Abstract
Through surveys, the study assesses cultural competency levels among EMT students and prehospital healthcare providers. Understanding cultural competence is vital for improving EMS practice in an increasingly diverse population. It involves respecting diverse beliefs and values and engaging in continuous learning. A rating scale tool titled Cultural competence self-assessment checklist by the Central Vancouver Island Multicultural Society evaluated participants’ cultural competency levels, offering valuable data.1
The study included prehospital provider employees in NYC, EMTs, and paramedic students to gather diverse perspectives. Findings suggest a correlation between racial identity, occupation in EMS, and awareness of privilege when interacting with Black Indigenous and People of Color (BIPOC) communities. Caucasian individuals in EMS who participated in the study are more likely to acknowledge privilege than non-Caucasian individuals, prompting further investigation into factors influencing this disparity.
Despite the challenges in providing care sensitive to cultural differences, a better understanding of cultural competence is required to develop efficient educational and training initiatives that will lead to high-quality professional EMS practice for a population that is becoming more and more diverse. The first steps toward achieving cultural competence involve understanding oneself and accepting others. The literature also acknowledges that cultural competence goes beyond mere terminology and interest in other cultures.
To truly live in harmony with various cultural traditions, one must possess knowledge, acceptance, and a commitment to lifelong learning. Cultural competence involves recognizing and respecting diverse populations’ beliefs, values, and practices. It also requires healthcare professionals and emergency medical technicians to actively engage in ongoing learning and reflection to improve their ability to provide culturally sensitive care.
By prioritizing cultural competence in education and training programs, EMS professionals can ensure that they are equipped to meet the unique needs of an increasingly diverse population. The study aims to evaluate the understanding of cultural knowledge, awareness, and skills within EMS programs and prehospital healthcare providers in the industry to help identify areas of strength and opportunities for ongoing personal and professional development.
Introduction
The demographics of the U.S. are changing at an unprecedented rate. According to the 2015 U.S. Census, Hispanics and Latinos are the largest minority group in the country (Weir et al., 2021). Furthermore, it is anticipated that minorities will account for 54% of the country’s population by 2050.2 (2015) U.S. Census Bureau. According to the Population Estimates Program of the U.S. Census Bureau, a single racial group makes up 98% of all U.S. residents.3
People who identify as belonging to just one race are referred to as being in a “single racial group.” White, black, or African American individuals, as well as Asian, American Indian, Alaska Native, and Pacific Islander individuals, make up these populations. The remaining 2% of people identify as belonging to two or more single-race categories. These individuals are referred to as being in a “multiracial group” and represent the growing diversity within the United States. The multiracial group includes individuals who identify with combinations of the racial categories, reflecting their mixed heritage and cultural backgrounds.
The diversity of the population has steadily increased, creating problems for both those who provide and receive healthcare. It’s crucial to consider several factors when providing care for a diverse population, including communication styles, cultural differences, explanatory styles, and interpreter services. According to the U.S. Census Bureau, 20% of Americans spoke a language other than English at home as of 2007.2
The challenges brought on by linguistic diversity have grown more complex. Healthcare professionals frequently struggle to convey medical information in a way that avoids cultural misunderstanding, in addition to a lack of understanding about how culture may affect patients’ perceptions of their health or illness.
The purpose of this article is to discuss the value of cultural diversity amongst prehospital healthcare providers. A review of the literature suggests that EMS providers demonstrate competence in cultural assessment through ongoing education and training to recognize diversity of populations to provide culturally competent care to the increasing number of diverse healthcare consumers.
It is crucial to stress the need for ongoing education and training, as it can equip EMS providers with the knowledge and tools to address the unique needs of diverse populations, ultimately improving health outcomes for all patients.
Background and Purpose
When culture is overlooked, barriers to providing effective services may emerge. Culturally diverse populations, for example, frequently face barriers such as out-of-home placements and more restrictive settings, as well as professionals who may have good intentions but have yet to be trained to work with culturally diverse populations.
