Download Cultural Competence Background

HealthStream Regulatory Script
[Cultural Competence: Background and Benefits]
Version: [12.02.04]
Lesson 1:
Lesson 2:
Lesson 3:
Lesson 4:
Introduction
Clinical and Legal Significance of Cultural Competence
Theory of Cultural Competence
Practice of Cultural Competence
Lesson 1: Introduction
1001
Introduction
Welcome to the introductory lesson on background and benefits of
cultural competence.
IMAGE: 1001.JPG
In the healthcare setting, cultural competence refers to the
ability to provide appropriate and effective medical care and
services to members of various cultural groups.
This ability rests on a set of attitudes, skills, policies, and practices
that make it possible for providers and organizations to understand
and communicate with their patients on an in-depth level.
As your partner, HealthStream strives to provide its customers with excellence in
regulatory learning solutions. As new guidelines are continually issued by regulatory
agencies, we work to update courses, as needed, in a timely manner. Since
responsibility for complying with new guidelines remains with your organization,
HealthStream encourages you to routinely check all relevant regulatory agencies
directly for the latest updates for clinical/organizational guidelines.
Point 1 of 6
2
1002
Introduction: The Culturally Competent Provider
The culturally competent provider is able to learn, understand, and
appreciate the health-related characteristics of both:
• Culturally diverse patient groups, in general
• Each unique patient and family, in particular
IMAGE: 1002.GIF
These characteristics include any values, beliefs, attitudes,
behaviors, practices, or other factors that may:
• Affect a patient’s health.
• Influence or affect the delivery of healthcare.
Point 2 of 6
1003
Introduction: Using Cultural Understanding
The culturally competent provider uses his or her understanding of
patient values, beliefs, and practices to:
• Improve the quality and efficacy of medical care for all
patients.
• Correct disparities [ glossary] in health status among
different cultural groups.
IMAGE: 1003.GIF
By contrast, failure to provide culturally competent care contributes
to:
• Less-than-optimal care for many patients
• Elevated rates of disease and mortality among certain
populations, due to social, economic, and cultural factors
Point 3 of 6
1004
Course Rationale
This course is the first in a two-part series designed to teach you
the key elements of cultural competence, as a starting point for you
to:
• Optimize your care and services for all patients.
• Maintain compliance with laws and recommendations
related to the delivery of culturally competent medical care.
IMAGE: 1004.JPG
This first course focuses on background and theory, including legal
and clinical implications of providing culturally competent care.
The second course in the series (Cultural Competence:
Providing Culturally Competent Care) focuses on specific
clinical best practices for delivering medical care and services in a
culturally competent manner.
Point 4 of 6
1005
Course Goals
After completing this course, you should be able to:
•
•
•
•
NO IMAGE
Distinguish the clinical outcomes associated with cultural
competence vs. lack of cultural competence in the
healthcare setting.
Identify laws and recommendations related to cultural
competence.
Recognize key terms related to cultural competence.
List “typical” characteristics of selected cultural groups.
Point 5 of 6
1006
Course Outline
This introductory lesson presents the course rationale, course
goals, and course outline.
FLASH ANIMATION: 1006.SWF/FLA
Lesson 2 provides additional background information on the
significance of cultural competence, both from a clinical standpoint
and a legal standpoint. After completing lesson 2, you should have
a better appreciation of the importance of delivering culturally
competent medical care.
Lesson 3 takes a closer look at the policy of cultural competence,
by defining terms and discussing theory.
Finally, lesson 4 takes a more practical look at cultural
competence, by reviewing some of the “typical” characteristics of
various cultural groups.
Point 6 of 6
Lesson 2: Clinical and Legal Significance
2001
Introduction
Welcome to the lesson on the clinical and legal implications of
providing culturally competent medical care.
FLASH ANIMATION: 2001.SWF/FLA
Point 1 of 17
2002
Objectives
After completing this lesson, you should be able to:
•
•
•
•
NO IMAGE
Recall statistics related to the cultural diversity of the
United States.
List adverse patient outcomes that can result from the
failure to provide culturally competent care.
List potential benefits of improving your cultural
competence.
Describe laws and recommendations related to culturally
competent healthcare delivery.
Point 2 of 17
2003
Cultural Diversity in the United States
The United States is a nation of tremendous cultural diversity:
•
•
•
IMAGE: 2003.JPG
Nearly 10% of all Americans today (28 million out of a total
population of close to 300 million) were born outside of the
United States.
Forty-four million Americans speak a language other than
English at home.
Over 300 different languages are spoken in the United
States.
Given this diversity, cultural competence is a necessity: providers
must be capable of delivering healthcare in a manner appropriate
to --- and respectful of --- any given patient’s language and culture.
Point 3 of 17
2004
Cultural Competence and the Practice of Medicine Today
Unfortunately, cultural competence is often lacking in the practice
of medicine today.
IMAGE: 2004.JPG
Instead of taking the time to learn, understand, and appreciate the
values, beliefs, practices, and communication patterns of their
patients, many providers --- whether consciously or subconsciously
--- rely on stereotypes and their own biases to guide the delivery of
healthcare.
As a result of stereotypes and biases, racial and ethnic minorities
in the United States today tend to receive lower quality care than
similar non-minorities (i.e., non-minorities with similar income and
health insurance).
Source: Institute of Medicine (IOM)
Point 4 of 17
2005
Cultural Competence and Quality of Care (1)
In what ways do racial and ethnic minorities receive lower quality
care?
IMAGE: 2005.GIF
Lack of cultural competence in the healthcare setting can lead to
the following adverse outcomes, with regard to medical care:
• Lack of medical care: Cultural minorities may choose not
to seek medical care at all, for fear of being misunderstood
or treated disrespectfully.
• Misdiagnosis: Miscommunication and misunderstanding
between providers and their cross-cultural patients --especially patients with limited English proficiency (LEP)
[glossary] --- can lead to inaccurate or incomplete historytaking, ultimately resulting in misdiagnosis.
• Inappropriate testing: Providers may not order
appropriate diagnostic tests for cultural minorities, because
they do not understand or believe the patient’s description
of symptoms. Alternatively, providers may
overcompensate by ordering too many tests.
• Suboptimal disease screening: Providers may miss
important opportunities for disease screening, because
they are not aware of the rates of certain disease
conditions among specific minority groups.
