LEARNING OUTCOME AND OBJECTIVES:  Upon successful completion of this continuing education course, you will be prepared to provide effective and respectful care for patients belonging to different populations, including those identifying as LGBTQ+. Specific learning objectives to address potential learning gaps include:

• Discuss elements of culturally competent care among different populations.
• Describe terminology that is inclusive and respectful of the LGBTQ+ community.
• Summarize health disparities, health risk factors, and clinical implications specific to members of the LGBTQ+ community.
• Identify best practices regarding collecting and protecting patient information for LGBTQ+ patients.
• Discuss elements of culturally competent care for LGBTQ+ patients, including physical space, informational materials, patient communication, and staff training.
• Examine the intersection of oppression, discrimination, and implicit biases in order to provide nondiscriminatory care.

CULTURAL COMPETENCY AMONG DIFFERENT POPULATIONS

According to the National Institutes of Health (2021), culture involves a combination of elements that are often specific to ethnic, racial, religious, geographic, or social groups. Some of these elements include personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions. These elements influence beliefs and belief systems surrounding health, healing, wellness, illness, disease, and delivery of health services.

In order to provide culturally competent care, nurses and other healthcare providers must be understanding and sensitive to the cultural characteristics common to certain populations, such as:

• Persons from various gender, racial, and ethnic backgrounds
• Persons from various religious backgrounds
• Lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) persons
• Children and senior citizens (older adults)
• Veterans
• Persons with a mental illness
• Persons with an intellectual, developmental, or physical disability

Healthcare professionals can provide improved care to diverse patients through education and training, increased knowledge and skills, and changes in attitudes and behaviors. Systems and organizations must also change their structures and culture in order to bring about better patient outcomes and reductions in disparities (Butler et al., 2016).

Race and Ethnicity

A patient’s race or ethnicity may contribute to various healthcare-related considerations:

• Physiologic variations make some groups more prone to certain diseases and conditions, such as sickle cell anemia among African Americans or Tay-Sachs disease among Eastern European Jews.
• A patient’s reaction to pain may be culturally prescribed; for example, some cultures encourage the open expression of emotions related to pain while others encourage suppression.
• Different ethnic groups have different norms of psychological well-being and acceptance of mental illness.
• Perceptions of appropriate personal space and physical contact, including between the sexes, vary among cultures.
• Different food preferences among cultural groups can be a factor in whether a patient is receiving adequate nutrition while in a hospital or other healthcare setting.
• Cultural views on sex roles, families, and relationships may impact areas such as decision making, privacy, and information sharing among patients, loved ones, and healthcare providers.
  (Taylor et al., 2019)

Religion

A patient’s religion and spirituality is often an important consideration in regard to medical decisions and culturally competent care. Therefore, healthcare providers should be aware of and respectful of a patient’s religious beliefs as they relate to issues such as diet, medicines that may include animal products, modesty, the preferred gender of their health providers, prayer times that may interfere with treatment regimens, and more.

Similarly, many patients may turn to their religious faith in order to reduce their anxieties, respond to healthcare challenges, and make difficult healthcare decisions, including end-of-life care and preparations. Health professionals should therefore provide an opportunity for patients to discuss their religious and spiritual beliefs and tailor their evaluation and treatment to meet patients’ specific needs.

Children

Culturally competent care for children requires an awareness of cultural differences that may have an impact on growth/development as well as other healthcare-related concerns. For instance:

• Common diets and feeding practices differ among groups and may contribute to nutritional or weight status in children.
• Parenting styles and health promotion behaviors can vary significantly, such as encouraging or discouraging independence in infants and toddlers.
• Practices such as infants and small children sharing a bed with parents may be of significance for the comfort of pediatric inpatients.
• Emotional development, such as acceptance around crying, can be affected by cultural views.
• For adolescents, cultural values and attitudes toward sexuality vary.

Nurses must consider these and other cultural habits, beliefs, language, and ethnicity in order to provide appropriate care for all children and families (Ricci et al., 2021).

Older Adults

Older adults are generally considered to be those ages 65 years and older. Health disparities become magnified in this population, and issues around race, ethnicity, sex, gender identification, sexual orientation, and disability continue to impact these patients’ access to healthcare and outcomes (Taylor et al., 2019).

Older adults have different healthcare needs due to normal physiologic changes of aging, the increasing prevalence of age-related disease, and other psychosocial factors. Despite these differences, culturally competent care for older patients requires nurses to avoid bias and discrimination based on age (referred to as ageism).

Stereotypes about aging, particularly in North America, are primarily negative—a time of ill health, loneliness, dependency, and poor physical and mental functioning (Donizzetti, 2019). Such negative attitudes toward and discriminatory treatment of older adults are present throughout the healthcare community and affect the quantity and quality of care provided to older patients, putting them at increased risk for undertreatment or overtreatment. For example, if a nurse has the belief that older adults are less healthy, less alert, and more dependent, then their initial assessment of the patient will reflect this belief (Swan & Evans, 2021).

