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Cultural Competence in Health Care

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

Principal Standard:
1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance:
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability:
9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Nursing Key Competencies for Baccalaureate Nurses

Key Competencies

These five competencies identify the key elements considered essential for baccalaureate nursing graduates to provide culturally competent care. These competencies serve as a framework for integrating suggested content and learning experiences into existing curricula.

  • Competency 1: Apply knowledge of social and cultural factors that affect nursing and health care across multiple contexts.
  • Competency 2: Use relevant data sources and best evidence in providing culturally competent care.
  • Competency 3: Promote achievement of safe and quality outcomes of care for diverse populations.
  • Competency 4: Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities.
  • Competency 5: Participate in continuous cultural competence development.

American Psychological Association Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations


The Guidelines represent general principles that are intended to be aspirational in nature and are designed to provide suggestions to psychologists in working with ethnic, linguistic, and culturally diverse populations.

  1.  Psychologists educate their clients to the processes of psychological intervention, such as goals and expectations; the scope and, where appropriate, legal limits of confidentiality; and the psychologists' orientations. 
    a. Whenever possible, psychologists provide information in writing along with oral explanations. 
    b. Whenever possible, the written information is provided in the language understandable to the client.

  2. Psychologists are cognizant of relevant research and practice issues as related to the population being served.
    a. Psychologists acknowledge that ethnicity and culture impacts on behavior and take those factors into account when working with various ethnic/racial groups. 
    b. Psychologists seek out educational and training experiences to enhance their understanding to address the needs of these populations more appropriately and effectively. These experiences include cultural, social, psychological, political, economic, and historical material specific to the particular ethnic group being served. 
    c. Psychologists recognize the limits of their competencies and expertise. Psychologists who do not possess knowledge and training about an ethnic group seek consultation with, and/or make referrals to, appropriate experts as necessary. 
    d. Psychologists consider the validity of a given instrument or procedure and interpret resulting data, keeping in mind the cultural and linguistic characteristics of the person being assessed. Psychologists are aware of the test's reference population and possible limitations of such instruments with other populations. 

  3. Psychologists recognize ethnicity and culture as significant parameters in understanding psychological processes. 
    a. Psychologists, regardless of ethnic/racial background, are aware of how their own cultural background/experiences, attitudes, values, and biases influence psychological processes. They make efforts to correct any prejudices and biases. 
         Illustrative Statement: Psychologists might routinely ask themselves, 'Is it appropriate for me to view this client
         or organization any differently than I would if they were from my own ethnic or cultural group?' 
    b. Psychologists' practice incorporates an understanding of the client's ethnic and cultural background. This includes the client's familiarity and comfort with the majority culture as well as ways in which the client's culture may add to or improve various aspects of the majority culture and/or of society at large. 
         Illustrative Statement: The kinds of mainstream social activities in which families participate may offer information
         about the level and quality of acculturation to American society. It is important to distinguish acculturation from
         length of stay in the United States, and not to assume that these issues are relevant only for new immigrants and
    c. Psychologists help clients increase their awareness of their own cultural values and norms, and they facilitate discovery of ways clients can apply this awareness to their own lives and to society at large. 
         Illustrative Statement: Psychologists may be able to help parents distinguish between generational conflict and
         culture gaps when problems arise between them and their children. In the process, psychologists could help both
         parents and children to appreciate their own distinguishing cultural values.
    d. Psychologists seek to help a client determine whether a 'problem' stems from racism or bias in others so that the client does not inappropriately personalize problems. 
         Illustrative Statement: The concept of 'healthy paranoia,' whereby ethnic minorities may develop defensive
         behaviors in response to discrimination, illustrates this principle. 
    e. Psychologists consider not only differential diagnostic issues but also cultural beliefs and values of the clients and his/her community in providing intervention. 
         Illustrative Statement: There is a disorder among the traditional Navajo called 'Moth Madness.' Symptoms include
         seizure-like behaviors. The disorder is believed by the Navajo to be the supernatural result of incestuous thoughts
         or behaviors. Both differential diagnosis and intervention should take into consideration the traditional values of
         Moth Madness. 

  4. Psychologists respect the roles of family members and community structures, hierarchies, values, and beliefs within the client's culture. 
    a. Psychologists identify resources in the family and the larger community. 
    b. Clarification of the role of the psychologist and the expectations of the client precede intervention. Psychologists seek to ensure that both the psychologist and client have a clear understanding of what services and roles are reasonable. 
         Illustrative Statement: It is not uncommon for an entire American Indian family to come into the clinic to provide
         support to the person in distress. Many of the healing practices found in American Indian communities are
         centered in the family and the whole community. 

  5. Psychologists respect clients' religious and/or spiritual beliefs and values, including attributions and taboos, since they affect world view, psychosocial functioning, and expressions of distress. 
    a. Part of working in minority communities is to become familiar with indigenous beliefs and practices and to respect them. 
         Illustrative Statement: Traditional healers (e.g., shamans, curanderos, espiritistas) have an important place in
         minority communities. 
    b. Effective psychological intervention may be aided by consultation with and/or inclusion of religious/spiritual leaders/practitioners relevant to the client's cultural and belief systems. 

