The term cultural competence is finally starting to become common parlance in the nursing profession. Although various definitions of cultural competence exist, when minority health experts talk about “culturally sensitive care” most nurses pretty much understand what this means. But how do patients–especially patients of color–define cultural competence? What exactly does culturally competent health care mean to them, and how do they want clinicians to provide it?
To answer these questions, a research team funded in part by the Agency for Healthcare Research and Quality (AHRQ) conducted a series of 19 community focus groups with racially and ethnically diverse health care consumers. The groups included 61 black participants, 45 Latinos and 55 non-Latino whites. As reported in the Healthcare Intelligence Network’s online newsletter Healthcare Daily Data Byte, some of the study’s key findings were:
• Definitions of culture common to all three ethnic groups include value systems (25% of focus group comments), customs (17%), self-identified ethnicity (15%), nationality (11%) and–surprisingly–stereotypes (4%).
• All three groups cited the following as cultural factors that either positively or negatively influenced the quality of health care encounters: clinicians’ sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), discrimination based on social class (9%), ethnic concordance of clinician and patient (8%) and age-based discrimination (4%).
• Differences between the minority and the white participants’ responses emerged in several areas. Only the black and Latino participants cited the following as important cultural factors: ethnicity-based discrimination (11%), clinicians’ acceptance of the role of spirituality (2%) and of family (2%). Additional factors specific to Latino respondents were language issues (21%) and immigration status (5%).
The first national study on Hispanic health risks and leading causes of death in the United States by the Centers for Disease Control and Prevention (CDC) showed that similar to non-Hispanic whites (whites), the two leading causes of death in Hispanics are heart disease and cancer. Fewer Hispanics than whites die from the 10 leading causes of death, but Hispanics had higher death rates than whites from diabetes and chronic liver disease and cirrhosis. They have similar death rates from kidney diseases, according to the new Vital Signs.
Health risk can vary by Hispanic subgroup. For example, nearly 66% more Puerto Ricans smoke than Mexicans. Health risk also varies partly by whether Hispanics were born in the United States or in another country. Hispanics are almost three times as likely to be uninsured as whites. Hispanics in the United States are on average nearly 15 years younger than whites, so taking steps now to prevent disease could mean longer, healthier lives for Hispanics.
“Four out of 10 Hispanics die of heart disease or cancer. By not smoking and staying physically active, such as walking briskly for 30 minutes a day, Hispanics can reduce their risk for these chronic diseases and others such as diabetes,” says CDC Director Tom Frieden, MD, MPH. “Health professionals can help Hispanics protect their health by learning about their specific risk factors and addressing barriers to care.”
This Vital Signs report recommends that doctors, nurses, and other health professionals
• work with interpreters to eliminate language barriers when patients prefer to speak Spanish.
• counsel patients with or at high risk for high blood pressure, diabetes, or cancer on weight control and diet.
• ask patients if they smoke and, if they do, help them quit.
• engage community health workers (promotores de salud) to educate and link people to free or low-cost services.
Hispanic and other Spanish-speaking doctors and clinicians, as well as community health workers or promotores de salud, play a key role in helping to provide culturally and linguistically appropriate outreach to Hispanic patients.
The Vital Signs report used recent national census and health surveillance data to determine differences between Hispanics and whites, and among Hispanic subgroups. Hispanics are the largest racial and ethnic minority group in the United States. Currently, nearly one in six people living in the United States (almost 57 million) is Hispanic, and this is projected to increase to nearly one in four (more than 85 million) by 2035.
Despite lower overall death rates, the study stressed that Hispanics may face challenges in getting the care needed to protect their health. Sociodemographic findings include:
• About one in three Hispanics have limited English proficiency.
• About one in four Hispanics live below the poverty line, compared with whites.
• About one in three has not completed high school.
These sociodemographic gaps are even wider for foreign-born Hispanics, but foreign-born Hispanics experience better health and fewer health risks than U.S.-born Hispanics for some key health indicators, such as cancer, heart disease, obesity, hypertension, and smoking, the report said.
The report also found different degrees of health risk among Hispanics by country of origin:
• Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites. Mexicans also are nearly twice as likely to die from chronic liver disease and cirrhosis as whites.
