Our study is one of the first to link provider cultural competence with the cultural competence of the clinics where they work. Our findings indicate that primary care providers who reported that their clinics had adopted recommendations made in the CLAS standards were more likely to have attitudes and behaviors that were culturally competent. However, this relationship between providers and the clinics did not hold true for knowledge relevant to caring for a racial minority population. This suggests that enhancing provider cultural competence (attitudes and behaviors) and clinic cultural competence may be synergistic strategies for reducing healthcare disparities.
There are at least three potential interpretations of the results from this cross-sectional study that should be considered. First, clinics that have adopted more culturally competent practices may influence providers to develop more culturally competent attitudes and behavior. Second, more culturally competent providers may be attracted to work in clinics with a higher level of cultural competence. Finally, providers with culturally competent attitudes and behaviors could influence the cultural competence of the clinics where they practice by advocating for diversity training, workforce diversity and use of culturally-appropriate patient education materials. Any combination of these three conditions could exist within a given clinical setting.
The effect size linking a more diverse support staff with provider cultural competence was small. Social learning theory and the attraction-selection-attrition cycle, however, supports the existence of this relationship in the varying directions proposed. Social learning theory asserts learning is affected by observing the behavior, attitudes and emotional reactions of others and by personal experience. This effect is optimized when there is institutional support (Pettigrew & Tropp, 2006
). Support staff of color may increase provider awareness of cultural issues and informally set the standards for behavior in interacting with racially discordant patients, creating an atmosphere that is welcoming or not (Chrisman, 2007
). They may also assist with interpretation of patient interactions and advise providers on ways to more effectively interact with their racially discordant patients (Kairys & Like, 2006
; Pacquiao, 2007
). Providers’ frequent contact with support staff in the provision of routine patient care and more limited time to interact with colleagues during busy clinic hours may explain why a relationship was seen with staff diversity and not provider diversity. Surrounding healthcare providers with a diverse support staff may be one way to compensate for the short supply of minority healthcare providers and to improve the delivery of culturally competent healthcare.
An alternative explanation for the association between staff diversity and provider cultural competence is that providers who are more culturally competent may self-select into more culturally competent organizations. Schneider’s attraction-selection-attrition cycle expands upon this interpretation by suggesting not only that people are attracted to organizations based on compatibility but organizations select people with common attributes (Schneider, Goldstein, & Smith, 1995
). Organizational homogeneity is perpetuated by people resigning or being fired when they do not fit the work environment.
The availability of clinic sponsored cultural diversity programs was associated with provider cultural motivation. Clinic sponsorship of such programs may serve as a surrogate for less visible clinic characteristics that are related to providers’ motivation to learn about cultures within their practice and society. In contrast, the availability of cultural diversity programs was not associated with provider power/assimilation attitudes, culturally competent behavior, or clinical and professional knowledge relevant to caring for minority groups.
The failure to see a relationship between attendance at a cultural competence training programs (whether clinic sponsored or not) and provider cultural competence may reflect a lack of standardization in training. The literature suggests that such training programs vary considerably in curricular focus, teaching methods, and depth of experience (Beach, Price, Gary, Robinson, Gozu, Palacio et al., 2005
). It is possible, for example, that providers in this study attended programs that only raised awareness of the importance of culture in the care of patients but did not include experiential learning or strategies that build skills. Didactic continuing education programs alone tend not to be effective in improving professional practice (Cauffman, Forsyth, Clark, Foster, Martin, Lapsys et al., 2002
; Davis, Thomson, Oxman, & Haynes, 1995
The provision of patient education materials adapted to the language or culture of the patients served in a clinic was associated with provider cultural motivation and culturally competent behaviors in the univariate analyses. Patient education materials tailored to culture and language may serve as cues to providers to take a complete history that includes cultural factors and to incorporate cultural issues important to the patient into the plan of care. In a synthesis of the literature, Davis et al. (1995)
concluded that such patient-mediated interventions are quite effective at inducing behavior change in providers.
Knowing a provider group’s characteristics may provide some guidance to better tailoring cultural competence program content to the needs of the target group. In this study, provider characteristics were associated with some but not all of the cultural competence concepts. Specifically, providers who were younger, female, politically liberal, a family physician, a U.S. medical graduate were more likely to have attitudes and/or knowledge consistent with cultural competence.
