Submit a 250 words summary essay about the article following APA format.

Diversity and Cultural

Competency in Health Care

Jean Gordon, RN, DBA

LEARNING OUTCOMES

After completing this chapter, the student should be able to:
☛ Define diversity.
☛ Define cultural competency.
☛ Define diversity management.
☛ Understand why changes in U.S. demographics affect the health care industry.

OVERVIEW

Demographics of the U.S. population have changed dramatically in the
past three decades. These changes directly impact the health care indus-
try in regard to the patients we serve and our workforce. By 2050, the term
“minority” will take on a new meaning. According to the U.S. Census Bureau,
by midcentury the white, non-Hispanic population will comprise less than
50 percent of the nation’s population. As such, the health care industry needs
to change and adopt new ways to meet the diverse needs of our current and
future patients and employees.

The American Heritage Dictionary of the English Language (4th ed.) defines
diversity as: “(1) the fact or quality of being diverse; difference, and (2) a point
in which things differ.” Dreachslin (1998) provided us with a more specific def-
inition of diversity. She defined diversity as “the full range of human similari-
ties and differences in group affiliation including gender, race/ethnicity, social
class, role within an organization, age, religion, sexual orientation, physi-
cal ability, and other group identities” (p. 813). For our discussions, we will
focus on the following diversity characteristics: (1) race/ethnicity, (2) age, and
(3) gender.

This chapter is presented in three parts. First, we discuss the chang-
ing demographics of the nation’s population. Second, we examine how these
changes are affecting the delivery of health services from both the patient’s
and employee’s perspectives. Because diversity challenges faced by the health
care industry are not limited to quality-of-care and access-to-care issues, in
part three of our discussions we explore how these changes will affect the
health services workforce, and more specifically the current and future leader-
ship within the industry.

15

CHAPTER 2

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CHANGING UNITED STATES POPULATION

There is no doubt that the demographic profile of the U.S. population has
undergone significant changes within the past 10 years regarding age, gender,
and ethnicity (see Table 2–1 ).

Data from the 2010 Census provide insights to our racially and ethnicall

y

diverse nation (Humes, Jones, & Ramirez, 2011). According to the 2010 Cen-
sus, 308.7 million people resided in the United States on April 1, 2010—an
increase of 27.3 million people, or 9.7 percent, between 2000 and 2010. The
vast majority of the growth in the total population came from increases in
those who reported their race(s) as something other than White alone and
those who reported their ethnicity as Hispanic or Latino. For the first time in
the 2000 Census, individuals were presented with the option to self-identify
with more than one race, and this continued with the 2010 Census. Using the
five race categories (White, Black/African American, American Indian/Alaska
Native, Asian, and Native Hawaiian/Other Pacific Islander) required by fed-
eral agencies, there are 57 possible multiple race combinations that could
have been selected by individuals in addition to “some other race.” In fact,
over 7 million or 2 percent of the U.S. population did so in the 2010 Census
by identifying with and choosing “some other race” or “two or more races.” It
is predicted that the number of Americans reporting themselves or their chil-
dren as multiracial will increase in the future. In addition to the changing eth-
nic and racial composition of America, another issue is the aging population.

Table 2–1 Population of the United States by Age, Gender, and Race/Ethnicity a

2000 2010

Number Percent Number Percent

Total population 281,421,906 100.0 308,745,538 100.0

Under age 19 80,473,255 25.7 83,267,556 26.9
Ages 19 to 64 165,956,888 61.9 185,209,998 60.0
Ages 65 and over 34,991,753 12.4 40,267,984 13.0

Males 138,053,563 49.1 151,781,326 49.2
Females 142,368,343 50.9 156,964,212 50.8

White 211,460,626 75.1 196,817,552 63.7
Black 34,658,190 12.3 37,685,848 12.2
Hispanic 35,305,818 12.5 50,477,594 16.3
Asian 10,242,998 3.6 14,465,124 4.7
American Indian 2,475,956 0.9 2,247,098 0.7
Some other race 15,359,073 0.5 1,085,841 0.1
Two or more races 6,826,228 0.2 5,966,481 0.2

a Percentages do not add up to 100 percent due to rounding and because Hispanics may be of any
race and are therefore counted under more than one category.
Data from U.S. Census Bureau, 2010 Census. DP-1 – United States: Profile of General Population
and Housing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census
Data as shown in the 2009 Population Estimates table; U.S. Census Bureau: National Population
Estimates; Decennial Census.

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According to the 2010 Census, 40 million people (13 percent of the U.S. popu-
lation) are 65 years of age or older. This is 12.3 million more people than in
2000 (see Figure 2–1 ).

During the past decade, the population aged 65 and over grew at a faster
rate (15.1 percent) than the population under age 45. This trend was expected
as the Baby Boomers (those born between 1946 and 1964) began reaching age
65 in 2011 (see Figure 2–2 ).

In addition to the increasingly older population, there is a declining number
of young people in America. From 1940 to 2010, the percentage of the Ameri-
can population under the age of 18 fell from 31 percent to 24 percent (U.S.
Census Bureau, 2012). This decline in America’s younger population will have
a direct effect on the industry’s ability to recruit health care professionals to
provide sufficient services in the future. Young people of all ethnicities must
be attracted to the health care industry as a career choice in order to meet the
health care needs of the country’s growing population.

Males and females are almost evenly divided for the total population, rep-
resenting 49.2 percent and 50.8 percent, respectively; however, in the pop-
ulation under 25 years, males dominate females, with 105 males for every
100 females. Among older adults, the male–female ratio reverses, with women
outnumbering men. However, there was an interesting change in the male–
female ratios for the population aged 60 and older between 2000 and 2010
(Howden & Meyer, 2011). A greater increase in the male population relative
to the female population for these age groups was noted. Males aged 60 to

0

65 to 74
years

2000 2010 2000 2010 2000 2010

75 to 84
years

85 years
and over

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

Women

Men

Figure 2–1 Population 65 Years and Over by Age and Sex, 2000 and 2010 (numbers in
thousands)

Data from U.S. Census Bureau, 2010 Census. DP-1 – United States: Profile of General Population and Housing Characteristics: 2010 Demographic Profile Data: U.S.
Census Bureau 2000 Census Data as shown in the 2009 Population Estimates table.

Changing United States Population 17

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74 increased by 35.2 percent, while their female counterparts increased by
29.2 percent. A narrowing of the mortality gap between men and women at
older ages in part accounts for this difference.

Race/Ethnicity

The U.S. population has continued to diversify during the past 10 years,
as minority populations continue to increase at a faster rate than the White
population. Although the White population still represents the largest group
(63.7 percent) of the U.S. population, this is down from 75.1 percent in 2000
(see Table 2–1 ).

In 2010, the Hispanic population represented the largest minority in the
United States, 16.3 percent of the population. This is up from 4.5 percent in
1970, the first census in which Hispanic origin was identified. The remain-
ing population is composed of 12 percent Black, 5 percent Asian and Pacific
Islanders, 1 percent American Indians and Alaska Natives, and 3 percent
those who identified themselves as belonging to another or more than one race
(see Table 2–1 ).

The Asian population in the United States is increasing rapidly as a per-
centage of the total population. From 2000 to 2010, the population of those

Figure 2–2 Projected Population of the United States by Age, 2000–2050 (Numbers in
thousands)

Data from Population Division, U.S. Census Bureau.

0
2010 2020 2030 2040 2050

50,000

100,000

150,000

200,000

250,000

Years

0–18

19–64

65 and over

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people who identified themselves as being Asian (either alone or in combina-
tion with another race) grew 43.3 percent, while the total population grew
only 9.7 percent (see Table 2–1 )

Aging Population

The world’s population is aging. According to the United Nations (2013),
slow population growth brought about by reductions in fertility leads to popu-
lation aging; that is, it produces populations where the proportion of older per-
sons increases while that of younger persons decreases. Globally, the number
of persons aged 60 and over is expected to more than triple by 2100, which
will represent 34 percent of the world’s population, or more than 3 billion indi-
viduals. Of this group, the number of persons aged 80 and over is projected to
increase almost sevenfold by 2100, representing just under one-third of the
world’s population aged 60 and over.

The United States is experiencing the same as the world’s aging popula-
tion. As reported by Howden and Meyer (2011), the 2010 Census reflects that
the number of people under age 18 was 74.2 million (24.0 percent of the total
population). The younger working-age population, ages 18 to 44, represented
112.8 million persons (36.5 percent). The older working-age population, ages
45 to 64, made up 81.5 million persons (26.4 percent). Finally, the 65 and over
population was 40.3 million persons (13.0 percent). Between 2000 and 2010,
the population under the age of 18 grew at a rate of 2.6 percent. The growth
rate was even slower for those aged 18 to 44 (0.6 percent). On the opposite
side, the country is experiencing substantially faster growth rates for older
ages. For example, the population aged 45 to 64 grew at a rate of 31.5 percent.
The large growth in this age group is primarily attributable to the aging of the
Baby Boom population. As noted previously, the growth rate (15.1 percent) of
the 65 and over population was faster than the population under age 45.

