Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Chapter 3: Strategies for Success in Implementing Cultural and Linguistic Competence Education

Responding to resistance to change or innovation requires providing a strong rationale. Those who will be affected by a curriculum for cultural and linguistic competence must be provided with good reasons for changing how they have been doing things or for adopting new behaviors. Some of those who resist change may ask why there is a need for cultural and linguistic competence within the health professions. This chapter outlines the following: 1.) the rationale for educating for cultural and linguistic competence, 2.) an overview of the change management process, and 3.) an examination of cultural and linguistic competence at the organizational level.

I. The Rationale for Educating for Cultural and Linguistic Competence

There are a number of significant reasons COEs have undertaken the effort to develop cultural and linguistic competence. Some of the best reasons have been collected by the National Center for Cultural Competence and are reported on the NCCC website (at http://gucchd.georgetown.edu/nccc/). They are used here with permission.

The reports by the IOM and other organizations cited earlier provide a compelling moral argument and social-justice rationale for cultural and linguistic competence within the health professions. In addition, the NCCC says there are other practical considerations, including the following:

A. To respond to current and projected demographic changes in the United States
B. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds
C. To eliminate disparities in the mental health status of people of diverse racial, ethnic, and cultural groups
D. To improve the quality of services and primary care outcomes
E. To meet legislative and regulatory mandates
F. To meet accreditation mandates
G. To gain a competitive edge in the marketplace
H. To decrease the likelihood of malpractice claims

A. Responding to current and projected demographic changes

The make-up of the American population continues to change as a result of immigration patterns and significant increases among racially, ethnically, culturally, and linguistically diverse populations already residing in the United States. Primary care organizations and Federal, state, and local governments must implement systemic change in order to meet the health and mental health needs of this diverse population. Census 2000 data show that more than 47 million persons speak a language other than English at home, an increase of nearly 48 percent since 1990. Since 1990, the foreign-born population has grown by 64 percent to 32.5 million persons, accounting for 11.5 percent of the U.S. population (Schmidley, 2003).

B. Eliminating disparities in health status

Nowhere are the divisions of race, ethnicity, and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, disparities continue in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Alaskan Natives, Pacific Islanders, and some Asian Americans as compared with that of the U.S. population as a whole (more information is available in the National Health care Disparities Reports for 2003 and 2004; http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.aspx). The U.S. Department of Health and Human Services (DHHS), through its 2010 Objectives, established goals for the elimination of racial and ethnic disparities in health. Six major areas of health status have been targeted for elimination, including cancer, cardiovascular disease, infant mortality, diabetes, HIV/AIDS, and child and adult immunizations. Regrettably, there has been little change in these indicators of illness and death since these goals were established in 2000.

C. Eliminating disparities in mental health status

The first Surgeon General’s report on mental health, Mental Health: A Report of the Surgeon General, 1999, emphasized the importance of culture for both patients and providers. “The cultures that patients come from shape their mental health and affect the types of mental health services they use,” the report said. “Likewise, the cultures of the clinician and the service system affect diagnosis, treatment, and the organization and financing of services.” (Executive Summary). This report, as well as a later supplement, 2001 Surgeon General's Report on Mental Health: Culture, Race, and Ethnicity, documents the pervasive disparities in mental health care. Specifically, the report revealed evidence that racially and ethnically diverse groups are less likely to receive needed mental health services and are more likely to receive poorer quality of care. Furthermore, the report goes on to say that these groups:

• Are over-represented among the vulnerable populations who have higher rates of mental disorders and more barriers to care and
  
• Face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health.

D. Improving the quality of services and primary care outcomes

Despite similarities, fundamental health-related differences among people also arise from such cultural factors as Nationality, ethnicity, acculturation, language, religion, gender, and age, as well as factors attributed to family of origin and individual experiences. These differences affect the health beliefs and behaviors of both patients and providers. They also influence the expectations that patients and providers have of each other. The delivery of high-quality primary care that is accessible, effective, and cost-efficient requires providers to have a deeper understanding of the sociocultural background of patients, their families and the environments in which they live. Recent studies have shown that culturally and linguistically competent primary care increases patient satisfaction and health outcomes, and provides higher levels of preventive care (Lasater et al, 2001; Saha et al, 1999).