Point 5 of 17
2006
Cultural Competence and Quality of Care (2)
Additional adverse outcomes related to lack of cultural competence
in the healthcare setting can include:
•
•
•
IMAGE: 2006.GIF
Noncompliance: Cultural minorities may not follow the
advice of medical providers, because of lack of trust and/or
understanding.
Reaction to drugs: Patients may not respond well to
medication, because providers fail to take into account
differences in the body’s processing of drugs. (Many drug
dosages and other medical standards are based on
studies of Caucasian patients --- but evidence suggests
that ethnic/racial makeup may affect how a patient
metabolizes and responds to a drug.)
Conflicting drugs: Harmful drug interactions may occur,
when a provider prescribes medication without taking into
account traditional remedies a patient may be using.
Point 6 of 17
2007
Cultural Competence and Health Disparities
Just as lack of cultural competence can lead to lower quality care
for cultural minorities, lack of cultural competence may be a
contributing factor in cross-cultural disease and outcome
disparities.
IMAGE: 2007.JPG
Examples of such disparities include:
• Increased risk of mortality among African-American
women with breast cancer, as compared to EuropeanAmericans with breast cancer
• Higher infant mortality rates among African-Americans and
Native Americans, as compared to European-Americans
• Increased mortality among African-Americans and Native
Americans with the flu, as compared to EuropeanAmericans with the flu
• Increased mortality among African-Americans, Native
Alaskans, and Native Hawaiians with colorectal cancer, as
compared to European-Americans with colorectal cancer
• Elevated rates of HIV/AIDS among African-Americans and
Latinos, as compared to European-Americans
For more examples of cross-cultural health disparities, see:
http://erc.msh.org/mainpage.cfm?file=7.0.htm&module=provider&la
nguage=English&ggroup=&mgroup=
Point 7 of 17
2008
Potential Benefits of Cultural Competence: Clinical (1)
We have just reviewed some of the negative consequences of
failing to provide culturally competent care.
NO IMAGE
But what are the potential benefits of cultural competence in the
healthcare setting?
They include:
• More successful patient education for cultural
minorities, as a result of targeting and communicating
health-related messages in culturally appropriate ways
• Increased likelihood that cultural minorities will seek
necessary healthcare, as a result of improved trust and
understanding between patients and providers
• Fewer diagnostic errors, when providers have the crosscultural understanding necessary to take accurate and
thorough medical histories from all patients, regardless of
cultural background
• More appropriate diagnostic testing and screening for
cultural minorities, when providers know and understand
the health-related practices, behavioral risk factors, and
genetic risks common among various cultural groups
Point 8 of 17
2009
Potential Benefits of Cultural Competence: Clinical (2)
Potential benefits of cultural competence in the healthcare setting
also include:
•
•
•
•
NO IMAGE
Fewer harmful drug interactions, when providers find
out about patient use of traditional remedies
Greater patient compliance, when providers work with
their patients to develop treatment plans that match patient
values, beliefs, and lifestyle
Expanded choices and access to high-quality
clinicians, when patients are not limited to a small pool of
providers who share their language and culture
Ultimately, equalization of cross-cultural health
disparities related to social, economic, and cultural
factors
Point 9 of 17
2010
Quality of Care, Health Disparities, and Clinical Outcomes: Summary
Potential Effects of Culturally Competent and Non-Competent Care
on Healthcare Delivery and Patient Health
Cultural Competence
Increased likelihood that cultural minorities will seek
necessary healthcare
Lack of Cultural Competence
Fewer diagnostic errors
Misdiagnosis
More appropriate diagnostic testing and screening for
cultural minorities
Inappropriate testing and suboptimal disease screening
Greater patient compliance
Noncompliance
Fewer harmful drug interactions
Drug reactions and interactions
Equalization of cross-cultural health disparities
Health disparities
Expanded choices and access to high-quality clinicians for
cultural minorities
Limited healthcare choices for cultural minorities
More successful patient education for cultural minorities
Limited/ineffective patient education for cultural minorities
Lack of medical care
Point 10 of 17
2011
Potential Benefits of Cultural Competence: Legal and Regulatory
Benefits of cultural competence relate not only to improved patient
outcomes, but also to improved compliance with relevant laws and
recommendations.
FLASH ANIMATION: 2011.SWF/FLA
Laws and recommendations related to cultural competence
include:
• Title VI of the Civil Rights Act of 1964
• JCAHO [glossary] position on cultural competency
• U.S. Department of Health and Human Services (HHS)
Office of Minority Health (OMH) recommendations for
national standards on culturally and linguistically [glossary]
appropriate services (CLAS)
Let’s take a closer look at each.
Point 11 of 17
2012
Title VI
Title VI of the Civil Rights Act of 1964 and its supporting legislation
require that any health- or social- service organization that
receives federal funding must provide language assistance to any
patient/client with limited English proficiency (LEP).
FLASH ANIMATION: 2012.SWF/FLA
Language assistance is defined as services that ensure effective
communication between the LEP patient and the provider, such
that:
• The LEP patient is able to communicate all relevant
information to the provider.
• The provider is able to understand all information
communicated by the LEP patient.
• The LEP patient is able to receive and understand all
necessary information, including a description of services
and benefits available.
• The LEP patient is able to receive services for which he or
she is eligible.
Guidelines for medical interpretation to achieve effective language
assistance are discussed in greater detail in Part 2 of this series
(Cultural Competence: Providing Culturally Competent Care).
Point 12 of 17
2013
JCAHO Position
Although JCAHO has not yet established any standards
specifically related to cultural competence:
FLASH ANIMATION: 2013.SWF/FLA
The Joint Commission views the delivery of services in a culturally
and linguistically appropriate manner as an important healthcare
safety and quality issue. Healthcare organizations are encouraged
to provide equitable care, treatment, and services across diverse
populations.
In January 2004, JCAHO started a project on cultural competence
(Hospitals, Language, and Culture: A Snapshot of the Nation).
Over a 30-month period, JCAHO will collect data from 60 different
hospitals, to determine the ability of these hospitals to address
issues of patient language and culture.
The results of this study will allow JCAHO to set realistic standards
for hospitals, related to meeting the cultural and linguistic needs of
their patients.