One of the most striking characteristics of the older population is the change
in the ratio of men to women as people age. As Howden and Meyer (2011,
p. 3) point out, this is a result of differences in mortality for men and women,
where women tend to live longer than men. As such, there are more females
then males at older ages. However, over the past decade an increase in the
male population relative to the female population has been noted. For exam-
ple, in 2010, there were 96.7 males per 100 females, representing an increase
from 2000, when the ratio was 96.3 males per 100 females (Howden & Meyer,
2011). This lowering of male mortality may be attributible to technological
advances, more preventive screening, and healthier lifestyles.

While the elderly population is not as racially and ethnically diverse as
the younger generations, it is projected to increase in its racial and ethnical
makeup over the next four decades. As in the past, the highest proportion
of the U.S. population aged 60 and over is White (78.8 percent). However,
within the racial composition of the older population, White is projected to
decrease by 10 percent by 2050, and all other race groups will increase in their
own populations. This change is already being seen. In 2000, the aged White
population was 82.5 percent, a 7 percent decrease compared with 2010. The
remaining makeup of this population group is 8.8 percent Black, 7.3 percent

Changing United States Population 19

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Hispanic, and 3.6 percent Asian, with other races forming the remainder. As
noted, this population group’s racial composition will continue to change over
the next 40 years.

Gender

As previously noted, according to the U.S. Census Bureau, in 2010,
50.8 percent of the U.S. population was female, and 49.2 percent was male—
almost identical to the 2000 Census. That translates to 96 men for every 100
women. However, the ratio of men to women varies significantly by age group.
There were about 105 males for every 100 females under 25 in 2010, reflecting
the fact that more boys than girls are born every year and that boys continue
to outnumber girls through early childhood and young adulthood. However,
the male–female ratio declines as people age. For men and women aged 25
to 54, the number of men for each 100 women in 2010 was 99. Among older
adults, the male–female ratio continued to fall as women increasingly out-
numbered men. For people 55 to 64, the male–female ratio was 93 to 100, but
for those 85 and older, there were only 48 men for every 100 women. These
male–female ratios reflect a new trend that has been occurring since 1980.
From 1900 to 1940, there were more males. Beginning in 1950, there were
increasingly more females due to reduced female mortality rates. This trend
reversed between 1980 and 1990 as male death rates declined faster than
female rates and as more men immigrated to the United States than women
(United States Department of Commerce, 2003).

When we look at education, it appears that females are outpacing men.
Among the population aged 25 and older, 88 percent of both men and women
were high school graduates. But of this group, 39 percent of men had gradu-
ated from college, as compared with 61 percent of women. However, even with
college degrees, only a high minority (44 percent) of women are employed in
management or professional positions.

IMPLICATIONS FOR THE HEALTH CARE INDUSTRY

The changing demographics of America’s population affect the health care
industry twofold. First, health care professionals and organizations need
to have cultural and linguistic competence to provide effective and efficient
health services to diverse patient populations. However, before we continue
our discussion, we need to define what is meant by cultural and linguistic
competence. Over the years, cultural competence has been defined in many
ways, such as “ongoing commitment or institutionalism of appropriate prac-
tice and policies for diverse populations” (Brach & Fraser, 2000; Weech-
Maldonado et al., 2002; see Hofstede’s Cultural Dimensions, Exhibit 2–1 ).
Linguistic competence has been defined as “the capacity of an organization
and its personnel to communicate effectively, and convey information in a
manner that is easily understood by diverse audiences including persons of
limited English proficiency, those who have low literacy skills or are not liter-
ate, and individuals with disabilities” (Goode & Jones, 2004). For our discus-
sions we adopted the definition used by the Office of Minority Health (OMH

)

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Exhibit 2–1 Hofstede’s Cultural Dimensions

One of the most extensive cross-cultural surveys ever conducted is Hofstede’s (1983)
study of the influence of national culture on organizational and managerial behaviors.
National culture is deemed to be central to organizational studies, because national cultures
incorporate political, sociological, and psychological components.

Hofstede’s research was conducted over an 11-year period, with more than 116,000
respondents in more than 40 countries. The researcher collected data about “values” from
the employees of a multinational corporation located in more than 50 countries. On the
basis of his findings, Hofstede proposed that there are four dimensions of national culture,
within which countries could be positioned, that are independent of one another. Hofstede’s
(1983, pp. 78–85) four dimensions of national culture were labeled and described as:

• Individualism–Collectivism: Individualism–collectivism measures culture along a self-
interest versus group-interest scale. Individualism stands for a preference for a loosely
knit social framework in society wherein individuals are supposed to take care of them-
selves and their immediate families only. Its opposite, collectivism, stands for a prefer-
ence for a tightly knit social framework in which individuals can expect their relatives,
clan, or other in-group to look after them in exchange for unquestioning loyalty. Hofstede
(1983) suggested that self-interested cultures (e.g., individualism) are positively related
to the wealth of a nation.

• Power Distance: Power Distance is the measure of how a society deals with physical and
intellectual inequalities, and how the culture applies power and wealth relative to its
inequalities. People in large Power Distance societies accept hierarchical order in which
everybody has a place, which needs no further justification. People in small Power Dis-
tance societies strive for power equalization and demand justification for power inequali-
ties. Hofstede (1983) indicated that group-interest cultures (e.g., Collectivism) have large
Power Distance.

• Uncertainty Avoidance: Uncertainty Avoidance reflects the degree to which members of a
society feel uncomfortable with uncertainty and ambiguity. The scale runs from tolerance
of different behaviors (i.e., a society in which there is a natural tendency to feel secure) to
one in which the society creates institutions to create security and minimize risk. Strong
Uncertainty Avoidance societies maintain rigid codes of belief and behavior and are intol-
erant toward deviant personalities and ideas.

• Weak Uncertainty: Avoidance societies maintain a more relaxed atmosphere in which
practice counts more than principles and deviance is more easily tolerated.

• Masculinity Versus Femininity: Masculinity versus femininity measures the division of
roles between the genders. The masculine side of the scale is a society in which the gen-
der differences are maximized (e.g., need for achievement, heroism, assertiveness, and
material success). Feminine societies are ones in which there are preferences for relation-
ships, modesty, caring for the weak, and the quality of life.

Hofstede proposed that the most important dimensions for organizational leadership are
Individualism/Collectivism and Power Distance, and the most important for decision-making
are Power Distance and Uncertainty Avoidance. Uncertainty Avoidance plays an integral
part in a country’s culture regarding change. For example, Nahavandi and Malekzadeh (1999,
pp. 495–496) point out that countries such as Greece, Portugal, and Japan have national cul-
tures that do not easily tolerate uncertainty and ambiguity. Therefore, the resultant behavior
emphasizes the issue avoidance or the importance of planned and well-managed activities.
Other countries, such as Sweden, Canada, and the United States, are able to tolerate change
because of the potential for new opportunities that may come with change.

The question frequently asked is whether Hofstede’s (1983) cultural dimensions are still
applicable today. Patel (2003) found that the characteristics of Chinese, Indian, and Austra-
lian cultures corroborated Hofstede’s study results. Patel’s study of the relationship between
business goals and culture, measured by correlating the relative importance attached to the

(continues)

Implications for the Health Care Industry 21

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of the U.S. Department of Health and Human Services, which defines “cul-
tural and linguistic competence as a set of congruent behaviors, attitudes,
and policies that come together in a system, agency, or among professionals
and that enables effective work in cross-cultural situations.” (United States
Department of Health and Human Services, 2013).

Second, because of the changing demographics of the nation’s population,
the health care industry needs to ensure that the health care workforce mir-
rors the patient population it serves, both clinically and managerially. As
noted by Weech-Maldonado et al. (2002), health care organizations must
develop policies and practices aimed at recruiting, retaining, and managing
a diverse workforce in order to provide both culturally appropriate care and
improved access to care for racial/ethnic minorities.

DIVERSITY ISSUES WITHIN THE CLINICAL SETTING

Consider the following:

Scenario One: An insulin-dependent, indigent black non-Hispanic
male was treated at a predominantly Hispanic border clinic. Later,
he was brought back to the clinic in a diabetic coma. When he awoke,
the nurse who had counseled him asked whether he had been follow-
ing her instructions. “Exactly!” he replied. When the nurse asked him
to show her, the monolingual Spanish-speaking nurse was startled
when the patient proceeded to inject an orange and eat it.

Scenario Two: As Maria (an elderly, monolingual Hispanic female)
was being prepared for surgery, which was not why she came to the
hospital, her designated interpreter (a young female relative) was
told by an English-speaking nurse to tell Maria that the surgeon was
the best in his field and she’d get through this fine. The young inter-
preter translated, “the nurse says the doctor does best when he’s in
the field, and when it’s over you’ll have to pay a fine!”

