1.Destructiveness: The attitudes, policies, and practices that are exhibited can be destructive to a culture. At the individual level, people in this phase believe that everyone should be more like the “mainstream.”
2.Incapacity: A biased, authoritarian system lacks the capacity to facilitate growth in cultur- ally diverse groups. Individuals at this level lack cultural awareness skills and believe that the dominant group is racially superior.
3.Blindness: A “we’re all human” approach is used, wherein culture, ethnicity, and race make no difference in how services are provided.
4.Precompetence:Also known as “cultural sensi- tivity,” wherein there is a desire and attempt made to deliver services in a manner respectful of cultural diversity. In general, there is aware- ness about the set of norms, values, and beliefs associated with a particular group, and how these affect group interactions and experiences.
5.Competence:There is an acceptance of, and re- spect for, cultural norms, patterns, beliefs, and differences. Individuals accept the influence of their own culture in relation to other cultures and are willing to examine components of cross-cultural interactions.
6.Proficiency:These individuals move beyond ac- cepting, appreciating, and accommodating cul- tural differences to developing skills to interact in culturally diverse settings. There is a motiva- tion toward developing culturally therapeutic approaches, and hiring staff who are specialists in cultural competence.
Application of the Cultural Competence Continuum
The following scenarios illustrate three phases along the cultural competence continuum.
Scenario 1
Background Information Tran is a 21-year-old Vietnamese woman Gravida 1, Para 0 who regis- tered for prenatal care at 16 weeks gestation. Since she arrived from Vietnam nine months ago, Tran has been living with her aunt, who has accompa- nied her to the clinic. The FOB is a 25-year-old Vietnamese man, currently unemployed. He has lived in the United States for three years with his aunt and uncle. Both he and Tran speak no English.
Tran was raised in a small village in the moun- tains of Vietnam where her mother sent her at the age of three because she could not afford to take care of her. When her mother died, Tran was brought to the United States by her aunt, the owner of a small jew- elry store. The aunt does not intend to accompany Tran on all of her visits. Displeased about this preg- nancy, she has told Tran that she and her boyfriend will have to find a place to live when the baby is born. Tran has little formal education and can read only at a fourth grade level. Social service has tried on numerous occasions to encourage Tran to take the English as a Second Language classes at the local church. Tran attended one class and refuses to re- turn; the reason is unknown.
FIGURE 3-1 Cultural competence continuum. Source:Cross et al. [31].
Incompetence ————————————————————————— Competence
Destructiveness —— Incapacity —— Blindness —— Precompetence —— Competence —— Proficiency
Tran has been labeled a poor historian by the OB staff at the health center. Tran has come to the clinic with facial and upper body bruises, and the midwife suspects that she is being battered. The midwifery service has two Vietnamese outreach workers in the clinical setting. One of the outreach workers, Lan, plans to accompany Tran for labor support. Lan has asked Tran about the bruises. She denies being beaten, and claims she obtained the bruises by falling and bumping into things.
The hospital where Tran is going to deliver has no Vietnamese staff employed in any capacity. The night that Tran goes into labor the outreach worker has a personal family crisis and is unable to provide any support. Tran’s aunt is away on business. The FOB accompanies Tran to labor and delivery, but he leaves and goes to the waiting room, where he remains. He does not see Tran again until she is being sent to the postpartum floor.
Tran has a spontaneous birth of a baby girl.
Lan comes to the hospital the next day to help Tran with newborn care and to prepare for going home.
The social service staff at the hospital are suspicious of Lan and do not believe she is translating their concerns regarding Tran’s possible history of bat- tering. Communication shuts down between Tran and the hospital staff. Tran is discharged home from the hospital on the second postpartum day.
Analysis This case study suggests a very typical pre- competence. The health center has responded to the community needs by hiring two Vietnamese outreach workers. The hospital, an extension of Tran’s health care system, is not responsive to this population’s need. The next step on the continuum would be for the hospital administration to provide translation coverage and to meet with the health center adminis- tration to implement hospital and community-based strategies to assist women from other cultures who they know will be receiving care at the hospital.
According to the Culturally and Linguistically Appropriate Services recommendations, health care organizations receiving federal funding must offer and provide interpreter service at no cost to patients with limited English proficiency [8].
Scenario 2
Background Information Marie is a 26-year-old CNM who is a recent graduate of her nurse-mid- wifery program. She is working at an urban health center in Boston doing full-scope midwifery in ful- fillment of her National Health Service Corps obli- gation. Of Irish and Italian decent, Marie was raised in a military family. Her family of origin has
settled in Illinois. She plans to return to Illinois to marry and join a physician/CNM practice when her obligation is completed in two years.
Gwendolyn is a 25-year-old African-American woman with five previous births who presented late for prenatal care. All of Gwendolyn’s children have been in state custody. The first four are in the tem- porary custody of her mother, and she has custody of her two-year-old daughter. Now living in a shel- ter, Gwendolyn is waiting for her Section 8 (afford- able housing) designation. She has a past history of depression treated with Prozac and individual counseling. She stopped taking the Prozac when she found out she was pregnant and decided not to re- turn for counseling. Gwendolyn has been in drug treatment on seven separate occasions in five differ- ent programs. Drug free for 10 months, her urine toxicology was negative x1.