Source:
JCAHO: http://www.jcaho.org/about+us/hlc/
Point 13 of 17
2014
CLAS Standards
The U.S. Department of Health and Human Services (HHS) Office
of Minority Health (OMH) recently released 14 recommendations
for national standards on culturally and linguistically appropriate
services (CLAS).
FLASH ANIMATION: 2014.SWF/FLA
These recommendations address issues such as:
• Culturally representative staffing
• Staff education and training
• Language-assistance services and materials (both written
and verbal)
• Organizational self-assessment
• Data collection
• Cross-cultural conflict and grievance processes
The goals of the recommendations are to:
• Correct disparities currently seen in patient access to and
receipt of medical care and services.
• Improve medical services by meeting the needs of each
individual patient.
For more details on the CLAS recommendations, see:
http://www.omhrc.gov/clas/ds.htm
Point 14 of 17
2015
Review
FLASH INTERACTION: 2015.SWF/FLA
Drag and drop each of the terms in the word bank to its proper place in the
table.
Cultural competence is
characterized by:
Effective communication
Thorough understanding of
individual patients
Willingness to learn
Lack of cultural competence is
characterized by:
Use of stereotypes
Biased delivery of healthcare
Making assumptions about patients
Point 15 of 17
2016
Review
Which of the following requires certain organizations to provide
meaningful language assistance to clients with limited English
proficiency (LEP)?
a.
b.
c.
d.
EMTALA
CLAS standards
Title VI of the Civil Rights Act of 1964
JCAHO standards on cultural competence
MULTIPLE CHOICE INTERACTION
Correct answer: C
Feedback for A: Incorrect. EMTALA requires Medicareparticipating hospitals to provide emergency medical
screening and stabilization to all patients, regardless of
ability to pay. The correct answer is C. Title VI requires
certain organizations to provide meaningful language
assistance to LEP clients.
Feedback for B: Incorrect. Although CLAS standards do
address the issue of language assistance, these standards
are recommendations only, not requirements. The correct
answer is C. Title VI requires certain organizations to
provide meaningful language assistance to LEP clients.
Feedback for C: Correct.
Feedback for D: Incorrect. Although JCAHO recognizes the
importance of culturally and linguistically appropriate care,
the Joint Commission has not yet formulated standards
related to this issue. The correct answer is C. Title VI
requires certain organizations to provide meaningful
language assistance to LEP clients.
Point 16 of 17
2017
Summary
You have completed the lesson on the clinical and legal
significance of cultural competence.
NO IMAGE
Remember:
•
•
•
•
•
•
The United States is a nation of tremendous cultural
diversity.
Cultural competence is often lacking in the practice of
medicine today, leading to adverse patient outcomes and
cross-cultural disparities in health status.
Delivering medical services in a culturally competent way
has many potential benefits for patients.
Title VI of the Civil Rights Act of 1964 requires any healthor social- service organization that receives federal funding
to provide effective language assistance to LEP
patients/clients.
JCAHO “…views the delivery of services in a culturally and
linguistically appropriate manner as an important
healthcare safety and quality issue.”
To correct cross-cultural health disparities and improve
medical services for patients, the HHS Office of Minority
Health (OMH) recently released 14 recommendations for
national standards on culturally and linguistically
appropriate services (CLAS).
Point 17 of 17
Lesson 3: Theory of Cultural Competence
3001
Introduction
Welcome to the lesson on theory of cultural competence.
FLASH ANIMATION: 3001.SWF/FLA
Point 1 of 17
3002
Objectives
After completing this lesson, you should be able to:
•
•
NO IMAGE
Recognize examples of how values, worldview, time
orientation, and social structure shape a patient’s
healthcare-related attitudes, beliefs, behaviors, and
practices.
Distinguish between ethnocentrism [glossary] and cultural
relativism [glossary].
Point 2 of 17
3003
Understanding Patients
As we have seen, cultural competence refers to the ability to
provide appropriate and effective medical care and services to
members of various cultural groups.
FLASH ANIMATION: 3003.SWF/FLA
This ability rests on a set of attitudes, skills, policies, and practices
that make it possible for providers and organizations to understand
their patients on an in-depth level.
How can we, as healthcare providers, achieve the necessary indepth understanding of our patients?
Useful information for comprehensive understanding includes the
patient’s healthcare-related beliefs, attitudes, behaviors, and
practices --- many of which arise from the patient’s underlying:
• Values
• Worldview
• Time orientation
• Traditional social structure
Let’s take a closer look at each of these four underlying
characteristics.
Point 3 of 17
3004
Understanding Patients: Values
A value is anything of importance to an individual or a culture.
FLASH ANIMATION: 3004.SWF/FLA
For example, in the United States, we tend to value:
• Money
• Freedom/independence
• Privacy
• Health/fitness
• Physical appearance
At some level, values always drive behavior. Therefore,
understanding a patient’s values can help you understand his or
her behavior.
When you understand a patient’s behavior at a value level, you are
better able to respond to that behavior in a respectful, effective
way.
Point 4 of 17
3005
Understanding Values: An Example
Mr. C is a 45-year-old patient under the care of Nurse Jones.
IMAGE: 3005.GIF
Mr. C’s family members wish to participate in the non-technical
aspects of his care.
Initially, Nurse Jones responds with irritation and annoyance, not
understanding why the C family refuses to recognize limitations on
visiting hours or the importance of self-care for the patient.
Mr. C explains that his family’s behavior arises out of the value
they place on family loyalty and duty. He tells Nurse Jones that his
wife and children would feel tremendous guilt and dishonor if they
did not assist him in every way they could.
Now that she understands that the C family is not ignoring her
instructions out of spite or stubbornness, Nurse Jones finds ways
of adapting the patient’s treatment plan to allow for significant
family involvement.
Point 5 of 17
3006
Understanding Patients: Worldview (1)
A person’s worldview consists of his or her basic
assumptions about the nature of reality.
FLASH ANIMATION: 3006.SWF/FLA
Most people believe their worldview without question.
This can lead to ethnocentrism: the belief that one’s own way is
right and natural, and that other ways are inferior, unnatural,
uncivilized, etc.
The opposite of ethnocentrism is cultural relativism. Cultural
relativism:
• Looks at behavior and beliefs in their cultural context
• Accepts that other ways may be different, but equally valid
Point 6 of 17
3007
Understanding Patients: Worldview (2)
Western healthcare tends to be ethnocentric, assuming that
Western approaches to healing are best, and that other methods
are not to be trusted or accepted.