These may seem rather humorous misunderstandings, but real-life experi-
ences such as these happen every day in the United States (Howard, Andrade,

various business goals with the national culture dimension scores from Hofstede’s study,
found that although the four cultural dimension scores were nearly 20 years old, they were
validated in this large, cross-national survey. In a study that measured 1,800 managers and
professionals in 15 countries, statistically significant correlations with the Hofstede indices
validated the applicability of the first study’s cultural dimension findings (Hofstede et al.,
2002). The findings from these studies suggest that Hofstede’s cultural dimensions continue
to be robust and are still applicable measure components of national culture differences.

NOTE: Hofstede (1991) subsequently included an additional dimension based on Chinese
values referred to “Confucian dynamism.” Hofstede renamed this dimension as a long-term
versus short-term orientation in life.

Exhibit 2–1 (Continued)

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& Byrd, 2001). For example, a survey by the Commonwealth Fund (2002)
found that black non-Hispanics, Asian Americans, and Hispanics are more
likely than white non-Hispanics to experience difficulty communicating with
their physician, to feel that they are treated with disrespect when receiving
health care, to experience barriers to access to care, such as lack of insur-
ance or not having a regular physician, and to feel they would receive better
care if they were of a different race or ethnicity. In addition, the survey found
that Hispanics were more than twice as likely as white non-Hispanics (33 per-
cent versus 16 percent) to cite one or more communication problems, such as
not understanding the physician, not being listened to by the physician, or not
asking questions they needed to ask. Twenty-seven percent of Asian Ameri-
cans and 23 percent of black non-Hispanics experience similar communication
difficulties.

Cultural differences between providers and patients affect the provider–
patient relationship. For example, Fadiman (1998) related a true and poignant
story of cultural misunderstanding within the health care profession. Fadi-
man described the story of a young female epileptic Hmong immigrant whose
parents believed that their daughter’s condition was caused by spirits called
“dabs,” which had caught her and made her fall down, hence the name of Fadi-
man’s book The Spirit Catches You and You Fall Down . The patient’s parents
struggled to understand the prescribed medical care that only recognized the
scientific necessities, but ignored their personal belief about the spirituality of
one’s soul in relationship to the universe. From a unique perspective, Fadiman
examined the roles of the caregivers (physicians, nurses, and social workers)
in the treatment of ill children. She studied the way the medical care system
responded to its own perceptions that the family was refusing to comply with
medical orders without understanding the meaning of those orders in the con-
text of the Hmong culture, language, and beliefs.

Because of our increasingly diverse population, health care professionals
need to be concerned about their cultural competency, which is more than just
cultural awareness or sensitivity. Although formal cultural training has been
found to improve the cultural competence of health care practitioners, Kund-
hal (2003) reported that only 8 percent of U.S. medical schools and no Cana-
dian medical schools had formal courses on cultural issues. However, changes
are occurring within the industry (see Exhibit 2–2 ) to assist health care prac-
titioners in the developing of their cultural competences as they encounter
more diverse patients. For example, in 2000 the Liaison Committee on Medi-
cal Education (LCME), the accrediting body of medical schools, introduced the
following accreditation standard for cultural competence:

The faculty and students must demonstrate an understanding of
the manner in which people of diverse cultures and belief systems
perceive health and illness and respond to various symptoms, dis-
eases, and treatments. Medical students should learn to recognize
and appropriately address gender and cultural biases in healthcare
delivery, while considering first the health of the patient.

This standard has given added impetus and emphasis to medical schools to
introduce education in cultural competence into the undergraduate medical
curriculum (Association of American Medical Colleges, 2005, p. 1). In addition,

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The Joint Commission has implemented patient-centered communication
accreditation standards, which require hospitals to meet certain mandates
related to qualifications for language interpreters and translators, identify-
ing and addressing patient communication needs, collecting patient race and
ethnicity data, patient access to a support individual, and nondiscrimination
in care (The Joint Commission, 2014).

Over the past decade, the Commonwealth Fund has been a leader in the
effort “to eliminate the cultural and linguistic barriers between health care
providers and patients, which can interfere with the effective delivery of health
services” (Beach, Saha, & Cooper, 2006, p. vi). The Commonwealth Fund
(2003), in addition to funding initiatives regarding quality of care for under-
served populations, has also initiated an educational program that assists
health care practitioners in understanding the importance of communication
between culturally diverse patients and their physicians, the tensions between
modern medicine and cultural beliefs, and the ongoing problems of racial and
ethnic discrimination. The goals of this program are for clinicians to:

1. Understand that patients and health care professionals often have dif-
ferent perspectives, values, and beliefs about health and illness that can
lead to conflict, especially when communication is limited by language
and cultural barriers.

2. Become familiar with the types of issues and challenges that are partic-
ularly important in caring for patients of different cultural backgrounds.

3. Think about each patient as an individual, with many different social,
cultural, and personal influences, rather than using general stereotypes
about cultural groups.

Exhibit 2–2 Unequal Treatment

A study in 2002 by the Institute of Medicine, entitled Unequal Treatment: Confront-
ing Racial and Ethnic Disparities in Health Care, found that a consistent body of research
demonstrates significant variation in the rates of medical procedures by race, even when
insurance status, income, age, and severity of conditions are comparable. This research indi-
cated that U.S. racial and ethnic minorities receive even fewer routine medical procedures
and experience a lower quality of health services than the majority of the population. For
example, minorities are less likely to be given appropriate cardiac medications or to undergo
bypass surgery, and are less likely to receive kidney dialysis or transplants. By contrast,
they are more likely to receive certain less desirable procedures, such as lower-limb ampu-
tations for diabetes.

The study’s recommendations for reducing racial and ethnic disparities in health care
included increasing awareness about disparities among the general public, health care pro-
viders, insurance companies, and policy makers.

Reproduced from unequal treatment: Confronting racial and ethnic disparities in health
care (p. 3), by B. D. Smedley, A. Y. Stitch, and A. R. Nelson (Eds.), 2002, Washington, DC:
National Academy of Sciences, Institute of Medicine Committee on Understanding and
Eliminating Racial and Ethnic Disparities in Health Care.

24 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

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vijendra.umarwal
Sticky Note
AU: We have updated credit line from provided element log. Please review and suggest.

4. Understand how discrimination and mistrust affect the interaction of
patients with physicians and the health care system.

5. Develop a greater sense of curiosity, empathy, and respect toward patients
who are culturally different, and thus be encouraged to develop better
communication and negotiation skills through ongoing instruction.

Reproduced from World’s Apart, Facilitator’s Guide by Alexander Green, MD, Joseph Betancourt, MD, MPH, and J. Emilio Carrillo, MD, MPH, The Commonwealth
Fund, p. 4.

In addition to the Commonwealth Fund, the W. K. Kellogg Foundation
has led efforts to lessen the recognized disparity of racial and ethnic minor-
ity groups’ representation among the nation’s health professionals. It was the
Kellogg Foundation that requested the Institute of Medicine’s (2004) study
entitled In the Nation’s Compelling Interest: Ensuring Diversity in the Health
Care Workforce . The Institute of Medicine found that racial and ethnic diver-
sity is important in the health professions because:

1. Racial and minority health care professionals are significantly more
likely than their peers to serve minority and medically underserved
communities, thereby helping to improve problems of limited minority
access to care.

2. Minority patients who have a choice are more likely to select health care
professionals of their own racial or ethnic background. Moreover, racial
and ethnic minority patients are generally more satisfied with the care
that they receive from minority professionals, and minority patients’
ratings of the quality of their health care are generally higher in racially
concordant than in racially discordant settings.

3. Diversity in health care training settings may assist in efforts to improve
the cross-cultural training and competencies of all trainees.

Reproduced from In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce.

In addition to the Commonwealth Fund and the W. K. Kellogg Foundation,
other organizations are active in bridging cultural differences in an attempt
to lessen health disparities. For example, in 2000 the OMH developed a list of
standards for Culturally and Linguistically Appropriate Services (CLAS), which
health care organizations and practitioners should use to ensure equal access
to quality health care by diverse populations. In 2013, these standards were
expanded to reflect the growth in the field of cultural and linguistic competency.
There are now 15 standards under four categories: (1) Principal Standard,
(2) Governance, Leadership, and Workforce, (3) Communication and Language
Assistance, and (4) Engagement, Continuous Improvement, and Accountability.

Principal Standard
1. Provide effective, equitable, understandable, and respectful quality care

and services that are responsive to diverse cultural health beliefs and prac-
tices, 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 allo-
cated resources.

Diversity Issues within the Clinical Setting 25

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3. Recruit, promote, and support a culturally and linguistically diverse
governance, leadership, and workforce that are responsive to the popula-
tion 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 pro-

ficiency and/or other communication needs, at no cost to them, to facili-
tate 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 inter-
preters 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 organiza-
tion’s planning and operations.

10. Conduct ongoing assessments of the organization’s CLAS-related activi-
ties and integrate CLAS-related measures into measurement and con-
tinuous 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 sustain-
ing CLAS to all stakeholders, constituents, and the general public.

Reproduced from the National CLAS Standards, The office of Minority Health, U.S. Department of Health and Human Services.

