An Examination of Cultural and Linguistic Competence In

AN EXAMINATION OF CULTURAL AND LINGUISTIC COMPETENCE IN HEALTH CARE Except where reference is made to the work of others, the work described in this dissertation is my own or was done in collaboration with my advisory committee. This dissertation does not include proprietary or classified information. _______________________________________ Marilyn V. Whitman Certificate of Approval: ______________________________ ______________________________ Thomas J. Vocino Anne Permaloff, Chair Professor Professor Political Science and Public Political Science and Public Administration Administration ______________________________ ______________________________ Caleb M. Clark Bradley Moody Professor Associate Professor Political Science Political Science and Public Administration ______________________________ Joe F. Pittman Acting Dean Graduate School AN EXAMINATION OF CULTURAL AND LINGUISTIC COMPETENCE IN HEALTH CARE Marilyn V. Whitman A Dissertation Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Auburn, Alabama December 15, 2006 AN EXAMINATION OF CULTURAL AND LINGUISTIC COMPETENCE IN HEALTH CARE Marilyn V. Whitman Permission is granted to Auburn University to make copies of this dissertation at its discretion, upon request of individuals or institutions and at their expense. The author reserves all publication rights. __________________________ Signature of Author __________________________ Date of Graduation iii DISSERTATION ABSTRACT AN EXAMINATION OF CULTURAL AND LINGUISTIC COMPETENCE IN HEALTH CARE Marilyn V. Whitman Doctor of Philosophy, December 15, 2006 (M.P.A., University of North Florida, 1999) (B.A., Stetson University, 1998) 320 Typed Pages Directed by Anne Permaloff The increasing number of foreign-born persons in the United States is creating significant cultural and linguistic challenges for health care providers. The Department of Health and Human Services, Office of Minority Health (OMH) has issued standards to guide hospitals in the provision of culturally and linguistically appropriate care to all patients. This research used a combination of mail and Internet surveys to examine whether Alabama’s 101 general medical and surgical hospitals are meeting these standards. The surveys were directed to Chief Executive Officers (CEOs), Human Resource Directors (HRDs), and Registered Nurses (RNs). iv The findings indicate that health care providers do believe that the increasing foreign-born population will pose future cultural and linguistic challenges for their hospitals and the overwhelming majority has witnessed an increase in the number of non- English speaking patients. HRDs indicated that their hospitals are actively recruiting persons from diverse cultural, religious, and linguistic backgrounds, yet the distribution of their hospitals’ workforce by race indicates that hospitals are having difficulty finding qualified candidates from races other than White, non-Hispanic and Black or African American. A greater percentage of CEOs and RNs indicated that their hospitals do have trained interpreters on staff; however, an overwhelming majority of RNs indicated that interpreters are not available on all shifts and they have not been trained on how to effectively use interpreters. Hospitals are having difficulty finding trained interpreters in their area and often rely on non-English speaking patients to bring a family member or friends to help translate, a practice discouraged by OMH and most research on competent care. In addition, a greater percentage of RNs agreed that they prefer to care for a patient that is of the same culture and speaks the same language because it is easier. While some of the OMH standards are being met, many are not, and policies and procedures described by CEOs are often contrary to the perceptions of those held by the RNs, suggesting miscommunication. Overall, Alabama general medical and surgical hospitals appear to be taking the initial steps to prepare for the diversifying patient population. All respondents indicate a willingness to become more culturally and linguistically competent, but a great deal needs to be accomplished before Alabama hospitals meet the OMH standards. v ACKNOWLEDGEMENTS The author would like to express thanks to those who were instrumental in the development of this research study. I owe a debt of gratitude to Dr. Anne Permaloff, whose infinite wisdom, encouragement, and patience pushed me to be better than I ever imagined I could be. I could never have done this without you. Thank you to Dr. Thomas Vocino and Dr. Caleb Clark who provided ongoing support and to Dr. Bradley Moody who always seemed to know when I needed a good laugh. A very special thanks to N. Genell Lee, Executive Director of the Alabama Board