• Smoking overall among Hispanics (14%) is less common than among whites (24%), but is high among Puerto Rican males (26%) and Cuban males (22%).
• Colorectal cancer screening varies for Hispanics aged 50 to 75 years.
• About 40% of Cubans get screened (29% of men and 49% of women).
• About 58% of Puerto Ricans get screened (54% of men and 61% of women).
• Hispanics are as likely as whites to have high blood pressure. But Hispanic women with high blood pressure are twice as likely as Hispanic men to get it under control.
“This report reinforces the need to sustain strong community, public health, and health care linkages that support Hispanic health,” says CDC Associate Director for Minority Health and Health Equity, Leandris C. Liburd, PhD, MPH, MA.
Breast density, which is associated with breast cancer risk, was found to be higher in black/African American women than white women when measured using novel quantitative methods, according to research presented at the American Association for Cancer Research’s annual meeting, held on April 18-22, 2015.
“Since breast density is associated with breast cancer risk, a better understanding of racial differences in breast density levels could help us identify women at the highest risk for breast cancer and target prevention strategies to those women,” says Anne Marie McCarthy, PhD, a research fellow at Massachusetts General Hospital in Boston.
Black women in the study had a significantly higher absolute area density of 40.1 cm2 compared with 33.1 cm2 in white women. In addition, black women had a significantly higher volumetric density of 187.2 cm3 compared with 181.6 cm3 in white women.
After adjusting for other factors associated with breast density, including age, body mass index, hormone therapy, and reproductive factors, black women were found to have significantly higher breast density than white women across all measures.
According to McCarthy, breast density refers to the amount of fibroglandular tissue in the breast when observed on a mammogram. Fibroglandular tissue appears as white on the mammogram, making it difficult to visually detect breast cancers. Research has shown that women who have the highest breast density have a four-to-six times greater risk for breast cancer compared with women with lower breast density.
Traditionally, radiologists examine mammograms and assign patients a breast density level; however, this assignment can be subjective, McCarthy says. Instead, in this study, McCarthy and colleagues used fully automated computer algorithms to produce both the conventional two-dimensional breast density measurement and a three-dimensional volumetric estimate of breast density. The study included 1,589 black/African American women and 1,256 white women who underwent screening mammography at the University of Pennsylvania from 2010 to 2011.
“Our findings are using a new, quantitative and, perhaps, more reliable way to measure breast density,” McCarthy says. “Our next step will be to see how quantitative density measures and other imaging biomarkers are associated with cancer risk, cancer subtype, and stage of diagnosis by race.”
This study was funded by the National Institutes of Health. The computer software used for breast density estimation has been made publicly available and free for research purposes by the University of Pennsylvania.
Many adults in the United States are not getting the recommended screening tests for colorectal, breast, and cervical cancers, according to data published in the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report. For 2013, screening for these types of cancers either fell behind previous rates or showed no improvement.
Among adults in the age groups recommended for screening, about 1 in 5 women reported not being up-to-date with cervical cancer screening, about 1 in 4 women reported not being up-to-date with breast cancer screening, and about 2 in 5 adults reported not being up-to-date with colorectal cancer screening.
The report found that colorectal cancer testing was essentially unchanged in 2013 compared with 2010. Pap test use among women aged 21 to 65 years was lower than in 2000, and the number of mammography screenings was stagnant, showing very little change from previous years.
“It is concerning to see a stall in colorectal cancer screening rates,” says Lisa C. Richardson, MD, MPH, director of CDC’s Division of Cancer Prevention and Control. “We must find new ways to make people and providers aware that getting tested for colorectal cancer could prevent cancer and save their lives.”
Researchers reviewed data from the National Health Interview Survey 2013, which is used to monitor progress toward Healthy People 2020 goals for cancer screening based on the most recent U.S. Preventive Services Task Force guidelines.
The screening data for 2013 show that 58.2% of adults aged 50 to 75 years reported being screened for colorectal cancer; 72.6% of women aged 50 to 74 had a mammogram; and 80.7% of women aged 21 to 65 had a Pap test. All of these percentages are below the Healthy People 2020 targets.