Another diversity area that has shown progress since 2007 is the use of
the Healthcare Equality Index (HEI) of the Human Rights Campaign (HRC)
Foundation by hospitals and other organizations. This survey is a resource
for health care organizations seeking to provide equitable, inclusive care to
lesbian, gay, bisexual, and transgender (LGBT) Americans—and for LGBT
Americans seeking health care organizations with a demonstrated commit-
ment to their care (HRC, 2014). In 2013, facilities in all 50 states and most

26 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

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U.S. veterans hospitals participated in using the HEI, with 93 percent and
87 percent reporting that sexual orientation and gender identity were
included in their patient nondiscrimination policies, respectively. These non-
discrimination policies are required for Joint Commission accreditation. In
addition, both The Joint Commission and the Centers for Medicare and Med-
icaid Services require that facilities allow visitation without regard to sexual
orientation or gender identity. Furthermore, 96 percent and 85 percent of par-
ticipants reported that sexual orientation and gender identity, respectively,
were also included in their employment nondiscrimination policies. The HEI
has two sections: (1) the core four leader criteria and (2) the additional best
practices checklist. The Core Four Leader Criteria are reflected in Table 2–2 .
The Additional Best Practices Checklist is designed to familiarize HEI partici-
pants with other expert recommendations for LGBT patient-centered care, to
help identify and remedy gaps.

AGING POPULATION

In addition to the changing ethnic and racial composition of America,
another area of concern is the growing elderly population. Technology has
given us the ability to enhance longevity; the challenge now is whether or not
the health care profession can learn how to best serve this growing population
of patients.

As our citizens grow older, more services are required for the treatment
and management of both acute and chronic health conditions. The profession
must devise strategies for caring for the elderly patient population. America’s
older citizens are often living on fixed incomes and have small or nonexistent

Table 2–2 Health Care Equality Index’s Core Four Leader

Criteria

Criteria

Patient Nondiscrimination a. Patient nondiscrimination policy (or patients’ bill of
rights) includes the terms “sexual orientation” and
“gender identity”

b. LGBT-inclusive patient nondiscrimination policy is
communicated to patients in at least two documented
ways

Equal Visitation a. Visitation policy explicitly grants equal visitation to
LGBT patients and their visitors

b. Equal visitation policy is communicated to patients in
at least two documented ways

Employment
Nondiscrimination

Employment nondiscrimination policy (or equal employ-
ment opportunity policy) includes the terms “sexual
orientation” and “gender identity”

Training in LGBT
Patient-Centered Care

Staff receive training in LGBT patient-centered care

Reproduced from Human Rights Campaign Foundation, HEI Core Four Leader Criteria. Available
at: http://www.hrc.org/hei/the-core-four-leader-criteria.

Aging Population 27

9781284087062_CH02_PASS02.indd 27 17/02/15 6:10 PM

support groups. Although this may be considered an American infrastructure
dilemma, the reality is that medical professionals must be able to understand
and empathize with poor, sick, elderly people of all races, sexes, and creeds.

The term “ageism” was coined in 1968 by Robert N. Butler, M.D., a pio-
neer in geriatric medicine and a founding director of the National Institute
on Aging (NIA). Butler was among the first to identify the phenomenon of age
prejudice, initially describing it as “a systematic stereotyping of and discrimi-
nation against people because they are old.”

Ageism can be defined as “any attitude, action, or institutional structure,
which subordinates a person or group because of age or any assignment of
roles in society purely on the basis of age” (Traxler, 1980, p. 4). Health care
professionals often make assumptions about their older patients on the basis
of age rather than functional status (Bowling, 2007). This may be due to the
limited training physicians receive in the care and management of geriatric
patients. For example, Warshaw and colleagues (2002, 2006) related that med-
ical residents have only limited training in geriatric medicine. Findings from
Warshaw et al.’s 2006 study were compared with those from a similar 2002
survey to determine whether any changes had occurred. Of the participating
three-year residency training programs, only 9 percent required six weeks or
more of training. As in 2002, the residency programs continue to depend on
nursing home facilities, geriatric preceptors in nongeriatric clinical ambu-
latory settings, and outpatient geriatric assessment centers for the medical
residents’ geriatrics training. A report from the Alliance for Aging Research
(2003) related that there continue to be shortcomings in medical training, pre-
vention, screening, and treatment patterns that disadvantage older patients.
The report outlined five domains of ageism in health care:

1. Health care professionals do not receive enough training in geriatrics to
properly care for many older patients.

2. Older patients are less likely than younger people to receive preventive
care.

3. Older patients are less likely to be tested or screened for diseases and
other health problems.

4. Proven medical interventions for older patients are often ignored, lead-
ing to inappropriate or incomplete treatment.

5. Older people are consistently excluded from clinical trials, even though
they are the largest users of approved drugs.

On a positive note, Perry (2012) relates that progress against systematic
ageism in health care has begun, in part, due to the passing of the 2010
Affordable Care Act (ACA). He notes that the law’s various provisions, such as
Medicare’s increased focus on chronic disease prevention, new models of care
for reducing re-hospitalizations, and improved care coordination, as well as
annual screening for cognitive impairment, will assist with changing attitudes
toward elderly patients.

Before moving to our next discussion regarding diversity management,
we pause to provide a brief overview of the efforts being made regarding the
measuring and reporting of cultural competency. Measurement and reporting
are needed to ensure that culturally competent care can be translated into:

28 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

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(1) improved health outcomes and more patient-centered care, and (2) action-
able initiatives for providers that result in meaningful improvement. Through
the support of the Robert Wood Johnson Foundation (RWJF), in 2009, the
National Quality Forum (NQF) endorsed a comprehensive national frame-
work based on a set of seven interrelated domains (and multiple subdomains)
for evaluating cultural competency across all health care settings, as well as
a set of 45 recommended practices based on the framework. This was followed
by RAND’s development of a cultural competency implementation measure-
ment tool. This tool is an organizational survey designed to assist health care
organizations in identifying the degree to which they are providing culturally
competent care and addressing the needs of diverse populations, as well as
their adherence to 12 of the 45 NQF-endorsed cultural competency practices.
In 2012, NQF endorsed 12 quality measures that address health literacy, lan-
guage access, cultural competency, leadership, and workforce development
(RWJF, 2014). These quality measures are the first endorsed by NQF that
specifically address health care disparities and cultural competency.

DIVERSITY MANAGEMENT

Diversity management is a challenge to all organizations. Diversity man-
agement is “a strategically driven process whose emphasis is on building
skills and creating policies that will address the changing demographics
of the workforce and patient population” (Svehla, 1994; Weech-Maldonado
et al., 2002). In 2004, the National Urban League published its first study
on employees’ perceptions regarding the effectiveness of their companies’
diversity programs. The results of the organization’s 2009 follow-up survey
found that progress has been made over the past five years in certain areas.
However, leadership commitment to diversity and companies clearly com-
municating their platform on how they value diversity are still lagging (see
Table 2–3 ).

As reflected in Table 2–3 , organizations have improved in communicat-
ing effectively regarding their diversity platforms but need to focus on their
(1) commitment to, (2) accountability for, (3) action on, and (4) measurement
of these initiatives. The good news is the notable increases reflecting the
intrinsic acceptance of diversity and inclusion by the American worker. As
reported by the National Urban League (2009), the playing field appears more
level, diverse talent is being developed and retained, and customer/consumer
diversity is being recognized.

While some gains have been made in regard to increasing diversity in the
field of health care management, recent studies continue to suggest that there
is still ample room for improvement. The Institute for Diversity in Health
Management, an affiliate of the American Hospital Association, was formed
in 1994 to address the problem that was disclosed in a 1992 study that minori-
ties held less than 1 percent of top management positions within the industry.
In addition, the study revealed that African American health care executives
made less money, held lower positions, and had less job satisfaction than
their white counterparts. A 1997 follow-up study, expanded to include Latinos
and Asians, found that although the gap had narrowed in some areas, not

Diversity Management 29

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much had changed. As examples, a study by Motwani, Hodge, and Crampton
(1995) found that only 27.7 percent of health care workers in six Midwest hos-
pitals felt that their institutions had a program to improve employee skills
in dealing with people of different cultures, and only 38.9 percent felt that
management realized that cultural factors were sometimes the cause of con-
flicts among employees. Weech-Maldonado, et al. (2002) found that hospitals
in Pennsylvania had been relatively inactive with employing diversity man-
agement practices, and equal employment requirements were the main driver
of diversity management policy. Five years later, Weech-Maldonado and col-
leagues (Weech-Maldonado, Elliott, Schiller, Hall, Dreachslin, & Hays, 2007;
Weech-Maldonado, Elliott, Schiller, Hall, & Hays, 2007) continued to find low
levels of diversity management activity within California hospitals. Since that
time, the Institute for Diversity in Health Management, in collaboration with
other organizations, designed several initiatives to expand health care leader-
ship opportunities for ethnically, culturally, and racially diverse individuals,
thus increasing the number of these individuals entering and advancing in
the field.