The negative impact of these issues is exacerbated by the number of professionals of color and professionals trained to work specifically with diverse populations is decreasing in proportion to the growth rates of the diverse groups.4 Furthermore, while many programs strive to provide services in a culturally competent manner, there are few systematic approaches to assessing a worker’s readiness to work cross-culturally.5
A person’s or a population’s values, beliefs, customs, traditions, ways of thinking, norms, and mores are referred to as their culture. Attitudes, ideas, and behaviors are passed down through the generations. Cultural values shape our perspectives on life, our thinking, and our decision-making. Depending on the culture, we may identify as a sister, brother, eldest, youngest, matriarch, or patriarch in the family. The definitions of additional roles that are assumed within the family structure are also impacted by culture.
Although ethnic cultures vary greatly, each ethnic group has its own unique set of additional cultural norms. Generational traits define different cultures that might exist within the same family. Members of one ethnic group might not share the same traditions or religious convictions. As a result, it can be challenging to treat multiple members of a single family that spans several generations. In this context, the role of the EMS provider in compiling a precise health history becomes crucial to convey a care plan effectively.
The Office of Minority Health (OMH) of the U.S. Department of Human Services completed and published Setting the Agenda for Research on Cultural Competency in Health Care in September 2016.6The study aimed to determine how cultural competency affects healthcare delivery and professional development. In particular, the Cross definition and the descriptions from the Culturally and Linguistically Appropriate Services (CLAS) standards served as the foundation for the definition of cultural competence.7
Working successfully in cross-cultural environments requires a system, organization, or group of professionals who adhere to a standard set of congruent behaviors, attitudes, and policies. Culture is a term that incorporates all the institutions, language, thoughts, communications, behaviors, habits, beliefs, values, and practices of a racial, ethnic, religious, or social group. “Competence” is the ability of an individual or a group to effectively operate within the cultural norms, practices, and expectations set by clients and their communities.
Leininger and McFarland define cultural diversity as variations or distinctions in core beliefs, meanings, patterns, values, symbols, and ways of life.8 There are variations among people and cultures. These numerous factors all increase the risk of patient and provider miscommunication. Salimbene emphasizes the importance of healthcare professionals being aware of their and their patient populations’ perceptions of healthcare. Governmental organizations have acknowledged the need for healthcare professionals to receive training on cultural diversity.
Through the Office of Public Health and Science and the OMH, the U.S. Department of Health and Human Services has collaborated with the Agency for Health Care Research and Quality to study cultural diversity and competence.9 The establishment of Setting the Agenda for Research and Cultural Competency in Health Care aimed to analyze the various elements of cultural competence, define its meaning, and assess its influence on healthcare delivery and health outcomes.10
OMH helped in the development of the National Standards on CLAS.11 Three major categories—organizational support for cultural competence, language access services, and culturally competent care—are used to categorize the 14 standards. The OMH was aware of the need to provide services in a way that was both linguistically and culturally appropriate.
However, the existing rules were insufficient and often led to miscommunication and suboptimal outcomes. Healthcare professionals lacked direction on how to treat patients from different cultural backgrounds and ensure the best outcomes because there were no comprehensive guidelines. This lack of comprehensive guidelines underscores the urgent need for change and improvement in healthcare delivery.
The realization that there was a need for national standards led to the development of a national focus on CLAS standards. The final version, published in the Federal Register in 2000, included recommendations from all stakeholders, including healthcare organizations, communities, and providers. The 2003 Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” highlights minorities and healthcare quality.12
The paper asserts that despite considering factors such as insurance, comorbidities, education, and socioeconomic status, minorities still receive care of worse quality. The report also recognizes the complexity of differences in the healthcare system. Wilson-Stronks et al. published One Size Do Not Fit All: Meeting the Health Care Needs of Diverse Populations in 2008 as a response.13,14 This report aimed to investigate prehospital (EMS) resources and additional strategies that hospitals could use to meet the needs of various populations while still paying attention to their own infrastructure.
Wilkes-Stronks et al. claim that there is no universally applicable solution, and that the complexity of the problem requires the attention of all parties involved in the healthcare system.13,14
A recurring theme is the requirement for hospitals and other healthcare organizations to make progress in their efforts to become culturally competent. It’s critical to keep learning and to grasp the overall complexity of various cultures. There is no one-size-fits-all approach to fostering cultural competence and diversity.