IMAGE: 3007.GIF
Cultural competence, however, demands cultural relativism. As
culturally competent healthcare providers, we must be willing to:
•
•
Acknowledge the potential validity of other methods.
As safe and appropriate, incorporate traditional or folk
medicine into treatment plans for patients who place a high
value on spiritual, herbal, or other non-Western remedies.
Point 7 of 17
3008
Understanding Worldview: An Example
According to the worldview of Western medicine, infection is
caused by microorganisms (i.e., bacteria, viruses, fungi).
IMAGE: 3008.GIF
Ms. P believes that her bacterial pneumonia is the result of an
imbalance of “heat” and “cold” in her body.
Although Western medicine would insist that antibiotics can cure
bacterial pneumonia, antibiotics are unlikely to help Ms. P:
• Ms. P may not take prescribed antibiotics, since she does
not see how they could be useful to her.
• Even if Ms. P takes antibiotics, she may not reach a true
state of healing, since she will not believe she has
corrected the underlying problem of heat/cold imbalance.
In other words, a patient’s mind/beliefs must always be considered
and accommodated when treating the body, both to:
• Help ensure compliance.
• Help ensure full healing.
Explaining and discussing treatment options with a patient, to
arrive at a culturally appropriate and mutually acceptable treatment
plan, is discussed in greater detail in Part 2 of this series (Cultural
Competence: Providing Culturally Competent Care).
Point 8 of 17
3009
Understanding Patients: Time Orientation
Time orientation has two aspects:
•
•
FLASH ANIMATION: 3009.SWF/FLA
Emphasis on past, present, or future
Attention to clock time
Let’s take a closer look at each.
Point 9 of 17
3010
Time Orientation: Past, Present, or Future
Persons with a past-time orientation tend to:
• Be traditional.
• Do things the way they have always been done.
IMAGE: 3010.GIF
Persons with a present-time orientation tend to:
• Look to today.
• Make few plans or provisions for the future.
Persons with a future-time orientation tend to:
• Place trust and faith in technologic innovations.
• Plan for the future.
Point 10 of 17
3011
Past, Present, or Future Time: An Example
Western healthcare tends to be future-focused, emphasizing
preventive medicine and follow-up care, and eagerly adopting the
newest techniques and medications.
IMAGE: 3011.GIF
Patients with a more present focus may have difficult complying
with medical advice related to prevention or follow-up, or any
condition not causing symptoms right now.
For example, it may be difficult for such patients to remember to
take medication for high blood pressure, or to complete a course of
antibiotics once they start to feel better.
Point 11 of 17
3012
Time Orientation: Clock Time
Some people pay careful attention to the passage of time,
according to the clock.
IMAGE: 3012.GIF
Others mark time by activities or other means.
Western healthcare is clock-focused: arriving at 11:00 means that
you are late for a 10:15 appointment.
Patients who are not clock-focused would consider both 11:00 and
10:15 “mid-morning,” and would not worry about being late.
Point 12 of 17
3013
Understanding Patients: Social Structure
In terms of power, authority, and opportunity, a social structure
may be egalitarian or hierarchical [glossary}.
FLASH ANIMATION: 3013.SWF/FLA
In an egalitarian society, such as the United States, all people are
equal (in theory, if not in practice).
In a hierarchical society, by contrast, people are not considered
inherently equal. Social status is based on characteristics such as
age, sex, lineage, or occupation.
Point 13 of 17
3014
Understanding Social Structure: An Example
Western healthcare operates within a presumed egalitarian social
structure, in which all competent adult patients have equal
authority and power to make healthcare decisions for themselves.
IMAGE: 3014.GIF
Some patients, however, may be used to a more hierarchical
structure.
For example:
• Husbands within certain cultural traditions may expect to
make healthcare decisions for their wives and children.
• A patient from a cultural tradition that holds professionals
such as doctors and teachers in exceptionally high regard
may expect the provider to make treatment decisions for
him or her.
Point 14 of 17
3015
Review
Which of the following best supports the development of cultural
competence?
a.
b.
c.
d.
Ethnocentrism
Cultural relativism
Future time orientation
Focusing exclusively on observed patient/family behavior
MULTIPLE CHOICE INTERACTION
Correct answer: B
Feedback for A: Incorrect. Ethnocentrism is the belief that
one’s own way is right and natural, and that other ways are
inferior, unnatural, uncivilized, etc. Although Western
healthcare tends to be ethnocentric, cultural competence
demands cultural relativism (answer choice B) --- a
willingness to accept that other ways may be different, but
equally valid.
Feedback for B: Correct. Cultural competence demands
cultural relativism --- a willingness to accept that other
ways may be different, but equally valid.
Feedback for C: Incorrect. Future time orientation is
common in Western medicine, but may not match the
present time orientation of many patients. The correct
answer is C. Cultural competence demands cultural
relativism --- a willingness to accept that other ways may
be different, but equally valid.
Feedback for D: Incorrect. Focusing exclusively on
observed behavior can block cultural competence, when a
provider misunderstands or comes into conflict with his or
her patients because of a failure to consider the core
values that underlie the observed behavior. The correct
answer is C. Cultural competence demands cultural
relativism --- a willingness to accept that other ways may
be different, but equally valid.
Point 15 of 17
3016
Review
FLASH INTERACTION: 3016.SWF/FLA
Complete the following table with terms from the word bank.
A person with a…
Past-time orientation
Present-time orientation
Future-time orientation
Tends to:
Do things the way they have always
been done.
Look to today.
Trust technological innovations.
Point 16 of 17
3017
Summary
You have completed the lesson on practice of cultural
competence.
NO IMAGE
Remember:
•
•
•
•
•
•
•
A value is anything of importance to an individual or
culture.
A person’s worldview consists of his or her basic
assumptions about the nature of reality.
Western medicine tends to be ethnocentric. Cultural
competence, however, demands cultural relativism.
Time orientation has two aspects: emphasis on past,
present, or future, and level of attention to clock time.
A social structure may be egalitarian or hierarchical.
Cultural values, worldview, time orientation, and social
structure can shape healthcare-related attitudes, beliefs,
behaviors, and practices.
Understanding a patient’s values, worldview, time
orientation, and social structure can help you better
understand and respond to the patient’s healthcare-related
attitudes, beliefs, behaviors, and practices, in a respectful
and effective way.
