Renee Kinder

Many years ago, a speech therapist from the mountains of eastern Kentucky found himself spending weeks out of every month traveling between the boroughs of New York City for work.

Saying the initial experience was culture shock is an understatement. 

He grew up in a town literally absent of traffic or street signs, had limited exposure to individuals of different cultures, and knew very little about how to book a flight — much less the importance of having an E-ZPass. Yes, there are many stories of angry New Yorkers associated with that one.

Yet somehow, he found himself there, in December, being handed a guitar during holiday celebrations at a skilled nursing facility in Queens and being asked to “play something that everyone will know.”

The “he” in this story is my husband, who took a literal gamble and went straight into the Kenny Rogers classic…..

“The Gambler”
On a warm summer’s evening
On a train bound for nowhere
I met up with a gambler
We were both too tired to sleep
So we took turns a-starin’
Out the window at the darkness
The boredom overtook us
And he began to speak

He’s a much better storyteller than I, as is the culture of many in eastern Kentucky, and he claims by the second verse regardless of differences in racial, ethnic, religious or social groups he had them all singing in unison.

If all things were only that easy.

Culture, it’s a sensitive topic, best not to gamble on this one.

Furthermore, culture, cultural awareness and cultural competence are collectively listed a total of 125 times in the 861 pages of the updated State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities, (Rev. 208, 10-21-22).

Are your teams prepared to understand the associated updates and impacts on care decision-making for the entire interdisciplinary team (IDT)?

First, let’s start with some definitions. 

Culture is the conceptual system that structures the way people view the world; it is the particular set of beliefs, norms and values that influence ideas about the nature of relationships, the way people live their lives and the way people organize their world. 

Cultural Competency is a developmental process in which individuals or institutions achieve increasing levels of awareness, knowledge and skills along a cultural competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities.

Culturally Competent Care, or cultural competency, (also known as cultural responsiveness, cultural awareness, and cultural sensitivity) refers to a person’s ability to interact effectively with persons of cultures different from his/her own. It means being respectful and responsive to the health beliefs, practices and cultural and linguistic needs of diverse population groups, such as racial, ethnic religious or social groups.

The interventions in the resident’s care plan must reflect the individual resident’s needs and preferences and align with the resident’s cultural identity

Next, why is this a focus?

History and background

Cultural competence has emerged as an important issue for three practical reasons. 

First, as the United States becomes more diverse, practitioners will increasingly see people with a broad range of perspectives on health, often influenced by their social or cultural backgrounds. 

Second, research has shown that provider-patient communication is linked to health outcomes. 

Third, two landmark Institute of Medicine reports — Crossing the Quality Chasm and Unequal Treatment — highlight the importance of patient-centered care and cultural competence in improving quality and eliminating health disparities.

Increasingly diverse demographics among nursing home residents require nursing homes to provide culturally competent care. 

Cultural competency, which includes language, and cultural preferences, and other cultural aspects such as thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups, is an important aspect of person-centered care. 

Therapy providers should also consider many aspects of cultural preferences which may impact the delivery of care, such as: 

  • Food preparation and choices; 
  • Clothing preferences such as covering hair or exposed skin; 
  • Physical contact or provision of care by a person of the opposite sex; or 
  • Cultural etiquette, such as avoiding eye contact or not raising the voice. 

Additionally, facilities should consider: 

  • Offering activities that are culturally relevant to resident populations within the facility; 
  • Group activities with both sexes may not be permitted or appropriate in some cultures, or the type of programming may be in conflict with his/her cultural preferences; 
  • Providing reading materials, movies, newspapers in the resident’s preferred language may help orient a resident to date, times and events. 
  • Allowing the performance of religious rites at end of life to the extent possible; and 
  • Certain medications, procedures or treatments may be prohibited

Documentation should be comprehensive.

There are several tools that facilities may use in addition to the Resident Assessment Instrument to assist them in identifying a resident’s cultural preferences.

Chapter 3 of the RAI gives guidance on completing Minimum Data Set (MDS) items in section A that addresses Race, Ethnicity and Language with which the resident most closely identifies. 

These MDS items may be indicators of a resident’s culture and may indicate further assessment is necessary to determine if there are any cultural preferences which should be honored while the resident is in the facility. The categories in this classification are socio-political constructs and should not be interpreted as being scientific or anthropological in nature. They provide demographic race/ethnicity specific health trend information. 

MDS Section A identifies whether the resident wants or needs an interpreter and the resident’s preferred language. Inability to make needs known and to engage in social interaction because of a language barrier can result in isolation, depression, and unmet needs. Language barriers can interfere with accurate assessmentResident-specific approaches must be developed and included in the resident’s care plan. These interventions must be provided consistently, and supervising staff should monitor the delivery of care and staff interactions with the resident to assure they are implemented as written. Using consistent staff, to the extent possible, will assist the resident in feeling more comfort in the facility. If concerns related to culturally competent and/or trauma-informed care planning are identified, see additional guidance at §483.21(b) in F656.

Cultural competence, it’s not a topic to gamble on.

As every gambler knows

That the secret to survivin’

Is knowin’ what to throw away- like misconceptions about others

And knowin’ what to keep- perhaps including a greater appreciation of our own beliefs and practices.

Ready to learn more?

Consider the following resources:
The National Center for Cultural Competence

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, developed by the HHS Office of Minority Health

The Office of Minority Health “Think Cultural Health” website

Georgetown University’s Cultural Competence in Health Care: Is it important for people with
chronic conditions?

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab
and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category.
Additionally, she serves as Gerontology Professional Development Manager for the American Speech
Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University
of Kentucky College of Medicine community faculty and is an advisor to the American Medical
Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at
[email protected]