The relationship found between provider characteristics and power/assimilation attitudes is consistent with the literature and supported our hypotheses. In this study, female, family practice and liberal providers had power/assimilation attitudes that were more empathetic toward the challenges faced by minority racial groups living in a Euro-Caucasian dominated society. The association between female gender and a more positive attitude toward treating minorities has also been found in studies with medical students (Crandall, George, Marion, & Davis, 2003
; Crandall, Reboussin, Michielutte, Anthony, & Naughton, 2007
; Gurung & Mehta, 2001
). Female physicians are more likely to attend to the psychosocial needs of patients and to encourage patient participation.(Roter & Hall, 2004
). More broadly, men, irrespective of race or ethnicity, score higher than women on social dominance orientation, a measure of the degree to which individuals desire and support group-based hierarchy and the dominance of ‘superior’ groups over ‘inferior’ groups (Pratto, Sidanius, Stallworth, & Malle, 1994
; Sidanius, Pratto, & Bobo, 1994
The finding that family physicians tended to have culturally competent power/assimilation attitudes is consistent with the founding principles of the family medicine movement, which emphasize providing healthcare to the underserved and providing humanistic care (Stephens, 1998
). In one study, medical students choosing family medicine as a career were more likely to demonstrate a societal commitment and less likely to be concerned with personal prestige (Wright, Scott, Woloschuk, Brenneis, & Bradley, 2004
). According to some scholars, liberal political orientation which indicates support for egalitarianism and the rights of minorities, and the acceptance of culturally competent power/assimilation attitudes are synonymous (Kerlinger, 1984
). The belief that disadvantage such as poverty is largely mediated by societal forces rather than factors within the control of the individual underlies liberal but not conservative ideology (Gaertner, 1973
Providers that were more confident in caring for disadvantaged patients tended to exhibit attitudes reflecting understanding of the implications of white privilege and acceptance of other cultural groups’ customs and values. It may be that providers who are comfortable providing healthcare to patients who are less fortunate than themselves are those with the capacity to be open-minded towards persons from diverse social backgrounds. This characteristic underlies cultural humility, which is the ability to check the power imbalance in the provider-patient relationship, practice ongoing self-reflection and self-critique, and seek to understand the patient’s unique perspective (Tervalon & Murray-Garcia, 1998
The incongruity between confidence in caring for minorities and knowledge may be explained by students’ and less experienced clinicians’ blind spots about their lack of skills and abilities. In one study, nursing students scored higher than experienced hospital and public health nurses on a scale measuring confidence in performing transcultural nursing skills (Bernal & Froman, 1987
). In another study, senior nursing students who received some cultural course content felt less confident in providing culturally sensitive care than similar students not exposed to the training (Alpers & Zoucha, 1996
The inverse relationship of provider age with knowledge is consistent with curriculum trends in U.S. medical and nursing schools and the literature. In response to the increasing cultural diversity of the population, U.S. medical schools have increased their efforts to include multicultural issues in their curricula. Comparison of studies conducted in 1978 and then in 2000 found a 45% increase (from 60% to 95%) in the integration of socio-cultural issues into the curricula (Flores, Gee, & Kastner, 2000
; Wyatt, Bass, & Powell, 1978
). Similar studies of U.S. nursing school curricula could not be found, but there has been an increasing number of publications in the nursing literature exploring the content, teaching methods, evaluation and faculty qualifications needed to ensure that nursing programs adequately prepares nurses to meet the needs of culturally diverse patient populations.
Limitations of this study should be noted. First, a standardized measure of provider cultural competence was not used. Although there are a number of measures of provider cultural competence in the literature, few measures have been psychometrically tested (Gozu et al., 2007
) and none fit our provider and patient population, and our operational definition of cultural competence. While our provider cultural competence measure has not been extensively tested, it advances earlier studies of cultural competence in practice settings which have relied on more limited measures such as providers’ ability to speak a second language, attendance at cultural competence programs or global self-ratings cultural competence (Fernandez, Schillinger, Grumbach, Rosenthal, Stewart, Wang et al., 2004
; Mazor, Hampers, Chande, & Krug, 2002
; Wade & Bernstein, 1991
Second, objective and comprehensive measures of clinic cultural competence would have strengthened the study. Although the researchers were unable to collect objective data, providers within clinics were reasonably consistent in their response to the clinic cultural competence items. The clinic characteristics studied were limited to those that were visible to providers in their daily work and did not include underlying organizational infrastructure (e.g. governing board diversity, community and organizational assessment and the collection of race and ethnicity data), as identified in the CLAS standards. The inclusion of these infrastructure characteristics, indicative of organizational cultural competence, in future studies would be informative.
Third, the sample size may have underpowered the study to detect relationships of provider and clinic characteristics with provider cultural competence. A number of provider and clinic characteristics were close to but did not meet the criteria for significance of p < .05. Although our sample size was small, it did exceed the sample size of comparable studies examining provider cultural competence in practice settings
Fourth, the cross-sectional design of this study limits our ability to draw causal inferences. Quantitative research is needed to understand in greater depth the nature of the relationships that were found. A randomized trial or longitudinal study might help to determine the temporal direction of the relationships between provider and clinic cultural competence.
Fifth, the generlizability of study findings to primary care providers working in small group and solo practices, and in rural settings is not known. The perspectives and experiences of providers choosing to work in these settings may differ from providers choosing to practice in urban and suburban locations, larger group practices or clinics with a principal mission of serving the disadvantaged. Differences in provider and clinic characteristics could alter the association between provider and clinic cultural competence.
In conclusion, we believe that the recommendations of the Institute of Medicine and the CLAS Standards to take a multilevel approach to reducing health care disparities by improving cultural competence at the clinic and the provider levels are prudent. Our study indicates that an interrelationship between provider and clinic cultural competence exists. Healthcare organizations can support clinicians in better caring for their patients of color by adopting practices that increase provider and staff awareness of the cultural needs of patients and integrate cultural competence into the daily work. Healthcare organizations must recognize that brief cultural diversity training programs are unlikely to induce changes in attitude or behavior without the implementation of additional organizational supports. Because they often have influence over their practice environments, providers should be taught not only ways of improving their own care to minority patients but also what ongoing support they should expect from the organizations where they work. Cultural competence evolves from a concerted effort by both clinicians and healthcare organizations to identify and remove the barriers impeding quality care to vulnerable populations.