E. Meeting legislative and regulatory mandates

The requirement for care to be delivered in a culturally and linguistically competent manner is increasingly emphasized by legislative and regulatory bodies. As both an enforcer of civil rights law and a major purchaser of health care services, the Federal government has a pivotal role in ensuring culturally competent health care services. Title VI of the Civil Rights Act of 1964 mandates that “no person in the United States shall, on ground of race, color, or National origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” In August 2003, the DHHS Office for Civil Rights issued a revised Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (http://www.hhs.gov/ocr/lep). In December 2000, the DHHS Office of Minority Health published in the Federal Register the National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, a document which provides guidance on the provision of health care to diverse populations.
(http://www.omhrc.gov/omh/programs/2pgprograms/finalreport.pdf)

F. Meeting accreditation mandates

State and Federal agencies rely on private accreditation entities to set standards and monitor compliance. The Joint Commission on the Accreditation of Health care Organizations, which accredits hospitals and other health care institutions; the Liaison Committee on Medical Education, the accrediting organization for medical education; and the National Committee for Quality Assurance, which accredits managed care organizations and behavioral health managed care organizations, support standards that require cultural and linguistic competence in health care. (P. 4, National Center for Cultural Competence, Bureau of Primary Health Care Project.)

See Chapter 10, Resources, Section I for additional references.

G. Gain a competitive edge

A significant portion of publicly financed primary care services continues to be delegated to the private sector. The issues that are of the most concern to health care consumers, purchasers, and providers in the current social and political environment are rising health care costs, quality of care, and the effectiveness of service delivery. Therefore, while the research in this area is relatively new, it stands to reason that as the U.S. population continues to diversify, organizations that embrace the values of cultural and linguistic competence when providing primary care may be well positioned in the current market and in the future. For example, health care organizations such as Aetna, Blue Cross, and Kaiser Permanente have focused efforts on marketing to discrete ethnic and racial groups with the promise of taking into consideration the specific health needs of those populations.

H. Decreasing the likelihood of malpractice claims

Lack of awareness about cultural differences and failure to provide interpretation and translation services can result in liability under tort principles in several ways. Practitioners may discover, for example, that they are liable for damages as a result of treatment in the absence of informed consent. Also, health care organizations and programs face potential claims that their failure to understand beliefs, practices, and behaviors on the part of providers or patients breaches professional standards of care. In some states, patients’ failure to follow instructions because they conflict with values and beliefs may raise a presumption of negligence on the part of the provider.

II. An Overview of the Change Management Process

As organizations evolve along a developmental continuum that moves from ignoring cultural and linguistic differences in patients to one that carefully considers the effect of cultural variation on patient care, the changes required for such a complex process must be managed carefully. In this role of managing change, COEs have a unique mandate and opportunity. The mandate concerns the requirement to integrate and institutionalize cultural and linguistic competency within their academic organizations and to disseminate their cultural and linguistic competency knowledge and skills to the broader community. There is an opportunity to become early adopters of cultural and linguistic competency principles and practices, and thereby contribute to the improvement in the health status of Americans, particularly among underserved populations. Yet when COEs take on the task of becoming culturally and linguistically competent, they must expect some resistance to the concept of cultural and linguistic competence. Therefore, it may be useful to understand the change-management process.

A. The Change Process and Resistance to Change

Creating institutions and organizations in which cultural and linguistic competency is the norm involves change. For COEs, the change process around cultural and linguistic competency begins in the academic environment. As progress is achieved within academic institutions, it will be important for those employed by COEs to expand their efforts to affiliated health delivery organizations, such as hospitals and clinics. It will also be important for at least one, and preferably a number of forward-looking individuals, to assume a leadership role in an effort to lead the change process of developing cultural and linguistic competency. These leaders will need to champion the cause against those who will resist the call for change.

As mentioned in Chapter 1, COEs have neither the mandate nor the authority to require adherence to cultural and linguistic competency principles within their parent universities. It is also clear that the promotion of cultural and linguistic competency is only one of several mandates for which COEs are accountable. The fact remains, however, that clinicians and educators in the COEs have a unique opportunity to serve as leaders and advocates for cultural and linguistic competency and the processes of cultural change that will support this initiative.