Table 2–3 American Workers’ Perception

Statements 2009 2004 % Change

Leadership at my company is committed
to diversity

Agree 44% 45% −1%

Leaders at my company hold themselves
and their peers accountable for progress
in diversity

Agree 37% 42% −5%

Leaders at my company are actively
involved in diversity

Agree 38% 38% 0

My company has an effective diversity
initiative

Agree 42% 32% +10%

My company holds employees account-
able for advancing diversity

Agree 27% 27% 0

My company measures the effectiveness
impact of its diversity efforts

Agree 27% 35% −8%

The ideas and input of all employees are
valued and appreciated

Agree 77% 37% +30%

At my company everyone has an equal
chance to advance

Agree 62% 44% +18%

My company is committed to developing
people who are diverse

Agree 51% 38% +13%

At my company people who are different
tend to leave

Disagree 62% 50% +12%

The employees at my company demon-
strate an appreciation of our customers’
and consumers’ diversity

Agree 60% 48% +12%

Reproduced from National Urban League. (2009). Diversity Practices That Work: The American
Worker Speaks II. Available at: http://nul.iamempowered.com/sites/nul.iamempowered.com
/files/attachments/Diversity_Practices_That_work_2009 .

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HEALTH CARE LEADERSHIP

The American College of Healthcare Executives (ACHE), the National Asso-
ciation of Health Services Executives (NAHSE), the Institute for Diversity in
Healthcare Management (IFD), the National Forum for Latino Healthcare
Executives, and the Asian Health Care Leaders Association released a study
in 2009 that measured the representation of black non-Hispanics, Hispanics,
women, and other minorities in health care executive leadership roles. This
study was a follow up to similar studies completed in 1992, 1997, and 2002.
The study, completed in 2008, was based on a random-sample survey of 1,515
health care executives. Respondents worked in a variety of settings––hospi-
tals, health care–provider organizations, government health agencies, and
consulting and educational institutes (see Table 2–4 ).

Although the results of the 1997 study reflected improvements in diver-
sity over the 1992 study (see: www.ache.org ––Race and Ethnic Study 2002),
the 2002 and 2008 results indicated that the health care industry did not do
as well in promoting minorities and women in chief executive officer (CEO)
and chief operating officer (COO)/senior vice president positions. In the 2008
ACHE study, as noted by the authors of the study (p. 12) and reflected in
Tables 2–4 and 2–5 , 34 percent of CEOs are white men, compared to 28 per-
cent of them being Hispanic men, 16 percent black men, and 5 percent Asian
men. However, these disparities are not apparent among women, where all
racial/ethnic groups hold between 10 and 13 percent of CEO positions. When
all senior executive positions are considered, including chief executive officer
and chief operating officer/senior vice president, the proportion of white men
in such positions continues to exceed that of minority men. However, among
women, a higher proportion of Hispanic women than others are in senior exec-
utive positions. The two factors of race/ethnicity and gender are evident espe-
cially when comparing blacks and whites. For both blacks and whites, only
about half as many women attained CEO or COO/senior vice president posts
as their male counterparts.

In the 2013–2014 Benchmarking Survey by the Institute of Diversity, the
results highlighted that while there was some limited increase in the diversity
of hospitals’ leadership and governance, more positive movement is needed.
The study reported that minorities composed:

• 14 percent of hospital board members (unchanged from 2011)
• 12 percent of executive leadership positions (unchanged from 12 percent

in 2011)
• 17 percent of first- and mid-level management positions (up from 15 per-

cent in 2011)

Dreachslin and Curtis (2004) noted that career advancement of women and
racially/ethnically diverse individuals in health care management was char-
acterized by: (1) underrepresentation, especially in senior-level management
positions; (2) lower compensation, even controlling for education and experi-
ence; and (3) more negative perceptions of equity and opportunity in the work-
place. The researchers identified three areas that are key organization-specific
factors for shaping career outcomes for women and racially/ethnically diverse

Health Care Leadership 31

9781284087062_CH02_PASS02.indd 31 17/02/15 6:10 PM

Ta
b

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2

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sp

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(
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)

3

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:
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Ta
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le
2
–4

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(
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at
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e
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la
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k
W
h
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e

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is
p
an
ic

A
si
an

C
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O

1
9

%

3

7
%

2

3
%

1

1
%

3

2
%

1

6
%

3

4
%

2

8
%

5
%

C

O
O

/S
e
n
io

r
V

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e

P
re

si
d

e
n
t

2
5

2
5

2
4

2
3

1
4

2
3

2
2

1
5

1
7

V
ic

e
P

re
si

d
e
n
t

2
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1
9

2
3

2
0

1
6

2
0

2
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2
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9

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1
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n

(2
1
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)

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)
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2
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)

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6
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)

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3
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si
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.

32 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

9781284087062_CH02_PASS02.indd 32 17/02/15 6:10 PM

Ta
b
le
2

–5

A
m
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ri
c
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C
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%

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0
0
%

1
0
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%

1
0
0
%

1
0
0
%

1
0
0
%

1
0
0
%

n

(2
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Health Care Leadership 33

9781284087062_CH02_PASS02.indd 33 17/02/15 6:10 PM

individuals: (1) leadership and strategic orientation (i.e., senior management’s
commitment to successful implementation of diversity initiatives), (2) orga-
nizational culture/climate (i.e., the depth and breadth of the organization’s
strategic commitment to diversity leadership and cultural competence), and
(3) human resources practices (i.e., establishing best practices in advancing
the management careers of women and racially/ethnically diverse individuals,
such as formal mentoring programs, professional development, work/life bal-
ances, and flexible benefits).

On the basis of Dreachslin’s and others’ research, the NCHL, ACHE, IFD,
and the American Hospital Association developed the Diversity and Cultural
Proficiency Assessment Tool for Leaders (see Exhibit 2–3 ). The assessment
tool begins the process of developing a cultural awareness for the organiza-
tion’s workforce. Going forward, managers will need to develop models that
establish benchmarks for cultural competence to enable their organizations to
develop competent interventions, thereby improving the quality of health care
(Betancourt, Green, & Carrillo, 2002).

Exhibit 2–3 A Diversity and Cultural Proficiency Assessment Tool for Leaders

CHECKLIST

As Diverse as the Community You Serve

YES NO

• Do you monitor at least every three years the demographics of your com-
munity to track change in gender and racial and ethnic diversity?

• Do you actively use these data for strategic and outreach planning?

• Has your community relations team identified community organizations,
schools, churches, businesses, and publications that serve racial and ethnic
minorities for outreach and educational purposes?

• Do you have a strategy to partner with them to work on health issues
important to them?

• Has a team from your hospital met with community leaders to gauge their
perceptions of the hospital and to seek their advice on how you can better
serve them, in both patient care and community outreach?

• Have you done focus groups and surveys within the past three years in
your community to measure the public’s perception of your hospital as
being sensitive to diversity and cultural issues?

• Do you compare the results among diverse groups in your community and
act on the information?

• Are the individuals who represent your hospital in the community reflec-
tive of the diversity of the community and your organization?

• When your hospital partners with other organizations for community
health initiatives or sponsors community events, do you have a strategy in
place to be certain you work with organizations that relate to the diversity
of your community?

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Exhibit 2–3 (Continued)

YES NO

• As a purchaser of goods and services in the community, does your hospital
have a strategy to ensure that businesses in the minority community have
an opportunity to serve you?

• Are your public communications, community reports, advertisements,
health education materials, websites, etc. accessible to and reflective of the
diverse community you serve?

Culturally Proficient Patient Care

• Do you regularly monitor the racial and ethnic diversity of the patients
you serve?

• Do your organization’s internal and external communications stress your
commitment to culturally proficient care and give concrete examples of
what you are doing?

• Do your patient satisfaction surveys take into account the diversity of your
patients?

• Do you compare patient satisfaction ratings among diverse groups and act
on the information?

• Have your patient representatives, social workers, discharge planners,
financial counselors, and other key patient and family resources received
special training in diversity issues?

• Does your review of quality assurance data take into account the diversity
of your patients in order to detect and eliminate disparities?

• Has your hospital developed a “language resource,” identifying qualified
people inside and outside your organization who could help your staff com-
municate with patients and families from a wide variety of nationalities
and ethnic backgrounds?

• Are your written communications with patients and families available in
a variety of languages that reflects the ethnic and cultural fabric of your
community?

• Depending on the racial and ethnic diversity of the patients you serve, do
you educate your staff at orientation and on a continuing basis on cultural
issues important to your patients?

• Are core services in your hospital such as signage, food service, chaplaincy
services, patient information, and communications attuned to the diversity
of the patients you care for?

• Does your hospital account for complementary and alternative treatments
in planning care for your patients?

Strengthening Your Workforce Diversity

• Do your recruitment efforts include strategies to reach out to the racial
and ethnic minorities in your community?

• Does the team that leads your workforce recruitment initiatives reflect the
diversity you need in your organization?

• Do your policies about time off for holidays and religious observances take
into account the diversity of your workforce?