However, the contributions of many anthropologists and medical experts, including the significant work of Dr. Madeline Leininger and Dr. Yolanda Moses from the University of California, in addressing issues relating to self-evaluation, education, and acceptance of cultural similarities and differences, cannot be overstated.8
Guo and Castillo developed a framework to guide healthcare organizations and providers by outlining a few culturally competent strategies to improve patient outcomes and care quality for various populations.15 They determined that the provision of culturally competent care requires the three essential components of communication, monitoring, and feedback.
The American Medical Association, American Nurses Association, and The Joint Commission have acknowledged the importance of cultural competency and diversity training for healthcare professionals. More than just seasoned professionals, cross-cultural and linguistic proficiency is expected of seasoned professionals.
The U.S. Department of Health and Human Services has worked hard to enhance the curricula of the EMS and medical schools.9 In higher education institutions like medical, EMS, and nursing schools, there has been a renewed focus on this topic. However, training in topics like cultural competency, diversity, race relations, and ethnic sensitivities has been around for decades. Cultural diversity-focused curricula have many prerequisites, targets, and prospects.
The literature review will detail this to show the need for various theories, definitions, and suggested frameworks to train healthcare professionals to be more culturally competent.
The literature is abundant with recommendations for educating healthcare professionals to become culturally competent. A common thread that runs through all the theories is the understanding that cultural competence is a journey, not a destination. Campinha-Bacote’s model of cultural competence initially comprised four domains-cross-cultural interactions, cross-cultural learning, and cross-cultural awareness. Later, a fifth construct—cultural desire—was added to the model. The first concept, cultural awareness, is about understanding oneself, the impact of culture, one’s worldview, and how biases emerge.
The second quality, referred to as cultural knowledge, entails being aware of another person’s environment and point of view. This is referred to as learning about various worldviews and learning about biological ethnic differences.16
Different things can have an impact on how drugs are absorbed and how the body reacts to different medicines and herbs. Additional biological traits that are specific to ethnicity include genetics and hereditary conditions like Mediterranean or thalassemia anemia. Campinha-Bacote defines cultural skill as the capacity to elicit cultural information that is pertinent and significant to that patient.
This skill is a key component in providing effective healthcare, as it allows healthcare professionals to gather patient-specific information on values and beliefs. It’s critical to approach patients’ perceptions of their condition and treatment beliefs with compassion.
Cross-cultural interactions and cross-cultural desire are the final two concepts in Bacote’s Campinha-model theory. According to her, differences within groups outweigh those between them. It is crucial to understand this by looking at what is known or thought to be known by various cultural groups. She says that healthcare professionals should interact with various people to avoid stereotyping.
The final definition given by (Campinha-Bacote et al., 2019) is the desire to contribute to the development of cultural competence.10 Bacote’s definition of cultural desire, the newest addition to the Campinha model, is the motivation and desire to work with diverse populations (2019).10 Most importantly, Campinha-Bacote et al. advocate for patients to receive sincere care from their healthcare provider. Without cultural desire, the other components of skill, awareness, knowledge, and encounters on the road to cultural competence are lacking (2019).10
The structures of each cultural group vary in importance and impact how decisions about healthcare are made. It is also important to consider that patients may not always make decisions about their health. Often, family that is at the patient’s bedside can impose themselves on the patient’s care; whether it is to push for care, deny care or bombard the medical team with questions about the patient’s care. This is a cultural practice that can frequently irritate hospital staff.
However, in considering the law, despite cultural nuisances, there must always be competency of the patient which dictates the informed and implied consent. According to a New York State Department of Health Emergency Medical Technician, Basic Refresher Curriculum “Patients must be of legal age and able to make a rational decision, be informed of the steps of the procedures and all related risks and must be obtained from a conscious, mentally competent adult before rendering treatment” .17
Further, if the patient is unconscious, there is still a legal duty to render care, as it is implied that a patient would indeed consent to be cared for, unless there are circumstances of advance directives (such as a do not resuscitate). All in all, the patient does have the right to refuse treatment and documentation is vital.