Point 17 of 17
Lesson 4: Practice of Cultural Competence
4001
Introduction
Welcome to the lesson on the practice of cultural competence.
FLASH ANIMATION: 4001.SWF/FLA
Point 1 of 22
4002
Objectives
After completing this lesson, you should be able to:
•
•
•
NO IMAGE
Distinguish between generalizations and stereotypes.
Identify the appropriate use of generalizations, with regard
to providing culturally competent care.
Recognize selected generalizations, applicable to specific
culture groups.
Point 2 of 22
4003
Culture Groups
As discussed in lesson 3, cultural values, worldview, time
orientation, and social structure can shape a patient’s healthcarerelated attitudes, beliefs, behaviors, and practices.
FLASH ANIMATION: 4004.SWF/FLA
Let’s take a look at specific culture groups, giving consideration to
how the cultural characteristics of these groups influence their
healthcare-related attitudes and behaviors.
Important note: The cultural characteristics listed on the following
screen are generalizations. They indicate common trends and
patterns seen in various culture groups. Remember, however, that
each patient is unique. Never use generalizations as an ending
point --- but rather, as a starting point to learn more about a
patient’s unique values, beliefs, and practices.
Generalizations should NEVER be used to stereotype any given
individual patient, by assuming that the patient must fit the
generalizations assigned to his or her culture group!
Point 3 of 22
4004
Culture Groups: African-American (1)
Religion tends to be important in the lives of African-Americans.
Patients should be given time and privacy to pray, and clergy
should be allowed to participate in the patient’s care, as requested
and appropriate.
FLASH ANIMATION: 4004.SWF/FLA
The father or eldest male may be the spokesperson for the family,
and may have final say in healthcare decisions for family
members.
African-Americans tend to have a present-time orientation.
Providers should emphasize the importance of preventive
medications and/or taking medication even when symptoms have
abated or are not apparent.
Point 4 of 22
4005
Culture Groups: African-American (2)
African-Americans may refer to “high blood” or “low blood,”
conditions thought to be caused and corrected by eating certain
foods. Be sure to distinguish high blood from high blood pressure,
as some of the foods thought to correct high blood can worsen
high blood pressure.
FLASH ANIMATION: 4005.SWF/FLA
The tradition of herbal remedies is strong in the African-American
culture. Be sure to ask patients whether they are taking any herbal
remedies before prescribing medication, to avoid potentially
dangerous drug interactions.
Remember! These are generalizations, and should not be used to stereotype any
individual patient. These also are selected examples only. If you treat a large
number of African-American patients, you may wish to learn more about this culture
group at:
•
www.ggalanti.com/cultural_profiles/african_american.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 5 of 14
•
http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu
age=English, page 8 of 15
•
www.diversityresources.com/rc21d/african.html
Point 5 of 22
4006
Culture Groups: Anglo-American (1)
Anglo-American patients expect to be informed of the details of
their condition. They value direct eye contact, privacy, and
emotional control. They may expect nurses to provide
psychosocial [glossary] care.
FLASH ANIMATION: 4006.SWF/FLA
Patients in this culture group generally make healthcare decisions
for themselves (and/or, if parents, for their minor children), and
value self-care.
Poverty may lead to a present-time orientation, and consequent
non-compliance with preventive medicine recommendations.
Middle- and upper-class Anglo-Americans, on the other hand, tend
to have a future focus, and are likely to comply with medical advice
related to preventive and follow-up care.
Point 6 of 22
4007
Culture Groups: Anglo-American (2)
Anglo-Americans often prefer biomedicine [ glossary], but also may
use alternative approaches. Be certain to ask about herbal
remedies and other complementary medicine.
FLASH ANIMATION: 4007.SWF/FLA
Patients in this group expect an aggressive approach to treatment,
and assume that treatment will focus on killing germs. They may
demand antibiotics, even when unnecessary.
Remember! These are generalizations, and should not be used to stereotype any
individual patients. These also are selected examples only. If you treat a large
number of Anglo-American patients, you may wish to learn more about this culture
group at:
•
www.ggalanti.com/cultural_profiles/anglo.html
Point 7 of 22
4008
Culture Groups: Asian (1)
Asian patients may agree with their provider, to show respect.
Agreement does not necessarily indicate understanding, or an
intention to comply with the treatment plan. Avoid yes or no
questions (instead, ask for responses that demonstrate
understanding), and always stress the importance of compliance.
FLASH ANIMATION: 4008.SWF/FLA
Also to show respect, Asian patients may avoid eye contact with
the provider. Do not assume this means that the patient is angry or
uninterested.
Family members will expect to be involved in treatment decisions
and patient care. Allow family members to fulfill their family duty by
providing as much non-technical care as possible to the patient,
and expect that men may make healthcare decisions for their
wives.
Point 8 of 22
4009
Culture Groups: Asian (2)
Asian patients may not express pain. Pain medication should be
offered when appropriate, even if the patient does not request it.
FLASH ANIMATION: 4009.SWF/FLA
Family members may wish to protect a patient from hearing a poor
prognosis or terminal diagnosis. Before the need arises, ask the
patient which family member(s) should receive information about
his or her condition.
Coining [glossary] and cupping [glossary] are traditional medical
practices in many Asian cultures, and should not be mistaken for
signs of abuse.
Remember! These are generalizations, and should not be used to stereotype any
individual patient. These also are selected examples only. If you treat a large
number of Asian or Asian-American patients, you may wish to learn more about this
culture group at:
•
www.ggalanti.com/cultural_profiles/asian.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 7 of 14
•
http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu
age=English, page 10 of 15
•
http://erc.msh.org/mainpage.cfm?file=5.3.0.htm&module=provider&langu
age=English, page 6 of 10
•
www.diversityresources.com/rc21d/asian.html
Point 9 of 22
4010
Culture Groups: East Indian
East Indians may consider direct eye contact rude or disrespectful.
Silence may indicate acceptance or approval.
FLASH ANIMATION: 4010.SWF/FLA
Family members are likely to take over the activities of daily living
(ADL’s) for an East Indian patient. Unless patient self-care is
medically necessary, allow this expression of familial love and
duty.
The Sikh religion forbids cutting or shaving head or facial hair. Be
sure to consult with patients before surgical prep.