(continues)

Health Care Leadership 35

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Exhibit 2–3 (Continued)
YES NO

• Do you acknowledge and honor diversity in your employee communica-
tions, awards programs, and other internal celebrations?

• Have you done employee surveys or focus groups to measure their percep-
tions of your hospital’s policies and practices on diversity and to surface
potential problems?

• Do you compare the results among diverse groups in your workforce? Do
you communicate and act on the information?

• Have you made diversity awareness and sensitivity training available to
your employees?

• Is the diversity of your workforce taken into account in your performance
evaluation system?

• Does your human resources department have a system in place to measure
diversity progress and report it to you and your board?

• Do you have a mechanism in place to look at employee turnover rates for
variances according to diverse groups?

• Do you ensure that changes in job design, workforce size, hours, and other
changes do not affect diverse groups disproportionately?

Expanding the Diversity of Your Leadership Team

• Has your Board of Trustees discussed the issue of the diversity of the hos-
pital’s board? Its workforce? Its management team?

• Is there a Board-approved policy encouraging diversity across the
organization?

• Is your policy reflected in your mission and values statement? Is it visible
on documents seen by your employees and the public?

• Have you told your management team that you are personally committed
to achieving and maintaining diversity across your organization?

• Does your strategic plan emphasize the importance of diversity at all lev-
els of your workforce?

• Has your board set goals on organizational diversity, culturally proficient
care, and eliminating disparities in care to diverse groups as part of your
strategic plan?

• Does your organization have a process in place to ensure diversity reflect-
ing your community on your Board and subsidiary and advisory boards?

• Have you designated a high-ranking member of your staff to be responsible
for coordinating and implementing your diversity strategy?

• Have sufficient funds been allocated to achieve your diversity goals?

• Is diversity awareness and cultural proficiency training mandatory for all
senior leadership, management, and staff?

• Have you made diversity awareness part of your management and board
retreat agendas?

• Is your management team’s compensation linked to achieving your diver-
sity goals?

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In order to best serve their patient base, health care organizations and pro-
viders must be willing to invest the time, money, and effort needed to educate
all their employees. Educating senior staff is important, but so is educating
the entire health care workforce. Wilson-Stronks and Murtha (2010), Cejka
Search and Solucient (2005), and Kochan et al. (2003) have linked the effects
of diversity to business performance. Kochan and colleagues (2003) concluded
that the impact of diversity is dependent upon the following factors: organi-
zational culture, human resource practices, and strategy. In other words, the
impact of diversity is directly related to the organization’s ability to walk their
talk and can have a negative impact if not followed. For example, the Witt/
Kieffer’s 2011 national survey of 454 health care professionals, with 54 per-
cent representing senior executives, provides a deeper understanding of how
diversity is connected to measurable business benefits:

• Patient satisfaction: Nearly two-thirds (62 percent) believe cultural dif-
ferences improve patient satisfaction.

• Successful decision-making: More than half (57 percent) believe that cul-
tural differences support successful decision-making.

• Strategic goals: More than half of these respondents (54 percent) acknowl-
edge that diversity recruiting enables the organization to reach its stra-
tegic goals.

• Clinical outcomes: Nearly half (46 percent) believe diversity improves
clinical outcomes.

Dreachslin (2007) reinforces the need for mass customization of diversity
practices to be inclusive of disparities that are represented within the commu-
nities that health care organizations serve. In order to actively support busi-
ness strategy, organizations will need to provide employees with skills that
are inclusive of conflict-management skills, self-awareness, understanding of
cultural differences, validation of alternative points of view, and methods to
manage bias through effective human resource training and development.

Exhibit 2–3 (Continued)
YES NO

• Does your organization have a mentoring program in place to help develop
your best talent, regardless of gender, race, or ethnicity?

• Do you provide tuition reimbursement to encourage employees to further
their education?

• Do you have a succession/advancement plan for your management team
linked to your overall diversity goals?

• Are search firms required to present a mix of candidates reflecting your
community’s diversity?

Reproduced from Institute for Diversity in Health Management (2004).

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For health care managers to transform their organizations into an inclusive
culture where all employees feel the opportunity to reach their full potential,
Guillory (2004, pp. 25–30) recommended a 10-step process:

1. Development of a customized business case for diversity for your organi-
zation. In other words, how does diversity relate to the overall success of
the organization?

2. Education and training for your staff to develop an understanding of
diversity, its importance to your organization’s success, and diversity
skills to apply on a daily basis.

3. Establishment of a baseline by conducting a comprehensive cultural sur-
vey that integrates performance, inclusion, climate, and work/life balance.

4. Selection and prioritization of the issues that lead to the greatest break-
through in transforming the culture.

5. Creation of a three- to five-year diversity strategic plan that is tied to
organizational strategic business objectives.

6. Leadership’s endorsement of and financial commitment to the plan.
7. Establishment of measurable leadership and management objectives to

hold managers accountable to top leadership for achieving these objectives.
8. Implementation of the plan, recognizing that surprises and setbacks will

occur along the way.
9. Continued training in concert with the skills and competencies neces-

sary to successfully achieve the diversity action plan.
10. Survey one to one-and-a-half years after initiation of the plan to deter-

mine how inclusion has changed.
Reproduced from Guillory, W. A. (2004). The roadmap to diversity, inclusion, and high performance. Healthcare Executive, 19(4), 24–30.

Dreachslin (2007) reinforces the need for senior staff to “manage” diversity
and invest in professional development so that team members have the tools
they need to navigate their differences. As Dreachslin notes, “if left unman-
aged, demographic diversity will interfere with team functioning.” Managers
need to provide employees with training to enhance their conflict-manage-
ment skills, self-awareness, understanding of cultural differences, and meth-
ods to effectively manage bias.

THE FUTURE WORKFORCE

For the first time in modern history, our workforce consists of four separate
generations working side by side—and the differences among them are one
of the greatest challenges facing managers today (Wasserman, 2007). Bonnie
Clipper (2012, p. 45), author of The Nurse Manager’s Guide to an Intergenera-
tional Workforce , provides a humorous example for understanding the genera-
tions’ differences.

A nurse manager desperate for more staff, telephones four nurses to
ask whether they will pull an extra shift:

The first nurse says, “What time do you need me?”
The second nurse says, “Call me back if you can’t find anyone else.”

38 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

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The third nurse says, “How much will you pay me?”
The fourth nurse says, “Sorry, I have plans. Maybe next time.”

Adapted from Stokowski, L. A. (2013). The 4-generation gap in nurs-
ing. Medscape. Available at: www.medscape.com/viewarticle/781752

These different reponses are typical of the four different generations of
nurses currently working side by side at the bedside. The first response was
from the traditionalist generational cohort. This generation, born between 1925
and 1942, is typically characterized as dedicated, hardworking, and loyal. The
second response is from the Baby Boomer generation, those born between 1943
and 1960 who are viewed as optimistic, productive, and workaholics. The third
response is from Generation X, born between 1961 and 1981, typically referred
to as cynical, independent, and informal. The fourth response is reflective of the
Millennial generational cohort, born between 1982 and 2000, which is viewed
as confident, inpatient, and social. Becton, Walker, and Jones-Farmer (2014)
point out that although much has been written about their differences, there
still remains a gap in our understanding of each generational cohort’s values
and beliefs. As such, generational differences may best be explained by “age,
life stage, or career stage effects” (Becton, Walker, & Farmer, 2014, p. 176).

As part of diversity management, health care managers need to devise
strategies for attracting younger workers to enter the health care field while
maintaining positive relationships with older workers. For example, Barney
(2002, p. 83) points out that Generation X workers want “managers who lis-
ten, consider their ideas, and treat them as peers. They want to be part of
the decision-making process and want flexibility in their work environment
because they value their time and freedom.”

What about the Millennials, sometimes referred to as Generation Y?
Although this generational cohort has only recently begun to enter the work-
force, Millennials will be the fastest-growing segment of the working popula-
tion—they grew from 14 percent of the workforce to 21 percent over the past
four years, to nearly 32 million workers (Armour, 2005). Although it is impos-
sible to generalize about the wants and needs of millions of people in each gen-
eration, workplace experts tend to use the following characteristics to describe
the Millennials (Martin & Tulgan, 2006):

• High expectations of self: They aim to work faster and better than other
workers.

• High expectations of employers: They want fair and direct managers who
are highly engaged in their professional development.

• Ongoing learning: They seek out creative challenges and view colleagues
as vast resources from whom to gain knowledge.

• Immediate responsibility: They want to make an important impact on day
one.

• Goal oriented: They want small goals with tight deadlines so they can
build up ownership of tasks.

In addition to the younger workers, health care managers must also con-
sider the needs of older workers. For example, in a Robert Wood Johnson

The Future Workforce 39

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Foundation study, Hatcher and colleagues (2006) suggested that hospitals
seeking to recruit and retain older nurses need to implement strategies, such
as flexible work hours, increased benefits, newly created professional roles,
and an atmosphere of respect for nurses.