  6. Psychologists interact in the language requested by the client and, if this is not feasible, make an appropriate referral. 
    a. Problems may arise when the linguistic skills of the psychologist do not match the language of the client. In such a case, psychologists refer the client to a mental health professional who is competent to interact in the language of the client. If this is not possible, psychologists offer the client a translator with cultural knowledge and an appropriate professional background. When no translator is available, then a trained paraprofessional from the client's culture is used as a translator/culture broker. 
    b. If translation is necessary, psychologists do not retain the services of translators/paraprofessionals that may have a dual role with the client to avoid jeopardizing the validity of evaluation or the effectiveness of intervention. 
    c. Psychologists interpret and relate test data in terms understandable and relevant to the needs of those assessed. 

  7. Psychologists consider the impact of adverse social, environmental, and political factors in assessing problems and designing interventions. 
    a. Types of intervention strategies to be used match to the client's level of need (e.g., Maslow's hierarchy of needs). 
         Illustrative Statement: Low income may be associated with such stressors as malnutrition, substandard housing,
         and poor medical care; and rural residency may mean inaccessibility of services. Clients may resist treatment at
         government agencies because of previous experience (e.g., refugees' status may be associated with violent
         treatments by government officials and agencies). 
    b. Psychologists work within the cultural setting to improve the welfare of all persons concerned, if there is a conflict between cultural values and human rights. 

  8. Psychologists attend to as well as work to eliminate biases, prejudices, and discriminatory practices. 
    a. Psychologists acknowledge relevant discriminatory practices at the social and community level that may be affecting the psychological welfare of the population being served. 
         Illustrated Statement: Depression may be associated with frustrated attempts to climb the corporate ladder in an
         organization that is dominated by a top echelon of White males. 
    b. Psychologists are cognizant of sociopolitical contexts in conducting evaluations and providing interventions; they develop sensitivity to issues of oppression, sexism, elitism, and racism. 
         Illustrative Statement: An upsurge in the public expression of rancor or even violence between two ethnic or
         cultural groups may increase anxiety baselines in any member of these groups. This baseline of anxiety would
         interact with prevailing symptomatology. At the organizational level, the community conflict may interfere with open
         communication among staff.

  9. Psychologists working with culturally diverse populations should document culturally and sociopolitically relevant factors in the records. 
    a. number of generations in the country 
    b. number of years in the country 
    c. fluency in English 
    d. extent of family support (or disintegration of family) 
    e. community resources 
    f. level of education 
    g. change in social status as a result of coming to this country (for immigrant or refugee) 
    h. intimate relationship with people of different backgrounds 
    i. level of stress related to acculturation

National Association of Social Workers Standards and Indicators for Cultural Competence in Social Work Practice

Standard 1 Ethics and Values
Social workers shall function in accordance with the values, ethics, and standards of the NASW (2008) Code of Ethics. Cultural competence requires self-awareness, cultural humility, and the commitment to understanding and embracing culture as central to effective practice.

Standard 2 Self-Awareness
Social workers shall demonstrate an appreciation of their own cultural identities and those of others. Social workers must also be aware of their own privilege and power and must acknowledge the impact of this privilege and power in their work with and on behalf of clients. Social workers will also demonstrate cultural humility and sensitivity to the dynamics of power and privilege in all areas of social work.

Standard 3 Cross-Cultural Knowledge
Social workers shall possess and continue to develop specialized knowledge and understanding that is inclusive of, but not limited to, the history, traditions, values, family systems, and artistic expressions such as race and ethnicity; immigration and refugee status; tribal groups; religion and spirituality; sexual orientation; gender identity or expression; social class; and mental or physical abilities of various cultural groups.

Standard 4 Cross-Cultural Skills
Social workers will use a broad range of skills (micro, mezzo, and macro) and techniques that demonstrate an understanding of and respect for the importance of culture in practice, policy, and research.

Standard 5 Service Delivery
Social workers shall be knowledgeable about and skillful in the use of services, resources, and institutions and be available to serve multicultural communities. They shall be able to make culturally appropriate referrals within both formal and informal networks and shall be cognizant of, and PRA-BRO-25315.CC-Standards.qxp_NASWCulturalStandards2003.Q4.11 10/14/15 4:06 PM Page 4 5 work to address, service gaps affecting specific cultural groups.

Standard 6 Empowerment and Advocacy
Social workers shall be aware of the impact of social systems, policies, practices, and programs on multicultural client populations, advocating for, with, and on behalf of multicultural clients and client populations whenever appropriate. Social workers should also participate in the development and implementation of policies and practices that empower and advocate for marginalized and oppressed populations.

Standard 7 Diverse Workforce
Social workers shall support and advocate for recruitment, admissions and hiring, and retention efforts in social work programs and organizations to ensure diversity within the profession.

Standard 8 Professional Education
Social workers shall advocate for, develop, and participate in professional education and training programs that advance cultural competence within the profession. Social workers should embrace cultural competence as a focus of lifelong learning.

Standard 9 Language and Communication
Social workers shall provide and advocate for effective communication with clients of all cultural groups, including people of limited English proficiency or low literacy skills, people who are blind or have low vision, people who are deaf or hard of hearing, and people with disabilities (Goode & Jones, 2009).

Standard 10 Leadership to Advance Cultural Competence
Social workers shall be change agents who demonstrate the leadership skills to work effectively with multicultural groups in agencies, organizational settings, and communities. Social workers should also demonstrate responsibility for advancing cultural competence within and beyond their organizations, helping to challenge structural and institutional oppression and build and sustain diverse and inclusive institutions and communities.