As cited from the New York State Department of Health Emergency Medical Technician, Basic Refresher Curriculum “the patient may withdraw from treatment at any time. I.E., an unconscious patient regains consciousness and refuses transport to the hospital; refusal must be made by mentally competent adults; and the patient must be informed of and fully understand all the risks and consequences associated with refusal of treatment/transport, as well as signing a “release from liability” form”.17
According to Campinha-Bacote et al., cultural assessments should be carried out for all patients, not just those whose cultures are unknown to the healthcare provider (2019).10 Every patient deserves to have their cultural background considered when being treated and assessed. Researchers caution against categorizing things, like cultures, into categories.18
Different structures can be used to create social groups. Cultures can vary among themselves regarding gender, age, and religion. According to Purnell and Paulanka, developing cultural awareness is a process that leads to respect and acceptance.18
The range of awareness may be divided into several categories, including unconsciously incompetent (lack of awareness of cultural differences), consciously incompetent (awareness of knowledge deficit for cultural competence), consciously competent (healthcare worker consciously seeks information regarding a patient’s culture but is uncomfortable caring for diverse patients), and unconsciously competent (ability to provide culturally congruent care automatically).
Through cross-cultural interactions and immersion programs, individuals can develop awareness, knowledge, and a desire to become culturally competent. In cross-cultural interactions, language integration plays a role. Jones et al. investigated a project that involved American medical professionals and Mexican patients (2020).19
The project included both Spanish instruction and staying with Mexican families. The authors felt that although the project was only a weeklong, the immersion gave the medical staff practical knowledge and communication skills. Subtle variations in cultural communication practices, such as gestures, small talk, voice tonality, and eye contact, can impact healthcare professionals’ ability to receive and convey information to patients.
For example, consider the Spanish culture, where conducting a health assessment without first telling a story—asking about the family and engaging in small talk—is expected.
Another example is the non-physical location inquiry, which inquiries about the origin of the healthcare provider. The culturally acceptable response would be to describe where your parents, including uncles and aunts, are located since the question is not about where you live but about your family and background. Knowing the purpose of the communication is crucial for providers when collecting and sharing health data.
Methods
The project involves conducting one hundred and seventy-five consented electronical and paper surveys to gather data on the cultural competency levels of EMT students and working prehospital healthcare providers. This study was reviewed and deemed minimal risk and exempt by the IRB approved through Kings Borough Community College.
The researchers will analyze the data to identify strengths and areas for improvement in cultural awareness. The Cultural Competence Self-Assessment Checklist by the Central Vancouver Island Multicultural Society is a tool designed to help individuals and organizations evaluate their level of cultural competence. Cultural competence refers to the ability to interact effectively with people from different cultural backgrounds and understand and respect diversity.
The checklist typically includes statements or questions related to cultural competence, such as awareness of one’s biases, knowledge of different cultures, communication skills, ability to adapt to other cultural contexts, and willingness to learn and grow in cultural competence.
As a user of the checklist, you play a key role in the self-assessment process. You are asked to rate yourself or your organization on each statement or question, typically using a scale such as “strongly agree,” “agree,” “disagree,” or “strongly disagree.”
By completing the checklist, you can identify areas where you are strong in cultural competence and areas where you may need to improve. The Cultural Competence Self-Assessment Checklist is a powerful tool that promotes self-awareness, reflection, and continuous learning. Its aim is to foster more inclusive and respectful environments for people from diverse backgrounds.
By using this tool, individuals and organizations can take significant steps towards becoming more culturally competent and better equipped to engage with a diverse world.
By including participants from both hospital employees in New York City and EMT students in Brooklyn and Staten Island, we aim to gather a diverse range of perspectives and experiences. This multi-faceted approach will provide a comprehensive understanding of cultural competency within the emergency medical services industry.
While the research did not receive external funding, the findings from this study have the potential to significantly enhance future training programs and policies. These initiatives, aimed at improving cultural competency among EMTs and other prehospital healthcare providers, could ultimately elevate the standard of care provided to diverse patient populations in emergency medical situations.
