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 The purpose of this course is to outline and explore the most common or serious disparities in healthcare, address how it needs to be adjusted, and start the conversations needed to create a new generation of nurses who will close these gaps. This course fulfills the cultural competence and diversity, equity, and inclusion requirement for license renewal by the Oregon State Board of Nursing.

Introduction   

There is no doubt that modern medicine has made many technological advancements over the last few decades, forging the way for highly intricate diagnostic and treatment methods that improve the quality and longevity of many lives. However, in order to truly keep up with changing times, healthcare professionals must consider much more than the technical aspects of healthcare delivery. They must take a closer look and a more conscientious approach to the way in which care is delivered, particularly across a wide variety of demographics and characteristics. Ensuring care is delivered with empathy, respect, and equity, in a way that acknowledges and honors a patient’s difference,s transforms it from good to truly great. Practicing diversity, equity, and inclusion (DEI) as well as cultural competence in nursing professions must become a standard.  

Health Disparities

When covering cultural competence in nursing, it is vital that providers know that each patient is a unique individual. However, there are some characteristics such as race, gender, age, sexual orientation, or disability that can create gaps in the availability, distribution, and quality of healthcare delivered. These gaps can create lasting negative impacts on patients mentally, physically, spiritually, and emotionally and even lead to poorer outcomes than patients not within a dominant population. Modern healthcare professionals have a responsibility to learn to identify risks, provide sensitive and inclusive care, and advocate for equity in much the same way that they have a responsibility to learn how the human body, medications, or hospital equipment works.  

Epidemiology

In order to understand the importance of cultural competence in nursing as well as the best practices for DEI in healthcare, let’s turn to data.  

Healthy People 2020 provides a myriad of data that includes countless implications for changes that need to occur in healthcare settings for equitable care of all populations. The data includes statistics such as: 

• 12.6% of Black/African American children have a diagnosis of asthma, compared to 7.7% of white children (16).  
• The rate of depression in women ages 65+ is 5% higher than that of men of the same age, across all races (16). 
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (16). 
• 16.1% of Hispanics report not having health insurance, compared to 5.9% of white populations (16) . 
• The national average of infant deaths per 1,000 live births is 5.8. The rate for Black/African American infants is nearly double at 11 deaths per 1,000 births (16). 
• 12.5% of veterans are homeless, compared to 6.5% of the general U.S. population (16).  

Additional disparities are seemingly endless and point unquestionably to the fact that cultural competence and DEI awareness is no longer something that healthcare professionals can be uninformed about. The purpose of this Oregon Cultural Competency Course is to outline and explore the most common or serious healthcare disparities, address ways in which healthcare delivery needs to be adjusted, and start the conversations needed to create a new generation of healthcare professionals that will close these gaps.  

The importance of understanding DEI best practices in the health setting, as well as possessing cultural competence in nursing, is vital in making positive changes for all populations. 

Race & Ethnicity

One of the most significant disparities in healthcare, and the one garnering the most attention and campaigns for change in recent years, is race and ethnicity. However, when covering the best practices for cultural competence in nursing, it is essential that we go over this topic. Studies in recent years have revealed that minority groups, particularly Black Americans, are sicker and die younger than white Americans. Examples include:  

Current data shows that Black men are more likely to be diagnosed with prostate cancer and 2.5 times more likely to die from it than their white peers. A 2019 study through the University of Michigan Rogel Cancer Center explored prostate cancer outcomes when factors such as access to care and standardized treatment plans were controlled. They found that outcomes were comparable and Black men experienced similar mortality to the white men in the study, implying that they did not “intrinsically and biologically harbor a more aggressive disease simply by being Black” (11).

A 2020 study found that Black individuals over age 56 experience a decline in memory, executive function, and global cognition at a rate much faster than their white peers, often as much as 4 years ahead in terms of cognitive decline. Data in this study attribute the difference to the cumulative effects of chronically high blood pressure, more likely to be experienced by Black Americans (20).

Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth. One in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. Studies indicate that in addition to biases within the healthcare system, some of these poor outcomes may also be attributed to cumulative effects of lifelong inferior healthcare (1).

Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people are uninsured and 14% of Black people, compared to just 8.5% of White people. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and later diagnosis and poorer outcomes of life-threatening conditions (4).

The emerging data indicates that hospitalizations and deaths from COVID-19 disproportionately affect Black and Hispanic Americans, with Black people being 153% more likely to be hospitalized and 105% to die from the disease than white people. Hispanic people are 51% more likely to be hospitalized and 15% more likely to die from COVID-19 than white people (21).