of Nursing. Your passion and commitment made this research possible and for that, and so much more, I am eternally grateful. Mom and Dad, the day has finally come. This is the culmination of your efforts. Your boundless love, support, and encouragement have enabled me to reach far beyond my wildest dreams. The baton has been passed, and I am now ready to run my race. And last, but certainly not least, to my husband, Taylor, who absorbed the brunt of my misgivings and frustrations. Your unwavering devotion and confidence in my strength and ability to see this through made this possible and all the more sweeter! Thank you. vi Style manual or journal used: Publication Manual of the American Psychological Association (2001) Computer software used: Microsoft Word 2002 Microsoft Excel 2002 RFFlow Version 5.02 SPSS 13.0 for Windows Graduate Student Version vii TABLE OF CONTENTS PAGE LIST OF TABLES xii LIST OF FIGURES xvi CHAPTER I INTRODUCTION AND RESEARCH OBJECTIVES 1 Statement of the Problem 1 Overview of Subject 5 Research Questions 16 Purpose and Significance of the Research Questions 17 Theoretical Focus of the Study 18 Methodology and Approach 21 Limitations of the Study 24 Overview of Chapters 25 II LITERATURE REVIEW 27 Origins of Cultural Competence 27 Cultural Competence Defined 38 Cultural Competence Frameworks 41 Cultural Assessment Models and Guides 60 Communication and Health Care 67 Linguistic Competence 72 viii CHAPTER PAGE Cultural Diversity in the Health Care Workforce 78 Organizational Culture and Cultural and Linguistic Competence 84 Summary 88 III GOVERNMENTAL AND PROFESSIONAL RESPONSIBILITY FOR CULTURAL AND LINGUISTIC COMPETENCE IN HEALTH CARE 89 Beyond the Melting Pot 89 The Rising Number of Foreign-Born 93 Alabama’s Changing Demographics 99 History of Federal Efforts to Combat Growing Health Disparities 105 Professional Support for Cultural and Linguistic Competence 112 Assessment of Cultural and Linguistic Competence 116 Summary 118 IV METHODOLOGY AND APPROACH 119 Unit of Analyses and Method of Sample Selection 119 Method of Respondent Selection 123 Chief Executive Officers 123 Human Resource Directors 124 Registered Nurses 125 Survey Method 128 Discussion of Questionnaires 131 Internal and External Validity 136 Methods of Analysis 137 Characteristics of Hospital Population 138 Characteristics of Respondents: Chief Executive Officers 141 and Human Resource Directors Chief Executive Officer Sample 141 ix CHAPTER PAGE Human Resource Director Sample 143 Characteristics of Registered Nurse Population 145 Characteristics of Registered Nurse Respondents 148 V FINDINGS 153 CEO Sample Findings 153 HRD Sample Findings 164 RN Sample Findings 176 Summary of Findings 194 VI ANALYSIS 201 Crosstabulations 201 CEO Sample 201 HRD Sample 211 Analysis of CEO and HRD Responses from the Same 221 Hospital RN Sample 222 Analysis of CEO, HRD, and RN Responses from the 226 Same Hospital Cultural and Linguistic Competency in Urban v. Rural Hospitals 230 VII CONCLUSION 241 Implications of Findings and Recommendations 241 Future Directions 252 Significance of the Study 253 REFERENCES 255 APPENDICES 270 Appendix A 270 x CHAPTER PAGE Appendix B 271 Appendix C 273 Appendix D 279 Appendix E 280 Appendix F 281 Appendix G 283 Appendix H 290 Appendix I 291 Appendix J 292 Appendix K 294 Appendix L 303 Appendix M 304 xi LIST OF TABLES PAGE 3.1 Number and Percent of Foreign-Born in the U.S., 1880 to 2005 97 3.2 Demographics of U.S. Health Care Professionals 99 3.3 Alabama Population by Race, 1820 to 1990 101 3.4 Foreign-Born Population in Alabama, 1990 to 2005 102 4.1 Distribution of Alabama Hospitals Offering General Medical and 139 Surgical Services by Ownership 4.2 Distribution of Hospitals by Location 139 4.3 Distribution of Hospitals by Bed Size 140 4.4 Comparison of CEO Sample and Population by Classification 142 4.5 Comparison of HRD Sample and Population by Classification 144 4.6 Distribution of Registered Nurses by Gender 146 4.7 Distribution of Registered Nurses by Age 146 4.8 Distribution of Registered Nurses by Highest Level of Education 147 4.9 Distribution of Registered Nurses by Race 148 4.10 Comparison of RN Sample and Population by Demographic Indicator 150 5.1 CEO Sample Responses to Future Problems Due to Increase in 154 Foreign-Born (Percentages) 5.2 CEOs Responses to the Provision of and Their Commitment to 155 Culturally and Linguistically Appropriate Care (Percentages) 5.3 CEO Sample Responses Regarding Trained Interpreters on Staff 157 xii 5.4 CEO Sample Responses for Reasons Why There Are No Trained 158 Interpreters on Staff (Percentages) 5.5 CEO Sample Responses on Telephone Interpreter Service 159 5.6 CEO Sample Responses to Signage, Providing Foreign Language 160

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