Faculty members within COEs will no doubt react in many different ways to the idea of changes and additions to the curriculum necessitated by a new focus on cultural and linguistic competency, Flaherty-Zonis says. On the positive side, some people may see change as a challenge, an opportunity for personal and professional development, a way to enhance morale and increase productivity, or a way to renew their energy and passion for their work. On the other hand, some people may see change as a threat to their power and influence, a loss of familiarity and comfort, a statement that the way they have done things is wrong, or as a loss of control. Many people fear change for all these reasons and many more.

Most important for people involved in a process of change, especially culture change, is acknowledging and respecting all of these reactions, even those that may seem to stand in the way of change, Flaherty-Zonis continues. Some people will be ready, willing, and enthusiastic about the change process and others will be unwilling and reluctant. One strategy for diffusing resistance among those who fear change is to continually emphasize the positive. As with diversity programs, some people will resist a cultural and linguistic competency initiative because they will perceive it as an indictment of their historic practices. Challenging individuals directly about practices that are deemed to be insufficient or not up to date will likely result in their becoming defensive or defiant. A better strategy would be to acknowledge their expertise and provide clear guidance and simple steps that can be taken to begin the process of adding to it by implementing cultural and linguistic competency, and then recognizing and complimenting each small success.

If the institutionalization and integration of cultural and linguistic competency within an academic institution is to be successful, it must be well planned, Flaherty-Zonis adds. Those involved in planning the change should have well rationalized and clear goals. Additionally, individuals are more likely to be committed to the success of the cultural and linguistic competency program if they are given the opportunity to participate in its conceptualization and design. Each organizational unit within the institution should be encouraged to have goals for cultural and linguistic competency and a plan for achieving them that is well within the framework of the overall institutional goals for change. The goals and the plan set the direction for the change process.

B. Faculty and Staff Development

While students in COE programs are identified as the ultimate audience for cultural and linguistic competency training, faculty and other staff are the transmitters of this new mode of thinking and operating. The means of transmitting knowledge, skills, and attitudes are not only classroom activities, but also examples of cultural and linguistic competency that are demonstrated at all levels within the academic institution. Transmitting this knowledge and offering these examples will require training all faculty and staff in core competencies of cultural and linguistic competency. If cultural and linguistic competency is to become integrated into the organizational culture of the institution, all staff must be involved in understanding and practicing the principles of cultural and linguistic competency. Integrating cultural and linguistic competency into an organization’s culture is likely a long-term goal, and one that will require cognitive restructuring and skill training programs for staff, launching a planning process that includes all levels of staff, training to develop organizational cultural and linguistic competence, and a meaningful examination of the institution’s culture.

It is important to understand that beginning and sustaining culture change are not the same. They call for different skills. New ideas, even good ones, often fail to take hold because not enough attention is paid to specific ways of implementing and sustaining them. Implementing and sustaining ideas involves planning and identifying people who can help sell the ideas. Implementing and sustaining ideas also involves determining how to monitor the work and measure progress, how to modify the plan as needed, how to help people build commitment to the idea, and how to assess the culture change.

C. Managing Conflict

Since culture change usually involves conflict, it is important to identify and resolve conflicts in a skillful and timely manner. Conflicts can sometimes lead to exciting new ideas and important changes in the culture. Conflicts may help open people’s eyes to issues that need to be addressed and to new ways of operating. If people, especially those in leadership positions, see conflict in a negative way and as something to be avoided, the culture change process is less likely to be successful. On the other hand, if people can embrace conflict as a way to show respect for and clarify points of view, and to challenge old ideas and bring new ones into the open, then the culture change process is more likely to accomplish its goals.

Conflict in a change process often comes because some people view and label other people as “resistant.” While resistant is a legitimate word, it may not be useful to label people in a culture change process because such labeling ignores the causes of the resistance, and it is vitally important to understand the causes of resistance if they are to be overcome. People may react negatively to change because of fear; a sense of loss and grieving over what is gone; loss of control, influence and power; concern about the skill and the knowledge level necessary to make a change; skepticism; distrust of leadership; and a negative experience in the institution with other innovative ideas.