The potential reasons are many, from genetics to environmental factors such as socioeconomic status, but the data repeatedly shows that these factors are not enough to account for the disproportionate health outcomes. It comes down to inequity in the structure of the healthcare systems in which we all live. For example:  

Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures (13). 

There is also a lack of diversity in physicians. In 2018, 56.2% were white, while only 5% were Black and 5.8% were Hispanic. More often than not, patients will see a physician that is a different race than they are, which can mean their particular experiences as a minority person, and how that relates to their health, are not well understood by their physician (2).

While the Affordable Care Act increased the number of people who have access to health insurance, minority patients are still disproportionately uninsured, which leads to delayed care or no care, even when necessary (4).

Patients who are facing generational poverty may live in crowded homes or in food deserts due to outdated zoning laws created during times of segregation. This means less access to nutritious foods, fresh air, or clean water which has overall negative effects on health (21). 

Potential solutions to these problems are in the works across many fronts, but the breaking down and systemic inequality will likely require change on a broader, political level.  

Medical school admission committees could adopt a more inclusive approach during the admission process. For example, paying more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurriculars (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (13). This is one of the main drivers and only viable paths to having more minority representation in healthcare systems nationwide.  

Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1). 

Universal health insurance, basic housing regulations, access to grocery stores, and many other socio-political changes could also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location.  

Understanding the inequalities that currently exist in the healthcare system for those of minority races is essential in Oregon’s Cultural Competency Course. It is the healthcare provider’s duty to be an advocate for the patient, and the ability to recognize and identify practices that are not diverse, equitable, or inclusive to all races and ethnicities is vital in improving care delivery methods.

LGBTQ

Another highly at-risk group for healthcare inequity are members of the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community. When practicing cultural competence in nursing, the provider must become aware of how vulnerable this population is, especially in healthcare settings. Risks and examples of disparities within the LGBTQ community include:  

• Youth are 2-3 times more likely to attempt suicide  
• More likely to be homeless 
• Women are less likely to get preventative screenings for cancer 
• Women are more likely to be overweight or obese 
• Men are more likely to contract HIV, particularly in communities of color  
• Highest rates of alcohol, tobacco, and drug usage 
• Increased risk of victimization and violence 
• Transgender individuals are at an increased risk for mental health disorders, substance abuse, suicide, and are more likely to be uninsured than any other LGB individuals (17) 

Current data suggests that most of the health disparities faced by this group of people are due to social stigma, discrimination, lack of access or referral to community programs, and implicit bias from providers leading to missed screenings or care opportunities.  

Support systems and social acceptance are strongly linked to the mental health and safety of these individuals. Lack of support and acceptance in the home, workplace, or school leads to negative outcomes. Also, a lack of social programs to connect LBGTQ individuals to each other and build a community of safety and acceptance creates further gaps.  

There is currently still discrimination in access to health insurance and employment for this population which can affect the accessibility of quality health care as well as affordable coverage. 

Following this, a compilation of recent data showcases that there are significant issues with the quality and delivery of care provided to those in the LGBTQ community. This data includes: 

• In a 2018 survey of LGBTQ youth, 80% reported their provider assumed they were straight and did not ask (18).  
• In 2014, over half of gay men (56%) who had been to a doctor said they had never been recommended for HIV screening (14).  
• A 2017 survey of primary care providers revealed that only 51% felt they were properly trained in LGBTQ care (25).  

Although it is unclear as to whether this data stems from a lack of education or social awareness from the provider, it is evident that change needs to be made. 

In order to improve these conditions and close the gap for LGBTQ individuals, much can be done on the community level and in medical training: 

• Community programs should be available to create safe spaces for connection and acceptance. 
• Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals. 
• Cultural competence training in medical professions needs to include LGBTQ issues. 
• Data collection regarding this population needs to increase and be recognized as a medical necessity, as it is largely ignored currently. 

It is essential for providers to stay up-to-date on changes and health trends among the LGBTQ population, as healthcare delivery methods may require adjustments over time; this is critical when learning about cultural competence in nursing.

Gender & Sex

Gender and sex play a significant role in health risks, conditions, and outcomes due to a combination of factors, including biological, social, and economic elements. Among the differences in health data related to gender are:  

• Women are twice as likely to experience depression than men across all adult age groups (7).  
• About 12.9% of school-aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (9).  
• A 2010 study showed men and women over age 65 were about equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8% respectively) (5).  
• In the same study, 14% of elderly women were unable to walk one block, as opposed to only 9.6% of men of the same age (5).  
• Heart disease is the leading cause of death in women, yet women are shown to have lower treatment rates for heart failure and post-heart attack care, as well as lower prevalence but higher death rates from hypertension than men (6).  

