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company

A growing body of research and clinical evidence supports the importance of considering the whole patient, including the patient’s lived experience, when providing care. Cultural competence describes “the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.”¹

Because the term cultural competence might imply an achievement or endpoint, some experts recommend using the term cultural humility instead. Cultural humility is “a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.”² Other reviews include the term cultural safety, which encompasses humility and leaves room for identifying and addressing “culturally unsafe” practices.³ In this regard, promoting cultural safety becomes a patient safety strategy in a culturally diverse environment.

Benefits of Culturally Appropriate Care

The potential benefits of providing culturally appropriate care include greater patient comfort and engagement in their health and well-being. Asking patients relevant questions about their beliefs and practices can provide opportunities to incorporate cultural norms into their care.

Including cultural beliefs in patient conversations demonstrates respect and provides validation that sends a powerful message and potentially creates a stronger therapeutic relationship. Engaged patients are much more likely to participate in their own care, including obtaining diagnostic tests, filling prescriptions, and keeping follow-up and referral appointments. Patient participation in the treatment plan facilitates the diagnostic process and can decrease the risk of missed or wrong diagnoses.

In addition to improved adherence, increased patient satisfaction benefits the working environment and improves teamwork. Patients and their families may feel more comfortable sharing concerns earlier, making them less likely to seek legal or regulatory action.

A practitioner’s cultural competence—the ability to understand and interact effectively with people from other cultures—is critically important in helping to achieve health equity for all patients.

Steps to Improve Cultural Safety

Know the community. Determine the major ethnic groups and languages spoken in your service area. Does the patient population reflect the community? If not, ask why not and look for opportunities. Evaluate community social risks and available resources. Develop and formalize referral relationships.

Know the practice. Identify the skills, tools, and technologies necessary for practice success. Assess practitioner and staff skill levels and comfort in providing culturally appropriate care to the patient population. Facilitate access to role-based training that is culturally and linguistically appropriate. Create a safe environment for patients and staff—with awareness that tolerance goes both ways.

Is the practice environment conducive to culturally appropriate care? Encourage staff to share concerns, learning opportunities, and successes. Conduct cultural safety debriefs to discuss what went well and identify opportunities for improvement. Elicit insights from the community’s cultural leaders. Collaborate with patients to include cultural practices and beliefs in guidance and treatment plans. Ensure that posters and educational materials are diverse and inclusive. Develop strategies to provide a comfortable environment in the examination area for women who dress modestly. Provide modest clinical garments and ask patients what additional measures would make them comfortable.

Provide linguistically appropriate care. Address health literacy by ensuring that all patient-facing materials are written in plain language. (See the CDC’s Plain Language Materials and Resources page.) Ensure that patients understand their diagnosis and role in the treatment plan by using strategies such as the Institute for Healthcare Improvement’s (IHI’s) Ask Me 3 tool and the Agency for Healthcare Research and Quality’s (AHRQ’s) Teach-Back Method. Many patients have difficulty managing their medication dosing and schedule. Ask the patient and family to demonstrate how they dose pills and topical and injectable medications using AHRQ’s Show Me Method. (Find AHRQ’s Teach-Back and Show Me tools.)

Include patient education materials on the practice website, and assist patients in finding appropriate online material. Consider community resources: Libraries often have digital literacy programs. Provide patient-facing materials, such as informed consent forms, HIPAA Notice of Privacy Practices, and standard home care instructions in the top languages spoken by your patient population.

Ensure that practice systems, such as the EHR, support the journey. For example, does the registration module include information about patient primary language, communication and ability accommodations, religion, sexual orientation, sex assigned at birth, gender identity, chosen name, and pronouns? This information is essential to providing appropriate care and cultural safety. Although some of these elements may be available in the EHR, the module may not have been activated. Collecting sexual orientation and gender identity information requires humility and additional education. The National LGBTQIA+ Health Education Center’s Ready, Set, Go! guide is a good resource.

Ways to Practice Cultural Humility

Know yourself. Be human, and keep an open mind. Understand the risks that explicit and implicit biases pose to patients. Patients are often aware of a practitioner’s bias even when the practitioner is not. Bias interferes with the therapeutic relationship in several ways, including trust and transparency. Patients who are subject to bias may receive care that is below the standard received by those not exposed to bias. The result is healthcare inequity.

Address your biases. The journey to cultural humility requires introspection and intention. Ask friends and family if they have seen evidence of explicit or implicit bias. Implicit bias can be measured using an Implicit Association Test. Take one or more of the tests, and address the findings. One of the hallmarks of high reliability is deference to expertise. Take courses, watch how others interact, and ask questions. Share your learning, and invite others to do the same.

Communicate effectively. Use humility to learn from patients. Ask them what they think their condition is, what they call it, and what they believe caused it. These questions lay the groundwork for open communication about cultural beliefs and practices.

Be prepared for patients with limited English proficiency or those who have limited or no hearing or vision. Plan to use translators, and have available appropriate materials, such as large-print instructions in the main languages spoken by the practice and lists of translators. Expect that patients with low or no vision may want the practitioners to record instructions.

Use person-first language that maintains human dignity by seeing the patient as a person first, before the disease or condition. For example, use the term a person with diabetes instead of diabetic. Be mindful of exceptions, such as patients with autism who prefer the term autistic because they have embraced their condition and those who identify as LGBTQIA+ and call themselves queer.

Culturally appropriate care incorporates cultural safety, seeks to mitigate culturally unsafe practices, and is practiced with humility, resulting in improved patient relationships and better patient care.

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