D. The Importance of Leadership

Some people are great innovators. They are creative, intuitive, insightful problem-solvers. But these innovators sometimes forget that they need to lead others through the processes involved in innovation. They may not realize that if they fail to lead, others may not follow readily or enthusiastically. For this reason, institutionalizing cultural and linguistic competency within a COE and its host academic institution requires a firm commitment from all levels of an organization and particularly from its leaders. Thus, the university president, COE director, academic dean, curriculum dean, and other key decision-makers in the academic setting, regardless of title, will need to actively promote the cultural and linguistic competency initiative. While one person may have a vision of how cultural and linguistic competency might be integrated into the COE and host institution, he or she cannot change it alone. It is critical to have a group of people others trust, who support both the need for change and the direction of the change. It is necessary to have dedicated and skilled leadership and commitment throughout the organization if the changes are to have a positive effect on the cultural and linguistic competence of the students to be trained and, ultimately, the health status of the people they serve.

Any discussion about leadership clearly means those people who have authority because of their title and position. But within all organizations there are many informal leaders, particularly if there are significant sub-cultures. Cultural and linguistic competence programs will not be fully implemented if these informal leaders are not made champions in the cause and process of change. They should be involved from at the beginning of the process. If they are not included in the process, they may sabotage the work. Moreover, it is likely that they represent important perspectives that those leading the cultural change may otherwise miss. In addition, some people view change as a loss of power and influence, meaning it may be necessary to involve people who have power and influence at the start, so that they are part of the process.

Effective communication will be essential to the success of the COE’s cultural and linguistic initiatives, and communicating effectively and often is an important role of leadership. There is no substitute for effective communication. Within any organization, people will communicate regardless of whether or not they have accurate information. Therefore the best way to prevent rumors, misunderstandings, and unnecessary conflict is to provide accurate information in a timely fashion, and to address issues as they arise. Leaders should promote ongoing, honest, formal, and informal communication about what is happening before and during the change process. Doing so requires communicating in all directions, and listening often may be more important than speaking.

Ultimately, the success of the change process may be determined by the leadership’s commitment to change. The leader cannot and should not do the work alone. He or she has to lead the way, providing encouragement, support, ideas, passion, and commitment to the process as well as the outcomes. If the leader stops or turns away from the work, it will be difficult for the staff to keep it moving, or to see its value, and success is unlikely. More importantly, future attempts to bring about change may be met with staff skepticism, reluctance, and a refusal to participate. Staff may become immune to change.

To prevent such problems, leaders throughout the institution should remember that the change process is about meeting mandates and standards, while providing a hope-based environment and having the intention of improving the quality of life for staff, faculty, students, and health care consumers.

III. An Examination of Cultural and Linguistic Competence at the Organizational Level

A number of organizations have developed models and developmental frameworks for organizational change. COEs can use them to support the design and assessment of cultural and linguistic competence activities within their organizations. While all of the following models and development frameworks are not designed specifically for educating health care professionals, they would be useful to COEs nonetheless because they can be adapted for use in an educational setting for health care professionals.

Perhaps the most useful models for health care professionals are the National Standards for Culturally and Linguistically Appropriate Services in Health Care (known as the CLAS standards), from the U.S. Department of Health and Human Services, Office of Minority Health, and the Lewin Model of Cultural and Linguistic Competence. A third, the Cross Model, is useful in identifying the various stages of cultural and linguistic competence. In effect, these three models present guiding principles and goals designed to help COEs maintain a clear and constructive focus on cultural and linguistic competency as they negotiate the complexities of planning, designing, implementing, and evaluating cultural and linguistic competence training and education programs into existing curricula.

A. National Standards for Culturally and Linguistically Appropriate Services in Health Care (the CLAS Standards for Health Care Organizations)

As stated, COEs may find the CLAS standards among the most useful when developing cultural and linguistic competence curriculum. These standards hold that as the U.S. population becomes more diverse, medical providers and other professionals involved in health care delivery are interacting with patients and consumers from many different cultural and linguistic backgrounds. Because culture and language are vital factors in how health care services are delivered and received, it is important that health care organizations and their staff understand and respond with sensitivity to the needs and preferences that culturally and linguistically diverse patients and consumers bring to the health encounter. Providing culturally and linguistically appropriate services (CLAS) to these patients has the potential to improve access to care, quality of care, and ultimately, health outcomes. In fact, some organizations consider the CLAS standards to be akin to quality standards, and thus all clinicians need to have an understanding of them.