Generational diversity poses challenges for today’s and tomorrow’s employ-
ers. Younger workers have a strong need for immediate feedback, workers
now in their 30s and 40s demand greater work–life balance and flexibility,
and older workers expect increased benefits and professionalism. With a mul-
tigenerational workforce, employers will need to develop age-diversity train-
ing programs for their managers so they can better understand the needs and
expectations of each generation (Martin & Tulgan, 2006).

SUMMARY

Health care organizations need to be flexible to change and meet diversity
challenges. The greatest barrier to the industry’s success may be its inability
to understand and appreciate the increasing diversity within our population,
whether relating to patients or employees. As Kochan and colleagues (2003,
p. 18) related,

Diversity is a reality in labor markets and “customer” markets today.
To be successful in working with and gaining value from this diver-
sity requires a sustained, systemic approach and long-term commit-
ment. Success is facilitated by a perspective that considers diversity
to be an opportunity for everyone in an organization to learn from
each other how better to accomplish their work and an occasion that
requires a supportive and cooperative organizational culture as well
as group leadership and process skills that can facilitate effective
group functioning. Organizations that invest their resources in tak-
ing advantage of the opportunities that diversity offers should out-
perform those that fail to make such investments.

Similarly, Dobson (2012) states that although more research is needed, it
makes good business sense for organizations to invest in leadership diversity.
She argues that there are three interrelated strategies for organizations to
consider: (1) linking diversity with performance, (2) linking investments in
diversity to financial outcomes and organizational metrics of success, and
(3) making organizational leadership responsible for cultural competence as a
performance measure. When operational measures are connected with a cul-
turally competent organization, the results will be a reduction in health dis-
parities, increased patient satisfaction, and a more engaged workforce.

DISCUSSION QUESTIONS

1. Discuss what the term “diversity” means.
2. Explain the meaning of cultural competency.

40 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

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3. What do we mean when we say “diversity management”?
4. Explain why and how changes in U.S. demographics affect the health

care industry.

EXERCISE 2–1

You have been asked to join the hospital’s task force for developing a plan to
increase the organization’s workforce diversity from its current 20 percent level
to 40 percent over the next five years. How does your task force define diver-
sity? What recommendations would you make as a member of the task force?

EXERCISE 2–2

In 2012, the Alliance of Aging Research established the Healthspan Cam-
paign, a coalition of organizations committed to solving the challenges brought
about by the aging of the American population. With each passing year, the
percentage of people in the United States—and much of the world—over age
65 increases. This “Silver Tsunami” is expected to bring a flood of chronic dis-
ease and disabilities due to aging that could overwhelm the health care sys-
tems of many nations. Watch the films The Healthspan Imperative and What
Is the Silver Tsunami? at www.healthspancampaign.org . Discuss the effect of
the aging population on our health system and present recommendations for
how these challenges could be addressed.

EXERCISE 2–3

Visit the Hofstede Centre ( http://geert-hofstede.com/countries.html ) and
review the scores by country for the various cultural dimensions that Hofstede
identified. In light of these scores, think about some interactions you’ve had
with people (colleagues, patients, friends, etc.) born and raised in other coun-
tries. Do your interactions make more sense given this newly found insight?

EXERCISE 2–4

View the video titled Improving Patient-Provider Communication: Joint
Commission Standards and Federal Laws at www.jointcommission.org/mul-
timedia/improving-patient-provider-communication—part-1-of-4/ . The video
was a joint project of The Joint Commission and the U.S. Department of
Health & Human Services (HHS) Office for Civil Rights to support language
access in health care organizations.

With diverse patient populations come language translation issues. Medi-
cal interpretation is a challenge facing most health organizations. Medical
interpretation and translation services are costly. You are a member of your

Exercise 2–4 41

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hospital’s task force challenged to establish customer-focused, cost-efficient
communication programs. What recommendations would you make as a mem-
ber of the task force?

EXERCISE 2–5

In December 2012, the American College of Healthcare Executives released
its fifth report in a series of research surveys designed to compare the career
attainments of men and women health care executives. View this report, titled
A Comparison of the Career Attainments of Men and Women Healthcare Exec-
utives: 2012, at www.ache.org . In small groups, discuss the changes (if any)
regarding women advancing to senior leadership positions that have occurred
in the health care industry since the previous report in 2006.

EXERCISE 2–6

In April 2013, Modern Healthcare published its fourth biennial recogni-
tion of the Top 25 Women in Healthcare. The previous lists appeared in 2005,
2007, and 2009 and can be found on ModernHealthcare.com under “Recogni-
tions.” In small groups, discuss the changes (if any) over the past nine years of
the selected awardees population (i.e., employed in what sectors of the health
industry, what positions do/did they hold, race/ethnicity groups, and so on).

REFERENCES

Alliance for Aging Research . ( 2003 ). Ageism: How healthcare fails the elderly .
Available at: www.agingresearch.org

American College of Healthcare Executives . ( 2008 ). A race/ethnic comparison
of career attainments in healthcare management, Summary Report—2008 .
Available at: www.ache.org

American Nurses Association , Cultural Diversity in Nursing Practice , 1991 .
www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-
and-Resolutions/ANAPositionStatements/Position-Statements-Alphabeti-
cally/prtetcldv14444.html

Armour, S. ( 2005, November 6 ). Generation Y: They arrived at work
with an attitude . USA Today . Available at: www.usatoday.com/money
/workplace/2005-11-06-gen-y_x.htm

Association of American Medical Colleges . ( 2005 ). Cultural competence educa-
tion . Available at: www.aamc.org/download/54338/data/culturalcomped

Barney, S. M. ( 2002 ). A changing workforce calls for twenty-first century
strategies . Journal of Healthcare Management , 47 ( 2 ), 61–65 .

Beach, M. C. , Saha, S. , & Cooper, L. A. ( 2006 ). The role and relationship of
cultural competence and patient-centeredness in health care quality. The
Commonwealth Fund . Available at: http://www.commonwealthfund.org

42 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

9781284087062_CH02_PASS02.indd 42 17/02/15 6:10 PM

/publications/fund-reports/2006/oct/the-role-and-relationship-of-cultural-
competence-and-patient-centeredness-in-health-care-quality

Becton, J. B. , Walker, H. J. , & Jones-Farmer, A. ( 2014 ). Generational differ-
ences in workplace behavior . Journal of Applied Social Psychology , 44 ( 3 ),
175–189 .

Betancourt, J. , Green, A. R. , & Carrillo, E. ( 2002 ). Cultural competence in
health care: Emerging frameworks and practical approaches. The Common-
wealth Fund . Available at: www.commonwealthfund.org/usr_doc/betan-
court_culturalcompetence_576 ?section=4039

Bowling, A. ( 2007 ). Honour your father and mother: Ageism in medicine . Brit-
ish Journal of General Practice , 57 ( 538 ), 347–348 .

Brach, C. , & Fraser, I. ( 2000 ). Can cultural competency reduce racial and eth-
nic racial health disparities? A review and conceptual model . Medical Care
Review , 57 ( Suppl. 1 ), 181–217 .

Butler, R. ( 1969 ). Age-ism: Another form of bigotry . The Gerontologist , 9 ,
243–246 .

Ceijka Search and Solucient, LLC . ( 2005 ). Hospital CEO Leadership Survey .
St. Louis, MO : Ceijka Search and Solucient, LLC .

Clipper, B. ( 2012 ). The nurse manager’s guide to an intergenerational work-
force . Indianapolis, IN : Sigma Theta Tau International .

Commonwealth Fund . ( 2002 ). International health policy survey of adults
with health problems . Available at: www.cmwf.org

Commonwealth Fund . ( 2003 ). Worlds apart: A film series on cross-cultural
health care . Available at: www.cmwf.org

Dobson, E. ( 2012 ). Setting the stage for a business case for leadership diver-
sity in healthcare: history, research, and leverage . Journal of Healthcare
Management , 57 ( 1 ), 35–46 .

Dreachslin, J. L. ( 1998 ). Conducting effective focus groups in the context of
diversity: Theoretical underpinnings and practical implications . Qualitative
Health Research , 8 ( 6 ), 813–820 .

Dreachslin, J. L. ( 2007 ). Diversity management and cultural competence:
Research, practice and the business case . Journal of Healthcare Manage-
ment , 52 ( 2 ), 79–86 .

Dreachslin, J. L. , & Curtis, E. F. ( 2004 ). Study of factors affecting the career
advancement of women and racially/ethnically diverse individuals in
healthcare management . Journal of Health Administration Education ,
21 ( 4 ), 441–484 .

Fadiman, A. ( 1998 ). The spirit catches you and you fall down . New York, NY :
Farrar, Straus and Giroux .

Goode, T. & Jones, W. ( 2004 ). Increasing awareness and implementation of
cultural competence principles in health professions education . Journal of
Allied Health , 29 ( 4 ), 241–245 .

Guillory, W. A. ( 2004 ). The roadmap to diversity, inclusion, and high perfor-
mance . Healthcare Executive , 19 ( 4 ), 24–30 .