Remember! These are generalizations, and should not be used to stereotype any
individual patients. These also are selected examples only. If you treat a large
number of East Indian patients, you may wish to learn more about this culture group
at:
•
www.ggalanti.com/cultural_profiles/eastindian.html
Point 10 of 22
4011
Culture Groups: Hispanic/Latino (1)
Latinos place high value on direct eye contact, friendly physical
contact, and friendly interpersonal interaction. Therefore, it is
appropriate to maintain a friendly manner with Latino patients, and
to ask patients about their families and interests before focusing on
more direct health-related issues.
FLASH ANIMATION: 4011.SWF/FLA
Children are highly valued and loved. Allow family members to
express their love and concern by spending as much time as
possible with pediatric patients, as well as adult patients.
Healthcare decisions are thought of as family decisions. Involve
the family in decisions, and expect that wives may defer to their
husbands.
Point 11 of 22
4012
Culture Groups: Hispanic/Latino (2)
Latinos may refuse hospital foods that would upset their hot/cold
body balance. Offer alternatives.
FLASH ANIMATION: 4012.SWF/FLA
Many traditional Mexican foods are high in salt and fat. Be certain
to discuss nutrition, especially with diabetics and hypertensives
[glossary].
Latino patients may use herbal remedies. Be sure to ask before
prescribing medication.
Remember! These are generalizations, and should not be used to stereotype any
individual patient. These also are selected examples only. If you treat a large
number Latino patients, you may wish to learn more about this culture group at:
•
www.ggalanti.com/cultural_profiles/hispanic.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 4 of 14
•
http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu
age=English, page 7 of 15
•
http://erc.msh.org/mainpage.cfm?file=5.3.0.htm&module=provider&langu
age=English, page 4 of 10
• www.diversityresources.com/rc21d/hispanic.html
Point 12 of 22
4013
Culture Groups: Middle Eastern (1)
Your Middle Eastern patients may believe that communication
should be two-way. Thus, you may need to share information
about yourself, to receive information from the patient.
FLASH ANIMATION: 4013.SWF/FLA
Sexual segregation is an important aspect of Middle Eastern
culture. Be certain to assign same-sex caregivers and interpreters
(as necessary).
Middle Eastern men may answer for their wives. Women may
allow their husbands to make healthcare decisions for the family.
Point 13 of 22
4014
Culture Groups: Middle Eastern (2)
Islam is important to most Middle Eastern people. Be sure to allow
time and privacy to pray. Be aware that the attitude that personal
health is in the hands of Allah may lead Middle Eastern patients to
avoid taking an active role in their own healthcare.
FLASH ANIMATION: 4014.SWF/FLA
Middle Easterners may be accustomed to heavy use of
medication, and may expect that all treatment plans should involve
a prescription for medication.
Remember! These are generalizations, and should not be used to stereotype any
individual patient. These also are selected examples only. If you treat a large
number of Middle Eastern patients, you may wish to learn more about this culture
group at:
•
www.ggalanti.com/cultural_profiles/middle_eastern.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 9 of 14
• www.diversityresources.com/rc21d/me.html
Point 14 of 22
4015
Culture Groups: Native American (1)
Patients in this group may communicate through anecdotes and
metaphors [glossary]. During a conversation, the patient may
pause for an extended length of time, to indicate careful
consideration of the question or issue. Do not press the patient for
an answer. Avoid direct eye contact and/or speaking loudly.
FLASH ANIMATION: 4015.SWF/FLA
Any illness concerns the entire family. Depending on the family
structure of the patient’s tribe, healthcare decisions may be made
by the male head of the family, the female head of the family, or
the patient.
Native Americans tend not to have a clock-focused time
orientation.
Point 15 of 22
4016
Culture Groups: Native American (2)
Native American patients may be quite stoic [glossary] about pain.
Offer pain medication when appropriate, even if the patient does
not request it.
FLASH ANIMATION: 4016.SWF/FLA
If a patient wears a medicine bag [glossary], do not treat the bag
casually, or remove it without asking the patient.
Traditional healing may be an important part of any treatment plan
for a Native American patient. Accommodate traditional healers
and allow traditional rituals whenever possible. Never touch or
casually admire a ritual object.
Remember! These are generalizations, and should not be used to stereotype any
individual patients. These also are selected examples only. If you treat a large
number of Native American patients, you may wish to learn more about this culture
group at:
•
www.ggalanti.com/cultural_profiles/native.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 6 of 14
•
http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu
age=English, page 9 of 15
• http://erc.msh.org/mainpage.cfm?file=5.3.0.htm&module=provider&langu
age=English, page 5 of 10
Point 16 of 22
4017
Culture Groups: Russian/Eastern European (1)
When caring for patients in this cultural group, be sure to be firm
and respectful, making direct eye contact.
FLASH ANIMATION: 4017.SWF/FLA
Russians tend to have a high threshold for --- and a stoic attitude
toward --- pain. Offer pain medication when appropriate, even if the
patient does not request it.
Food is appreciated and a good appetite is admired. Patients and
family members may offer small gifts of food or chocolate. Be sure
to accept these, to avoid appearing rude.
Point 17 of 22
4018
Culture Groups: Russian/Eastern European (1)
Russian and/or Eastern European patients may not feel
comfortable with too many personal questions, and may be
suspicious of providers who take notes.
FLASH ANIMATION: 4018.SWF/FLA
Smoking, excessive use of alcohol, and lack of exercise may be
problematic.
Remember! These are generalizations, and should not be used to stereotype any
individual patients. These also are selected examples only. If you treat a large
number of Russian/Eastern European patients, you may wish to learn more about
this culture group at:
•
www.ggalanti.com/cultural_profiles/russian.html
•
www.diversityresources.com/rc21d/russian.html
•
www.diversityresources.com/rc21d/sov.html
•
http://erc.msh.org/mainpage.cfm?file=5.1.0.htm&module=provider&langu
age=English, page 10 of 14
•
http://erc.msh.org/mainpage.cfm?file=5.2.0.htm&module=provider&langu
age=English, page 12 of 15
• http://erc.msh.org/mainpage.cfm?file=5.3.0.htm&module=provider&langu
age=English, page 8 of 10
Point 18 of 22
4019
The Culture of Western Medicine
Now that we have looked at a few of the culture groups you may
encounter in your practice, let’s take a brief look at the culture of
Western medicine.