Unfortunately, until recently, a lack of comprehensive standards left organizations and providers with no clear guidance on how to provide CLAS in health care settings. In 1997, the Office of Minority Health (OMH) started developing National standards to provide a much-needed alternative to the patchwork of independently developed definitions, practices, and requirements concerning CLAS. OMH initiated a project to develop recommended National CLAS standards that would support a more consistent and comprehensive approach to cultural and linguistic competence in health care.

The CLAS standards were published in final form in the Federal Register on December 22, 2000, as recommended National standards for adoption or adaptation by stakeholder organizations and agencies. The standards are proposed as a means to correct inequities that currently exist in the provision of health services, and to make these services more responsive to the individual needs of all patients and consumers. The standards are intended to include all cultures and are not limited to any particular population group or sets of groups; however, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services. Ultimately, the aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans.

The CLAS standards are primarily directed at health care organizations and are particularly useful in hospital settings. However, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served.

It is particularly useful to study the CLAS standards in detail, in part because they say that culture and language have a considerable affect on how patients access and respond to health care services. The CLAS standards say that to ensure equal access to quality health care by diverse populations, health care organizations and providers:

1. Should promote and support the attitudes, behaviors, knowledge, and skills necessary for staff to work respectfully and effectively with patients and each other in a culturally diverse work environment.
2. Should have a comprehensive management strategy to address culturally and linguistically appropriate services, including strategic goals, plans, policies, procedures, and designated staff responsible for implementation.
3. Should use formal mechanisms for community and consumer involvement in the design and execution of service delivery, including planning, policy making, operations, evaluation, training, and, as appropriate, treatment planning.
4. Should develop and implement a strategy to recruit, retain, and promote qualified, diverse and culturally competent administrative, clinical, and support staff that are trained and qualified to address the needs of the racial and ethnic communities being served.
5. Should require and arrange for ongoing education and training for administrative, clinical, and support staff in culturally and linguistically competent service delivery.
6. Must provide all clients with limited English proficiency (LEP) access to bilingual staff or interpretation services.
7. Must provide oral and written notices, including translated signage at key points of contact, to clients in their primary language informing them of their right to receive interpreter services free of charge.
8. Must translate and make available signage and commonly used written patient educational material and other materials for members of the predominant language groups in service areas.
9. Should ensure that interpreters and bilingual staff can demonstrate bilingual proficiency and receive training that includes the skills and ethics of interpreting, and knowledge in both languages of the terms and concepts relevant to clinical or non-clinical encounters. Family or friends are not considered adequate substitutes because they usually lack these abilities.
10. Should ensure that the clients’ primary spoken language and self-identified race/ethnicity are included in the health care organization’s management information system, as well as any patient records used by provider staff.
11. Should use a variety of methods to collect and use accurate demographic, cultural, epidemiological, and clinical outcome data for racial and ethnic groups in the service area and become informed about the ethnic/cultural needs, resources, and assets of the surrounding community.
12. Should undertake ongoing organizational self-assessments of cultural and linguistic competence, and integrate measures of access, satisfaction, quality, and outcomes for CLAS into other organizational internal audits and performance improvement programs.
13. Should develop structures and procedures to address cross cultural ethical and legal conflicts in health care delivery and complaints or grievances by patients and staff about unfair, culturally insensitive or discriminatory treatment, or difficulty in accessing services, or denial of services.
14. Are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

B. The Lewin Model of Cultural and Linguistic Competence

While the CLAS standards explain what a culturally and linguistically competent health care organization must do to achieve cultural and linguistic competence, the Lewin model documents how an institution must be organized in order to move through the stages of development and support cultural and linguistic competence within the organization. The formal name of the Lewin model is “Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile.” It was prepared for the Health Resources and Services Administration of the U.S. Department of Health and Human Services in April 2002 by consultants with The Lewin Group, a health care and human services consulting firm in Falls Church, VA, and is available on the HRSA website at http://www.hrsa.gov/OMH/cultural1.htm.