Gwendolyn has 4 siblings that she is not willing to talk about. It has been two years since she has spoken to her mother, who refuses to allow her any access to her children. Gwendolyn dropped out of school in the seventh grade. When she comes to the clinic, she is demanding and argumentative with the clinic staff. She rarely keeps appointments, as pub- lic transportation to the clinic is difficult. The shel- ter where she stays is a 35-minute drive. She comes to the clinic when she can get a ride. The FOB is the same for all of her children. The relationship is abu- sive; the FOB is currently in prison serving a two- year sentence for battering her. She has been evicted from two apartment buildings because of persistent fights between her and the FOB.
Gwendolyn’s second prenatal care visit with Marie does not go well. Marie is frustrated with Gwendolyn because she arrives at the clinic unan- nounced, having missed her last two appointments.
Gwendolyn’s weight is 340 pounds, her blood pres- sure is 120/68, and her urine 2+ glucose, neg. pro- tein. Marie tells Gwendolyn she will have to wait because there are two patients before her.
Gwendolyn agrees and goes to the cafeteria to get something to eat. When she and Marie meet for the visit, she has a list of physical complaints she wants to discuss.
Gwendolyn’s goals for the visits are to speak to the outreach worker regarding housing and to ob- tain an ultrasound for sex determination because she would like to start collecting clothes for her baby. Marie wants to get a one-hour glucose test, and urine for toxicology as she thinks Gwendolyn has relapsed.
Gwendolyn refuses to give a urine sample and accuses Marie of looking for an excuse to take her
baby away. Marie refuses to discuss another ultra- sound and tells Gwendolyn that she “might as well write her a check for $500 now because an ultra- sound for sex determination is a waste of the tax- payers’ money.” She also tells Gwendolyn that she will not be seen at the clinic unannounced again without an appointment. Gwendolyn leaves and goes to the clinic director’s office and files a com- plaint of discrimination.
Marie tells the clinic director that she regrets the encounter and that she resents the charge of dis- crimination, as it would not matter to her what color Gwendolyn was. She says that she regards Gwendolyn as noncompliant and a drain on the clinical resources. The clinic director tells Marie that other staff members have heard her describe Gwendolyn using terms like “train wreck” and
“walking wounded.” Marie’s response is that Gwendolyn has no business bringing another child into the world. Marie isolates herself and does not speak to any of the staff for the rest of the day.
Gwendolyn transfers her care to another service.
Analysis This scenario is complex in nature, illustrat- ing several overlapping issues. There is cultural blind- ness on the part of both the provider and the client.
Marie believes that she treats all clients the same, re- gardless of race or socioeconomic status and that the health care system is set up to serve everyone with equal effectiveness. This approach makes Gwendolyn a victim and blames her for her problems, thereby ren- dering her culturally invisible. Leadership can be pro- vided here by providing training in which Marie is able to understand and acknowledge the influence of her own cultural roots, beliefs, and behaviors. From
this assessment, she can acquire skills to progress to- ward cultural competence.
Scenario 3
Background Information Itza is a 25-year-old mar- ried women from Cuba who presents for prenatal care with a midwifery service located in a commu- nity health center. Itza and her husband Rafael have been in the United States seven months. They came to the midwifery service based on a recommenda- tion from her sister-in-law, who recently received labor and birth care from the same group.
The demographics of this health center have changed rather rapidly. When the Hispanic/Latino population at the health center reached 20 percent, the administration applied for Healthy Start funding, with which the center hired two Spanish-speaking midwives, one trained medical assistant, and a case manager. Additionally the entire health center staff, including the administrators, have been involved in a yearlong cultural diversity training that includes de- veloping and participating in community-based health fairs. Itza was made to feel immediately at home as the waiting room has a variety of Spanish lit- eratures. Because Itza and Rafael speak very little English, they have been assured that a Spanish-speak- ing midwife and doula will support them in labor.
Analysis The midwifery service described in this scenario demonstrates the characteristics of a cul- turally proficient agency through its commitment to hiring multicultural providers and its active partici- pation in community health promotion projects [2].
Table 3-2 summarizes the characteristics of a cul- turally competent practitioner.
Characteristics of Culturally Competent Practitioners TABLE 3-2
• Move from cultural unawareness to an awareness and sensitivity of their own cultural heritage.
• Recognize their own values and biases and are aware of how they may affect clients from other cultures.
• Demonstrate comfort with cultural differences that exist between themselves and clients.
• Know specifics about the particular cultural groups they are working with.
• Understand the historical events that may have caused harm to a particular cultural group.
• Respect and are aware of the unique needs of clients from diverse communities.
• Understand the importance of diversity within as well as between cultures.
• Endeavor to learn more about cultural communities through client interactions, participation in cultural diversity dynam- ics, and consultations with community experts.
• Make a continuous effort to understand a client’s point of view.
• Demonstrate flexibility and tolerance of ambiguity, and are nonjudgmental.
• Maintain a sense of humor and an open mind.
• Demonstrate a willingness to relinquish control in clinical encounters, to risk failure, and to look within for the source of frustration, anger, and resistance.
• Acknowledge that the process is as important as the product.
Source:Randall-David, E. Culturally Competent HIV Counseling and Education. Rockville, MD: DHHS Maternal and Child Health Bureau, 1994.