IMAGE: 4019.SWF/FLA
As you review the following generalizations regarding Western
healthcare providers, consider whether any of them characterize(s)
you:
• Western healthcare tends to standardize definitions of
health and illness, and emphasizes that technology is allpowerful.
• The practice of Western medicine stresses health
maintenance and disease prevention, through
immunizations, regular screenings, etc.
• Western healthcare providers are systematic and
methodical. They like promptness, organization, and
efficiency. They dislike tardiness, chaos, and inefficiency.
• Use of jargon is common in Western healthcare.
• Western healthcare providers recognize and adhere to a
hierarchical system, in which a provider’s status is based
on education, experience, and professional
accomplishments.
• Western healthcare observes certain rituals around the
physical exam, surgical procedures, birth, death, etc.
Point 19 of 22
4020
Review
All patients within a given cultural group fit the generalizations
applicable to that group.
a. True
b. False
TRUE / FALSE INTERACTION
Correct answer: B
Feedback for A: Incorrect. Generalizations indicate
common trends and patterns seen in various culture
groups. Remember, however, that each patient is unique.
Generalizations should NEVER be used to stereotype any
given individual patient, by assuming that the patient must
fit the generalizations assigned to his or her culture group.
Feedback for B: Correct. Generalizations indicate common
trends and patterns seen in various culture groups.
Remember, however, that each patient is unique.
Generalizations should NEVER be used to stereotype any
given individual patient, by assuming that the patient must
fit the generalizations assigned to his or her culture group.
Point 20 of 22
4021
Review
FLASH INTERACTION: 4021.SWF/FLA
Drag and drop appropriate terms from the word bank to complete the table.
The following characteristic of
Western healthcare…
Desire for efficiency
Value placed on promptness
Emphasis on preventive medicine
Belief in the value and efficacy of
modern technology and
biomedicine
…may conflict with the following
characteristic of certain patients:
Use of long pauses during
conversation, to indicate careful
consideration
Lack of attention to clock-time
Present-time orientation
Belief in the value and efficacy of
traditional/folk medicine
Point 21 of 22
4022
Summary
You have completed the lesson on practice of cultural
competence.
NO IMAGE
Remember:
•
•
Generalizations indicate common trends and patterns
within a group, but should never be used to stereotype any
given individual.
Familiarize yourself with generalizations applicable to the
culture groups of patients served at your facility. Use these
generalizations as a starting point to 1) help understand
various culture groups, and 2) learn more about the unique
values, beliefs, and practices of each individual patient.
Point 22 of 22
Course Glossary
#
Term
Definition
coining
using a coin to vigorously rub the skin in a prescribed manner, causing a mild dermabrasion, with
the goal of releasing excess force "wind" from the body, hence restoring balance
placing small, heated glasses on the skin, forming a suction that leaves a red circular mark, with the
goal of drawing out a bad force
inequality or difference
limited English proficiency; used to describe people who do not speak English fluently
Joint Commission on the Accreditation of Healthcare Organizations
having to do with language
the belief that one’s way of doing things is the only right way
the belief that other ways may be different from one’s own, but equally valid in their
cultural context
a type of social organization that assumes the equality of all people, in which every
individual has an equal opportunity to obtain resources and the esteem of others in
leadership activities
a social structure in which there are ordered groupings of people
cupping
disparity
LEP
JCAHO
linguistic
ethnocentrism
cultural relativism
egalitarian
hierarchical
exacerbate
psychosocial
biomedicine
make worse
hypertensive
anecdote
a patient with high blood pressure
metaphor
stoic
medicine bag
involving both psychological and social aspects
the branch of medical science that applies biological and physiological principles to clinical
practice
short account of an incident
a figure of speech in which an expression is used to suggest a similarity between two
different things
seeming unaffected by pleasure or pain
a magical object used to control and direct supernatural forces; a charm
[Cultural Competence]
Pre-Assessment
1. Providers often do not order appropriate diagnostic tests for cultural minorities, because they do not understand or believe the patient’s
description of symptoms.
a. True
b. False
Correct: True
Rationale: This statement is true. Alternatively, providers may overcompensate by ordering too many tests.
2. Culturally competent delivery of healthcare can contribute to:
a. Fewer diagnostic errors
b. Fewer harmful drug interactions
c. Greater patient compliance with medical recommendations
d. All of these
e. None of these
Correct: All of these
Rationale: Cultural competence in the healthcare setting can contribute to more accurate diagnoses, fewer harmful drug interactions, and greater
patient compliance, as well as more successful patient education for cultural minorities; increased likelihood that cultural minorities will seek
necessary healthcare; improved healthcare access for cultural minorities; more appropriate health screening for cultural minorities; and, ultimately,
equalization of cross-cultural health disparities.
3. Your 10:15 patient arrives at 11:00. This patient is intentionally behaving in an inconsiderate and disrespectful manner.
a. True
b. False
Correct: False
Rationale: Although it may seem inconsiderate and disrespectful for a patient to arrive at 11:00 for a 10:15 appointment, if that patient comes from
a culture that is not clock-focused, he may consider both times mid-morning, and would not consider his arrival inconsiderately late.
4. In general, in which of the following cultures is direct eye contact valued as a way for patients to show respect for their healthcare provider?
a. Asian
b. East Indian
c. Native American
d. All of these
e. None of these
Correct: None of these
Rationale: All of these culture groups would tend to consider direct eye contact rude or disrespectful, when interacting with a healthcare provider.
5. Be certain to inquire regarding current use of herbal remedies before prescribing medication to:
a. Latino patients
b. Anglo-American patients
c. African-American patients
d. All of these
e. None of these
Correct: All of these
Rationale: The tradition of herbal healing is strong in the African-American culture group. Latinos and Anglos also might use herbal remedies. To
help avoid potentially harmful interactions, it is important to ask any patient about the current use of herbal remedies before prescribing
medication.
6. Which of the following is (are) true of the African-American culture group, as compared to European-Americans?
a. The African-American culture group has a higher infant mortality rate.
b. The African-American culture group has a higher rate of mortality due to flu.
c. The African-American culture group has a higher rate of mortality due to colorectal cancer.
d. All of these statements are true.
e. None of these statements is true.
Correct: All of these statements are true.