The following table shows the domains and corresponding focus areas as identified by Lewin.

Table 1
The Lewin Model: Domains and Focus Areas

Source: Linkins, K.W., McIntosh, S., Bell, J., and Umi, C., The Lewin Group, “Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile,” prepared for the Health Resources and Services Administration, U.S. Department of Health and Human Services, April 2002.

C. The Cross Model of Cultural competence (Cross et al., 1989)

One of the most important ways of identifying cultural competence was developed by Terry Cross, the executive director of the National Indian Child Welfare Association, in Portland, OR. The Cross Model (from the publication, Towards a Culturally Competent System of Care, Volume I, Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center. March 1989, pp. v-viii) describes the various stages of competence at the organizational level. Cross et al define cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.” (Pg. iv) These authors view cultural competence as a continuum ranging from cultural destructiveness to cultural proficiency.

The six stages of Cross’ cultural competence model are:

1. Cultural Destructiveness. Attitudes, policies, and practices within the organization are destructive to cultures and individual members of those cultures.
2. Cultural Incapacity. The organization does not intentionally seek to be destructive but rather lacks the capacity to help minority clients or communities.
3. Cultural Blindness. The organization functions with the belief that color or culture makes no difference and that all people are the same.
4. Cultural Pre-Competence. The organization recognizes its weaknesses and attempts to improve some aspects of its services to a specific population.
5. Cultural competence. The organization is characterized by acceptance and respect for differences, continuing self assessment regarding culture, careful attention to the dynamics of differences, continuous expansion of cultural knowledge, and a variety of service models to meet the needs of minority clients.
6. Cultural Proficiency. The organization seeks to develop a base of knowledge of culturally competent services by conducting research, developing new therapeutic approaches based on culture, publishing and disseminating information on cultural competence, and hiring specialists in culturally competent practices.

Other widely used models that educators and practitioners in COEs may wish to review include Bell and Evans, and Bennett. For more information on Bell and Evans see Bell, P., and Evans, J. (1981). Counseling the Black Client. Center City, MN: Hazelden Education Materials. Linda and Milton Bennett are a husband and wife team that run a Summer Institute on Intercultural Relations. Milton Bennett developed a staged model of personal development moving from cultural insensitivity to an advanced level of cultural sensitivity. Linda Bennett refined this model into an educational model best explained in: 1986 Modes of Cross-Cultural Training Conceptualizing Cross-Cultural Training as Education. International Journal of Intercultural Relations, Vol. 10: 117-134.

In their book, Bell and Evans explain that, in progressing through the stages of cultural awareness, there are different interaction styles that health care professionals may operate in either consciously or unconsciously. Bell and Evans (1981) describe five basic interpersonal styles that one may engage in when interacting with a client from another culture. Health care professionals must be aware of what interacting style they are operating in and strive toward a culturally liberated interacting style. The five styles are as follows:

1. Overt racism is when the health care professional interacts out of deep-seated prejudices that he or she has toward a particular cultural group. The health care professional will use the power of his or her attitudes and behaviors to dehumanize the client.
2. Covert racism is an interacting style in which the health care professional is aware of his or her fears of a specific cultural group, but knows that open expression of those attitudes is inappropriate. The health care professional attempts to hide or cover-up his or her true feelings.
3. Cultural ignorance is when the health care professional has little or no prior exposure to the specific cultural group and experiences fear due to his or her inability to relate to the client.
4. The color blind health care professional denies the reality of cultural differences that are important for effective interactions. In this interacting style, the health care professional has made a decision that he or she is committed to equality for all people and therefore treats all people alike, regardless of cultural background.
5. Finally, the culturally-liberated health care professional does not fear cultural differences and is aware of his or her attitude toward specific cultural groups. This health care professional encourages the client to express feelings about ethnicity and then uses these feelings as a shared learning experience.

Chapter 10, Section IIIB is a section that references many other assessment approaches and instruments appropriate to evaluating the cultural and linguistic competencies of organizations. Review of some of these materials may be useful in initial and ongoing assessment of progress related to achieving cultural competence within the COE.