A few common myths and realities about older adults include:

• Myth: Old age means mental deterioration. In reality, neither intelligence nor personality normally decrease because of aging.
• Myth: Older adults are not sexually active. In reality, although less frequent, sexual activity lasts well into the 90s in healthy older adults.
• Myth: Bladder problems are a problem of aging. In reality, incontinence is not a part of aging; it generally has a root cause and requires medical attention.
  (Taylor et al., 2019)

Veterans

Military service members, their families, and veterans have unique needs that require a culturally competent approach to healthcare services. Combat and military experiences directly and indirectly impact veterans’ health and well-being. It is important to recognize how military experiences may be associated with different adverse outcomes in order to provide quality interventions and support services.

The key elements of military culture include:

• Chain of command
• Strict routine and structure
• Respect for authority and oneself
• Strength (not asking for help)
• Honor (used to being trusted)
• Aggression (faster, harder, louder, meaner)

There is no conventional identity for a veteran. Not all veterans are older, served during wartime, were injured or have a disability, or are male. Likewise, not all those who served in the military self-identify as “veterans”; thus, healthcare professionals may ask, “Were you in the military?” instead of “Are you a veteran?”

Culturally competent care also includes an awareness of common stereotypes about the veteran population, which include:

• All veterans are in crisis.
• All veterans have posttraumatic stress disorder and/or substance use issues.
• All veterans have served in combat.
• All veterans have access to Department of Veterans Affairs (VA) healthcare.
• All veterans are homeless.
• All veterans want to be thanked for their service.
  (CalVet, n.d.)

Mental Illness

Despite all that has been learned and the urgency surrounding the need for evidence-based treatment, mental illness continues to be highly stigmatized (see table below). Mental illness–related stigma, including that which occurs in the healthcare system and among healthcare providers, creates serious barriers to access to healthcare and the quality of care a patient receives. The impact of provider stigma has been identified as the strongest barrier toward help-seeking behavior of individuals with mental illness.

MENTAL HEALTH MYTHS VS. FACTS

Myth	Fact
(Mental Health.gov., 2022)
Children do not experience mental health problems.	Even very young children may show early warning signs of mental health concerns. Half of those with mental health disorders show first signs before the person turns 14 years old.
People with mental health issues are violent, unpredictable, and dangerous.	The vast majority of those with mental health problems are no more likely to be violent than anyone else. Only 3% to 5% of violent acts can be attributed to individuals living with a serious mental illness. In fact, people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.
People with mental health issues, even those who are managing their illness, cannot tolerate the stress of holding down a job.	People with mental health problems are just as productive as other employees. Employers who hire people with mental health problems report good attendance and punctuality as well as motivation, good work, and job tenure on par with or greater than other employees.
Mental health problems are caused by a personality weakness or character flaws, and the individual can snap out of it if they try hard enough.	Mental health problems have nothing to do with being lazy or weak, and many people need help to get better. Many factors contribute to mental health problems, such as genes, physical illness, injury, brain chemistry, life experiences such as trauma or a history of abuse, or family history of mental health problems.
There is no hope for people with mental illness.	Studies show that people with mental health problems get better and many recover completely.
Therapy and self-help are a waste of time.	Treatment for mental health problems varies depending on the individual and could include medication, therapy, or both.

Lack of cultural understanding by healthcare providers may also contribute to underdiagnosis and/or misdiagnosis of mental illness in people from racially/ethnically diverse populations. Factors that contribute to these kinds of misdiagnoses include language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms. While racial/ethnic minority groups overall have similar (or, in some cases, fewer) mental disorders than Whites, they often bear a disproportionately high burden of disability resulting from mental disorders. People from racial/ethnic minority groups are also less likely to receive mental health care (APA, 2017).

Disability

The Americans with Disabilities Act (ADA) defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activities. Examples of elements of culturally competent care for patients with disabilities include:

• Ensuring all facilities are accessible in compliance with ADA requirements
• Providing individuals with access to communication aids and services, such as medical interpreters, signers, audio recordings, etc.
• Using “people first” language (see table below)
• Practicing disability etiquette when interacting, such as:
• Mobility impairments: Don’t push or touch someone’s wheelchair; bring yourself down to the person’s eye level to speak to them.
• Visual impairments: Identify yourself; don’t speak to or touch a working service animal.
• Hearing impairments: Speak directly to the person, not the interpreter; don’t assume they can read lips; don’t chew gum, wear sunglasses, or obscure your face.
• Speech disorders: Don’t finish the person’s sentences; ask the person to repeat or repeat yourself to confirm you understood.
• Developmental disabilities: Speak clearly using simple words; do not use “baby talk” or talk down to the person; do not assume they cannot make their own decisions unless you’ve been told otherwise.
(SHP, 2018)

EXAMPLES OF PEOPLE FIRST LANGUAGE

Instead of saying:	Say this:
(SHP, 2018)
Handicapped	Person with disability
Handicapped parking/seating	Accessible parking/seating
Patient	Use only when under a doctor’s care
Victim/suffering from	Had or has a disability
Retarded	Person with developmental disability or intellectual impairment
Wheelchair-bound	Uses a wheelchair
The Deaf/The Blind	A person who is deaf/blind