Results
The study’s findings suggest that there may be a correlation between racial identity, occupation in the emergency medical field, and awareness of privilege when interacting with BIPOC communities. The results indicate that white individuals in the emergency medical services industry are more likely to acknowledge their implicit biases in interactions with BIPOC groups compared to non-white individuals in the same field.
This raises important questions about how one’s racial identity and professional context may influence one’s understanding of bias and its implications in healthcare settings. Further research is needed to investigate the reasons behind this observed correlation. Possible factors to explore include personal experiences, educational background, exposure to diversity training, and workplace culture.
Understanding the root causes of this phenomenon is crucial to address any potential biases or disparities in care that may arise from differing levels of privilege awareness among healthcare providers.
It is essential for healthcare workers, regardless of their racial identity, to recognize and actively address their privilege to foster a more inclusive and equitable healthcare system.1By acknowledging and working to overcome biases and disparities, healthcare providers can help ensure that all individuals, regardless of race or background, receive the high-quality care they deserve.
This study underscores the importance of ongoing education and training on cultural competency and diversity in healthcare to promote positive patient interactions and outcomes.
Discussion
According to the literature, patient care professionals need knowledge, skills, exposure to different cultures, and ongoing education to provide appropriate care to diverse populations in the United States. Education should be continued throughout professional practice, starting in EMT, paramedic, and medical schools.
Just as it is essential for patients to understand their health condition, EMS professionals from various cultures may have different perspectives on health and medical care. Disagreements with patients and other healthcare professionals may result from these differences. There is still disagreement over the ideal way to implement a cultural competence education strategy. However, there is general agreement among experts regarding the importance and value that a healthcare professional with cultural competence can add to providing high-quality care and successful outcomes.
The Joint Commission states that patient safety is a top priority in healthcare settings.19 Patients will not heed medical advice if the necessity of the treatment or medication is not patiently and carefully explained to them. It might take longer to explain why and how to take medications to patients and families from various cultural backgrounds. Many cultures will adopt the elders’ advice and apply conventional therapeutic techniques. This could entail using herbal remedies and other practices that could interact negatively with widely used Western medical techniques.
Integrating cultural competency into EMS education and training is a complex task that requires a comprehensive and holistic approach. It’s not just about discrete modules on cross-cultural encounters; the curriculum should also provide opportunities for self-reflection, social awareness, and global engagement.22
By encouraging students to examine their biases, privilege and cultural lenses, as well as to critically analyze the social determinants of health, EMS programs can empower future responders to provide more equitable, empathetic, and effective care.1
This approach aligns with the emerging recommendations in the public health field, which stress the importance of intercultural competency training at multiple institutional levels.23 Similarly, research in higher education has shown that fostering cultural awareness and competency can promote mental health and well-being.24
Beyond cross-cultural encounters, cultural competency in EMS also necessitates understanding how broader sociocultural factors influence an individual’s health and healthcare experience.25 Prehospital care providers must be recognizant of how historical patterns of discrimination, socioeconomic disparities, and systemic barriers to healthcare can shape a patient’s perception and healthcare-seeking behaviors. By acknowledging these complex dynamics, EMS professionals can tailor their approach to provide more personalized, empathetic, and effective care.
Moreover, cultural competency in EMS extends beyond individual patient interactions; it also encompasses the ability to navigate and collaborate effectively within diverse teams and organizations. Effective teamwork and communication among EMS personnel from various backgrounds are essential to delivering high-quality, coordinated prehospital emergency care.
Cultivating a work environment that values diversity, promotes open dialogue, and fosters mutual understanding can enhance the cohesion and resilience of EMS teams, ultimately benefiting the communities they serve.
Recommendations for Additional Research
According to the literature review, the study supports the notion that increasing cultural competence necessitates both internal reflection and awareness. Healthcare professionals must develop critical competencies in the knowledge, skill, and awareness domains to care for various populations.
The diverse cultural community requires that healthcare professionals develop their skills and cultural sensitivity. However, providing culturally competent care has its challenges. Among them is a need for more diversity in the workforce and shoddy patient-provider communication.
Additionally, it is typical for employers in the healthcare industry to need more resources to provide services in various languages and cultures. One is the need for more interpreters for diverse patient populations and a lack of understanding of cultural norms and health literacy, both of which are essential for the populations served.