Hatcher, B. , Bleich, M. R. , Connolly, C. , Davis, K. , O’Neill Hewlett, P. , & Stokley
Hill, K. ( 2006 ). Wisdom at work: The importance of the older and experienced
nurse in the workplace . Princeton, NJ : The Robert Wood Johnson Founda-
tion . Available at: www.rwjf.org/files/publications/other/wisdomatwork

References 43

9781284087062_CH02_PASS02.indd 43 17/02/15 6:10 PM

Hofstede, G. ( 1983 ). The cultural relativity of organizational practices and
theories . Journal of International Business Studies , 14 ( 2 ), 75–89 .

Hofstede, G. ( 1991 ). Cultures and Organizations: Software of the Mind . Lon-
don, UK : McGraw-Hill .

Hofstede, G. , Van Deusen, C. A. , Mueller, C. B. , & Charles, T. A. ( 2002 ). What
goals do business leaders pursue? A study in fifteen countries . Journal of
International Business Studies , 33 ( 4 ), 785–803 .

Howard, C. , Andrade, S. J. , & Byrd, T. ( 2001 ). The ethical dimensions of cul-
tural competence in border healthcare settings . Family and Community
Health , 23 ( 4 ), 36–49 .

Howden, L. M. , & Meyer, J. A. ( 2011 ). Age and sex composition: 2010 . U.S.
Department of Commerce, Economics and Statistics Administration, U.S.
Census Bureau , Washington, DC .

Humes, K.R. , Jones, N.A. & Ramirez, R.R. ( 2011 ). Overview of race and His-
panic origin: 2010 . U.S. Department of Commerce, Economics and Statistics
Administration, U.S. Census Bureau , Washington, DC .

Human Rights Campaign ( 2014 ). Healthcare Equality Index . Available at:
http://www.hrc.org/hei

Institute for Diversity in Health Management . ( 2014 ). About the Institute .
Available at: www.diversityconnection.org/diversityconnection/about-us
/About-the-Institute.jsp

Institute of Medicine . ( 2004 ). In the nation’s compelling interest: Ensuring
diversity in the health care workforce . Washington, DC : National Academy
Press .

Kochan, T. , Bezrukova, R. , Jackson, A. , Jehn, K. , Leonard, D. , & Thomas, D.
( 2003 ). The effects of diversity on business performance: Report of the diver-
sity research network . Human Resource Management , 42 ( 5 ), 3–21 .

Kundhal, K. K. ( 2003 ). Cultural diversity: An evolving challenge to physi-
cian-patient communication . Journal of the American Medical Association ,
289 ( 1 ), 94 .

Martin, C. , & Tulgan, B. ( 2006 ). Managing the generation mix ( 2nd ed. ).
Amherst, MA : HRD Press .

Motwani, J. , Hodge, J. , & Crampton, S. ( 1995 ). Managing diversity in the
healthcare industry . Healthcare Supervisor , 13 ( 3 ), 16–25 .

Nahavandi, A. , & Malekzadeh, A. R. ( 1999 ). Organizational behavior: The per-
son-organization fit . Upper Saddle River, NJ : Prentice Hall .

National Urban League . ( 2009 ). Diversity practices that work: The American
worker speaks II . Available at: nul.iamempowered.com/sites/nul.iamem-
powered.com/files/attachments/Diversity_Practices_That_work_2009

Patel, C. ( 2003 ). Some cross-cultural evidence on whistle-blowing as an internal
control mechanism . Journal of International Accounting Research , 2 , 69–96 .

Perry, D. ( 2012 ). Entrenched ageism in healthcare isolates, ignores and imper-
ils elders . Aging Today , 33 ( 2 ), 1 .

Robert Wood Johnson Foundation . ( 2014 ). Improving health care by measuring
it . Available at: www.rwjf.org/content/dam/farm/reports/program_results_
reports/2014/rwjf412674

Svehla, T. ( 1994 ). Diversity management: Key to future success . Frontiers of
Health Services Management , 11 ( 2 ), 3–33 .

44 DIVERSITY AND CULTURAL COMPETENCY IN HEALTH CARE

9781284087062_CH02_PASS02.indd 44 17/02/15 6:10 PM

The Joint Commision . ( 2014 ). A crosswalk of the national standards for Cul-
turally and Linguistically Appropriate Services (CLAS) in health and health
care to The Joint Commission Hospital Accreditation Standards . Available
at: www.jointcommission.org/assets/1/6/Crosswalk-_CLAS_-20140718

Traxler, A. J. ( 1980 ). Let’s get gerontologized: Developing a sensitivity to
aging . The multi-purpose senior center concept: A training manual for prac-
titioners working with the aging . Springfield, IL : Illinois Department of
Aging .

United Nations . ( 2013 ). World population prospects: The 2012 revision—
Highlights and advance tables . New York . Available at: esa.un.org/wpp
/Documentation/pdf/WPP2012_HIGHLIGHTS

United States Census Bureau . ( 2012 ). A look at the 1940 Census . Available at:
www.census.gov/newsroom/cspan/1940census/CSPAN_1940slides

United States Department of Commerce, Bureau of the Census . ( 2003 ). Chart-
book on trends in the health of Americans . Retrieved March 21, 2004, from
InfoTrac online database.

United States Department of Commerce, Bureau of the Census . ( 2004 ). U.S.
interim projections by age, sex, race, and Hispanic origin . Available at:
www.census.gov/ipc/www/usinterimproj/

United States Department of Health and Human Services, Office of Minor-
ity Health [HHS OMH] . ( 2013 ). National standards for culturally and lin-
guistically appropriate services in health and health care: A blueprint for
advancing and sustaining CLAS Policy and Practice . Retrieved from www
.thinkculturalhealth.hhs.gov

Warshaw, G. A. ( 2002 ). Academic geriatrics programs in US allopathic and
osteopathic medical schools . Journal of the American Medical Association ,
288 , 2313–2319 .

Warshaw, G. A. , Bragg, E. J. , Thomas, D. C. , Ho, M. L. , & Brewer, D. E. ( 2006 ).
Are internal medicine residency programs adequately preparing physicians
to care for the Baby Boomers? A national survey from the Association of
Directors of Geriatric Academic Programs Status of Geriatrics Workforce
Study . Journal of the American Geriatrics Society , 54 ( 1 ), 1603–1609 .

Wasserman, I. ( 2007 ). Generations working together . Entrepreneur . Available
at: www.entrepreneur.com/article/183720

Weech-Maldonado, R. , Dreachslin, J. L. , Dansky, K. H. , DeSouza, G. , & Gatto,
M. ( 2002 ). Racial/ethnic diversity management and cultural competency:
The case of Pennsylvania hospitals . Journal of Healthcare Management ,
47 ( 2 ), 111–124 .

Weech-Maldonado, R. , Elliott, M. N. , Schiller, C. , Hall, A. , Dreachslin, J. L. ,
& Hays, R.D. ( 2007 ). Organizational and market characteristics associ-
ated with hospitals’ adherence to the CLAS standards . Presentation at the
APHA Annual Meeting in Washington, DC, on November 5.

Weech-Maldonado, R. , Elliott, M. N. , Schiller, C. , Hall, A. , & Hays, R. D.
( 2007 ). Does Hospitals’ adherence to the CLAS standards influence diverse
patients’ experiences with inpatient care . Presentation at the APHA Annual
Meeting in Washington, DC, on November 5.

Weil, P. , & Mattis, M. ( 2001 ). Narrowing the gender gap in healthcare man-
agement . Healthcare Executive 16 ( 6 ), 12–17 .

References 45

9781284087062_CH02_PASS02.indd 45 17/02/15 6:10 PM

Wilson-Stronks, A. , & Mutha, S. ( 2010 ). From the perspective of CEOs: What
motivates hospitals to embrace cultural competence? Journal of Healthcare
Management , 55 ( 5 ), 339–351 .

Witt/Kieffer ( 2011 ). Building the business case. Healthcare diversity leader-
ship: A national survey report. Institute for Diversity in Healthcare Man-
agement, Institute Resource Center . Available at: www.diversityconnection.
org/diversityconnection/membership/Institute-Resource-Center.jsp?fll=S12

OTHER SUGGESTED READING

Lantz, P. ( 2008 ). Gender and leadership in healthcare administration: 21st
century progress and challenges . Journal of Healthcare Management , 53 ( 5 ),
291–304 .

Institute of Medicine . ( 2004 ). In the nation’s compelling interest: Ensuring
diversity in the healthcare workforce . Available at: www.nap.edu/cata-
log/10885.html

A full list of reference texts discussing cultural beliefs and influences, issues,
and how to identify/develop materials can be found on the National Center
for Cultural Healing , at: www.culturalhealing.com/patientedu.htm

Information relating to Anne Fadiman’s book , The Spirit Catches You and You
Fall Down , may be viewed at: www.spiritcatchesyou.com

Learn more about how language and culture affect the delivery of quality ser-
vices to ethnically diverse populations at: www.diversityrx.org

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