The report found that adults without insurance or a usual source of health care generally had the lowest screening test use. For example, less than one quarter of adults in these groups reported recent colorectal cancer screening, compared with more than 60% of adults with private insurance or a usual source of health care. More efforts are needed to achieve cancer screening goals and reduce screening disparities.
The authors did report some good news: the proportion of women in the highest education and income groups who were screened for breast cancer exceeded the Healthy People 2020 target, and the proportion of people aged 65 to 75 who were screened for colorectal cancer was also near the target.
Through the Affordable Care Act, more Americans will qualify to get health care coverage that fits their needs and budget, including important preventive services such as screening for some cancers that may be covered with no additional costs. Visit Healthcare.gov to learn more.
Nurses believe medical errors could be reduced if the medical devices hospitals rely on for testing, monitoring, and treating patients could seamlessly share information, according to the results of a national survey of more than 500 nurses conducted online by Harris Poll on behalf of the Gary and Mary West Health Institute.
Each year, it is estimated that more than 400,000 Americans die from preventable medical errors. This not only takes an enormous emotional toll on families and friends, but also places a heavy economic burden on the nation—an estimated trillion dollars or higher. As hospitals wage a war on error, there is growing appreciation that medical devices, while individually safe and effective at improving care and saving lives, can create risks for patients and challenges for clinicians when not seamlessly connected.
According to the survey, half of these nurses said they witnessed a medical error resulting from a lack of coordination among medical devices in a hospital setting. Devices include everything from infusion pumps, ventilators, pulse oximeters, and blood pressure cuffs to electronic health records. The weighted survey was conducted online from January 7–16, 2015, and included 526 nurses (credentialed at RN or higher and with an education of BSN or higher) who work full–time in a non–school setting.
Among these nurses, three in five (60%) said medical errors could be significantly reduced if medical devices were connected and shared data with each other automatically. This problem could be addressed by the widespread adoption of open communications standards that allow for the safe and secure exchange of data.
“Nurses are the front line of patient care and have an unrivaled ability to identify and address problems at the intersection of patients and technology,” says Dr. Joseph Smith, West Health Institute’s chief medical and science officer. “The survey helps show how much of a nurse’s time could be better spent in direct care of patients and families, and how errors could be potentially avoided if medical devices, which have been so successful at improving patient care, were able to take the next step and seamlessly share critical information around the patient’s bedside.”
Medical device interoperability, the ability to safely share health information across various technologies and systems, could provide important benefits such as enhanced patient safety and better clinical outcomes at a lower cost. The West Health Institute has estimated that a system of connected devices could potentially save more than $30 billion each year by reducing redundant testing, manual data entry, and transcription errors.
According to the survey, nearly half of these nurses (46%) said an error is extremely or very likely to occur when information must be manually transcribed from one device to another.
“I have seen many instances where numbers were incorrectly transcribed or put in reverse or put in the wrong column when typed manually, which can cause errors,” said one nurse who participated in the anonymous poll.
But perhaps even more important, transcribing data “takes way too much time for the nurses to adequately care for the patient,” one nurse responded. Many of these nurses agreed, with more than two out of three (69%) saying manually transcribing data is very likely to take time away from patients who need attention.
“Nurses enter the profession because they want to care for patients, not because they are interested in programming machines,” says Patricia H. Folcarelli, RN, senior director of Patient Safety at the Silverman Institute for Health Care Quality and Safety at Beth Israel Deaconess Medical Center. “As many as 10 devices may monitor or treat a single patient in an intensive care unit. The nurse not only has to program and monitor the machines, he or she often spends a significant amount of time transcribing data by hand because the devices are not designed to share information.”
“It’s time that we free our health care workers to do what they do best and what they are most needed for, which is caring for patients,” says Smith. “Let’s not ask busy clinicians to do those things that technology can automate easily and effectively. Medical device interoperability can save lives, time, and money, and at the same time allow nurses to focus on caring for patients.”
ABOUT THE WEST HEALTH INSTITUTE
The Gary and Mary West Health Institute is an independent, nonprofit medical research organization that works with health care providers and research institutions to create new, more cost–effective ways of delivering high–quality care. For more information, visit www.westhealth.org.