As a result of provider and patient misunderstandings, patients frequently experience patient dissatisfaction and worse health outcomes. Even though the federal government, EMS programs, and medical school programs have provided guidelines to advance education and training, there still needs to be more focus, expertise, and consistency in advancing various educational programs. Even though it has shown the importance of cultural competence and the crucial training techniques for delivering culturally competent care, this is only the first of several qualitative and quantitative studies to understand cultural competency in Allied health programs better.
There will be recommendations for EMS professors to help health professionals gain knowledge, understand the importance of cultural diversity, and develop the abilities necessary to provide high-quality, culturally competent care. It is necessary to conduct more research on the levels of cultural education needed for EMS programs and the tools for measuring changes in cultural competence.
This will aid in the future development of EMS program curricula and evaluation of those curricula, preparing paramedic graduates to fully understand the needs of a variety of patients and be able to provide culturally competent care.
Conclusion
Understanding cultural competence involves more than just being familiar with the term and its definitions. Healthcare professionals must be committed to providing culturally competent care and having the required knowledge, skills, and resources.
This is especially true of EMS personnel, which may be the patient’s first contact with a medical professional. There are currently many difficulties because of the dynamic nature of healthcare, the diversity of patient populations, and the uniqueness of different cultures.
A deeper understanding of cultural competence is required to develop efficient educational and training strategies to lead to high-quality professional nursing practice for an increasingly diverse population despite challenges in providing care sensitive to cultural differences.
Cultural competence is crucial in healthcare as it ensures that healthcare providers can effectively communicate and provide care that is respectful of individual beliefs, values, and practices. By promoting cultural competence, healthcare professionals can bridge the gap between diverse patient populations and deliver equitable and patient-centered care.
However, it is important to acknowledge that achieving cultural competence is not a one-time task. It requires ongoing education, open-mindedness, and a commitment to continuously improving one’s knowledge and skills to meet the unique needs of each patient.
References
1. Cultural competence self-assessment … (n.d.). https://www.avma.org/sites/default/files/2022-02/DiversityCulturalCompetenceChecklist.pdf
2.Weir, H. K., Thompson, T. D., Stewart, S. L., & White, M. C. (2021). Peer reviewed: cancer incidence projections in the United States between 2015 and 2050. Preventing chronic disease, 18. https://doi.org/10.5888%2Fpcd18.210006
3.Colby, S. L., & Ortman, J. M. (2015). Projections of the Size and Composition of the US Population: 2014 to 2060. Population Estimates and Projections. Current Population Reports. P25-1143. US Census Bureau.
4.Uher, A., Fisher, M. H., & Josol, C. K. (2023). Cultural competency training for the social service professions: A systematic literature review. Multicultural Learning and Teaching, (0). https://doi.org/10.1515/mlt-2022-0024
5. Im, H., & Swan, L. E. (2021). Working towards culturally responsive trauma-informed care in the refugee resettlement process: Qualitative inquiry with refugee-serving professionals in the United States. Behavioral Sciences, 11(11), 155. https://doi.org/10.3390/bs11110155
6. Beasley, C., Jones-Locklear, J., & Jacobs, M. A. (2021). Cultural competence with American Indian clients: workforce and personal development. North Carolina Medical Journal, 82(6), 423-426.
7. de Peralta, A. M., Gillispie, M., Mobley, C., & Gibson, L. M. (2019). It’s all about trust and respect: cultural competence and cultural humility in mobile health clinic services for underserved minority populations. Journal of health care for the poor and underserved, 30(3), 1103-1118. https://doi.org/10.1016/j.pmedr.2021.101551
8. McFarland, M. R., & Wehbe-Alamah, H. B. (2019). Leininger’s theory of culture care diversity and universality: An overview with a historical retrospective and a view toward the future. Journal of Transcultural Nursing, 30(6), 540-557.