Rationale: African-Americans, as a group, have all of these health disparities, as compared to European-Americans.
7. Which of the following is (are) often problematic for Russian/Eastern European patients?
a. Smoking
b. Lack of exercise
c. Excessive use of alcohol
d. All of these
e. None of these
Correct: All of these
Rationale: All of these problems are relatively common in the Russian/Eastern European culture group.
8. Title VI of the Civil Rights Act of 1964 mandates that federally funded health-service organizations must:
a. Make hiring and firing decisions without regard to race, color, or gender.
b.
c.
d.
e.
Provide emergency medical care to all patients, regardless of ability to pay.
Provide language assistance to any patient with limited English proficiency (LEP).
All of these are correct.
None of these is correct.
Correct answer: Provide language assistance to any patient with limited English proficiency (LEP).
Rationale: Title VI requires health- and social- services organizations to provide meaningful language assistance to LEP patients/clients.
9. The Western healthcare system, as a whole, is characterized by:
a. Ethnocentrism
b. Cultural relativism
c. A present-time orientation
d. An egalitarian organizational structure
Correct: Ethnocentrism
Rationale: The Western healthcare system tends to be future-focused (emphasizing preventive medicine and the omnipotence of the latest
technology), hierarchical (according status based on education, experience, and professional accomplishments), and ethnocentric (assuming that
Western approaches to healing are best, and that other methods are not to be trusted or sanctioned).
10. You are explaining a treatment plan to an Asian patient. The patient expresses agreement with your instructions. You can assume that the
patient intends to comply with the treatment plan.
a. True
b. False
Correct: False
Rationale: Asian patients may agree with their provider, to show respect. Agreement does not necessarily indicate understanding, or an intention
to comply with the treatment plan. Avoid yes or no questions (instead, elicit responses that demonstrate understanding), and always stress the
importance of compliance.
Final Exam
Question Title: Question 1
Question: Nearly ___% of all Americans today were born outside the United States.
Answer 1:
Answer 2:
Answer 3:
Answer 4:
1
5
10
20
Correct Answer: 10
Answer Rationale: Nearly 10% of all Americans today (28 million out of a total population of close to 300 million) were born outside of the United
States.
Question Title: Question 2
Question: Ethnic/racial makeup cannot affect the metabolism of drugs.
Answer 1: True
Answer 2: False
Correct Answer: False
Answer Rationale: Many drug dosages and other medical norms are based on studies of Caucasian patients --- but evidence suggests that
racial/ethnic makeup can affect how a patient metabolizes and responds to a drug.
Question Title: Question 3
Question: The CLAS standards are meant to:
Answer 1: Correct current disparities in patient access to and receipt of medical care and services.
Answer 2: Improve medical services by making them better meet the needs of each individual patient.
Answer 3: Both of these are correct.
Answer 4: Neither of these is correct.
Correct Answer: Both of these are correct.
Answer Rationale: Both of these are goals of the CLAS standards.
Question Title: Question 4
Question: Understanding a patient’s values can help you better understand his or her behavior.
Answer 1: True
Answer 2: False
Correct Answer: True
Answer Rationale: At some level, values always drive behavior. Therefore, understanding a patient’s values can help you understand his or her
behavior.
Question Title: Question 5
Question: Which of the following is an example of cultural relativism?
Answer 1: A healthcare provider tells an African-American patient that voodoo is nonsense, and that he must take antibiotics if he wants to feel
better.
Answer 2: A healthcare provider acknowledges the importance of spiritual healing, and encourages a Native American patient to perform a
traditional healing ritual, in addition to using biomedicine.
Answer 3: Both of these are examples of cultural relativism.
Answer 4: Neither of these is an example of cultural relativism.
Correct Answer: A healthcare provider acknowledges the importance of spiritual healing, and encourages a Native American patient to perform a
traditional healing ritual, in addition to using biomedicine.
Answer Rationale: Cultural relativism accepts that other ways may be different, but equally valid.
Question Title: Question 6
Question: A patient is most likely not to take medication for asymptomatic high blood pressure if he or she comes from a(n) ________ culture.
Answer 1: Egalitarian
Answer 2: Hierarchical
Answer 3: Future-focused
Answer 4: Present-focused
Correct Answer: Present-focused
Answer Rationale: Patients with a present-time orientation tend to look today, and make few plans or provisions for the future. Therefore, these
patients may have difficulty complying with medical advice related to prevention, or any condition not causing symptoms right now.
Question Title: Question 7
Question: Which of the following patients is most likely to have a future-time orientation?
Answer 1:
Answer 2:
Answer 3:
Answer 4:
A middle-class Anglo-American
A middle-class African-American
An impoverished Anglo-American
An impoverished African-American
Correct Answer: A middle-class Anglo-American
Answer Rationale: African-Americans tend to have a present-time orientation. Poverty also can lead to a present-time orientation. Middle- and
upper- class Anglo-Americans, on the other hand, tend to be future-focused.
Question Title: Question 8
Question: Sexual segregation is an important part of ________ culture.
Answer 1:
Answer 2:
Answer 3:
Answer 4:
Answer 5:
Middle Eastern
Anglo-American
African-American
All of these
None of these
Correct Answer: Middle Eastern
Answer Rationale: Sexual segregation is an important part of Middle Eastern culture. For patients who practice sexual segregation, be certain to
assign same-sex caregivers and/or interpreters.
Question Title: Question 9
Question: During a conversation/consultation, a Native American patient may pause for long periods of time to indicate:
Answer 1: Lack of interest or concern
Answer 2: Annoyance with the healthcare provider
Answer 3: Careful consideration of the question or issue
Answer 4: Disapproval of the question or topic of discussion
Correct Answer: Careful consideration of the question or issue
Answer Rationale: During a conversation/consultation, a Native American patient may pause for long periods of time to indicate careful
consideration of the question or issue. Show respect for this communication style/pattern by not rushing or pressing the patient for an answer.
Question Title: Question 10
Question: ______ patients tend to be quite stoic about pain. Pain medication should be offered when appropriate, even if not requested.
Answer 1:
Answer 2:
Answer 3:
Answer 4:
Answer 5:
Asian
Russian
Native American
All of these
None of these
Correct Answer: All of these
Answer Rationale: All of these culture groups value stoicism. Patients may not indicate pain or request medication. Therefore, medication should
be offered when appropriate, even if not requested.