9. Grimm, B., Ramos, A. K., Maloney, S., Abresch, C., Tibbits, M., Lyons, K., & Palm, D. (2022). The most important skills required by local public health departments for responding to community needs and improving health outcomes. Journal of Community Health, 47(1), 79-86. https://doi.org/10.1007/s10900-021-01020-0
10. Campinha-Bacote, J. (2019). Cultural Competemility: A Paradigm Shift in the Cultural Competence versus Cultural Humility Debate–Part I. Online Journal of Issues in Nursing, 24(1). https://doi.org/10.1016/j.cnur.2023.11.009
11. Lee, S. (2021). Evaluation of the national CLAS standards: Tips and resources. Journal of Gerontological Social Work, 64(4), 442-445. https://doi.org/10.1080/01634372.2021.1882638
12. Amutah, C., Greenidge, K., Mante, A., Munyikwa, M., Surya, S. L., Higginbotham, E., … & Aysola, J. (2021). Misrepresenting race—the role of medical schools in propagating physician bias. New England Journal of Medicine, 384(9), 872-878. DOI: 10.1056/NEJMms2025768
13. Wilson-Stronks, A., Lee, K. K., Cordero, C. L., Kopp, A. L., & Galvez, E. (2008). One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: Joint Commission.
14. Kumpula, R. S. (2019). Approaches for addressing diversity in nursing education. Routledge International Handbook of Nurse Education, 318-334.
15. Woodward, E. N., Singh, R. S., Ndebele-Ngwenya, P., Melgar Castillo, A., Dickson, K. S., & Kirchner, J. E. (2021). A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implementation Science Communications, 2(1), 61. https://doi.org/10.1186/s43058-021-00146-5
16. Module 2: – new york state department of health. (n.d.). https://www.health.ny.gov/professionals/ems/pdf/refmod2.pdf
17. Majnoon, S., Yates, V. M., Asgarpour, H., Mirza Aghazadeh Attari, A., & Lotfi, M. (2023). Cultural competence of nursing educators at medical universities of 2nd regional planning in Iran. BMC Medical Education, 23(1), 1-12. https://doi.org/10.1186/s12909-023-04274-5
18. Ginsburg, H. P. (2020). The development of addition in the contexts of culture, social class, and race. In Addition and subtraction (pp. 191-210). Routledge. ISBN 9781003046585
19. Abualhaija, N. (2021). CLARIFYING CULTURAL COMPETENCE IN NURSING: A CONCEPT ANALYSIS APPROACH. Journal of Cultural Diversity, 28(1). https://doi.org/10.1016/j.nedt.2020.104728
20. Jones, S. M. (2018). Trust development with the Spanish-speaking Mexican American patient: A grounded theory study. Western journal of nursing research, 40(6), 799-814.
21. Hatlie, M. J., Nahum, A., Leonard, R., Jones, L., Nahum, V., Krevat, S. A., … & Smith, K. M. (2020). Lessons learned from a systems approach to engaging patients and families in patient safety transformation. The Joint Commission Journal on Quality and Patient Safety, 46(3), 158-166. https://doi.org/10.1016/j.jcjq.2019.12.001
22. Krishnan, L. A., Jin, L., & Calahan, C. A. (2021). Enhancing Intercultural Competence: Can it be done without Studying Abroad?. Teaching and Learning in Communication Sciences & Disorders, 5(2), 7. https://doi.org/10.30707/TLCSD5.2.1624983591.687169
23. Luquis, R., Perez, M. A., & Suarez, S. (2022). An assessment of cultural and linguistic competence in public health preparation programs. Pedagogy in Health Promotion, 8(4), 271-279. https://doi.org/10.1177/23733799221115104
24. Solchanyk, D., Ekeh, O., Saffran, L., Burnett-Zeigler, I. E., & Doobay-Persaud, A. (2021). Integrating cultural humility into the medical education curriculum: strategies for educators. Teaching and learning in medicine, 33(5), 554-560. https://doi.org/10.1080/10401334.2021.1877711
25. Griffith, D. M., Efird, C. R., Baskin, M. L., Webb Hooper, M., Davis, R. E., & Resnicow, K. (2024). Cultural sensitivity and cultural tailoring: Lessons learned and refinements after two decades of incorporating culture in health communication research. Annual Review of Public Health, 45(1), 195-212. https://doi.org/10.1146/annurev-publhealth-060722-031158