It is also important to differentiate the difference between gender and sex when practicing cultural competence in nursing.  

Sex is a description of the biological and genetic differentiations, broadly categorized between male and female. Gender is a social construct of differences in societal norms or expectations surrounding men and women. For someone looking to better practice cultural competence in nursing and provide both equitable and inclusive care, it is essential that you know this differentiation.  

Some health conditions are undeniably attributable to the anatomical and hormonal differences of biological sex; for example, uterine cancer can only be experienced by those who have a uterus. But many of the inequalities listed above disproportionately burden women due to the social and economic differences they experience in society; for example, 1 in 4 women experience intimate partner violence as compared to 1 in 9 men (22).  

What are the reasons for this? A lot of it has to do with how women are perceived in society, how their symptoms may present differently than their male counterparts, or how their symptoms are presented to and received by medical professionals.  

• For centuries, any symptoms or behaviors that women displayed (largely mental health related) that male doctors could not diagnose fell under the umbrella of hysteria. The recommended treatment for this condition was anything from herbs, isolation, sex, or abstinence and it is only in the last one hundred years or so that more accurate medical diagnoses began to be given to women. Hysteria was not deleted from the DSM until 1980 (27). 
• The Cameron study found that women were more verbose in their encounters with physicians and may not be able to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (5).  
• The same study also indicated that women tend to have more caregiver responsibilities and feel less able to take time off for hospitalizations or treatments (5).  
• Symptoms of mental health disorders like ADHD may look different in girls than in boys. Girls who are having difficulty focusing may be categorized as “chatty” or “daydreamers” by teachers, whereas boys are more likely to draw attention for being hyperactive or disruptive when both are actually experiencing symptoms of ADHD and could benefit from treatment (10).  

In order to close these gaps and ensure equitable care for men and women, the way that teachers, doctors, and nurses view and respond to girls and women must be adjusted.  

• Children who are struggling in school should be looked at more comprehensively and the differences in learning styles widely understood.  
• Screening questionnaires and standard preventive care are used when caring for clients in primary care.  
• Social services should be utilized to help determine if women are pushing aside their own healthcare needs due to responsibilities at home.  
• Medical professionals must be trained in the history of inequality among women, particularly in regard to mental health, and proper, modern diagnostics must be used.  
• The differences in communication styles of men and women should be understood when caring for patients.
  

Religion

Religion can impact when patients seek care, which treatments they will participate in, and how they perceive their care. Even advanced technology in healthcare can be perceived as unsatisfactory if it violates religious preferences for patients, so it is very important for healthcare professionals to be aware of certain religious preferences to provide the most competent and sensitive care possible. Consequences of culturally incompetent care include:  

• Negative health outcomes due to not participating in care that violates their religious beliefs. 
• Patient relationships with healthcare professionals can suffer if they feel disrespected or misunderstood, causing patients to delay or avoid seeking care altogether.  
• Dissatisfaction with care can even lead to long-term trauma surrounding major events like birth, death, or chronic disease if a patient felt uninvolved or disrespected in their care (26).  

There are many religions with different practices and ordinances, but we will cover some of the more major and common implications regarding health practices here. Typically, views on pregnancy/birth, death, diet, modesty, and treatment for illness are the most important areas for healthcare professionals to understand. Providers must continue to educate themselves on the practices and preferences of various religions; it is essential to practicing cultural competence in nursing.

Disclaimer: Please note that each religion has many variations and that not all practices may be the same. The following information has been sourced from “Cultural Religion Competency in Clinical Practice,” written by Drs. Diana Swihart, Siva Naga S. Yarrarapu, and Romaine L. Martin (26). 

Buddhism

Study and meditate on life, cause and effect, and karma, working towards personal enlightenment and wisdom. They believe the state of mind at death determines their rebirth and prefer a calm and peaceful environment without sedating drugs. Have ceremonies around birth and death. Their diet is usually vegetarian (26).  

Christian Science

Based on the belief that illness can only be healed through prayer. They typically choose spiritual healing for disease or illness prevention and treatment. Often refuse vaccines and delay treatment for acute illnesses. They avoid tobacco and alcohol but have no other dietary restrictions (26). 

The Church of Jesus Christ of Latter-Day Saints/Mormon 

Heavily family-oriented, involvement of family in major health/life events is important. Strict abstinence outside of heterosexual marriage. Fasting is required monthly, exempt during illness. Blood or blood products are accepted. Abortion is prohibited unless it is a result of a rape or the mother’s life is in danger. Two elders present for the blessing of those ill or dying (26). 

Hinduism

Centers on leading a life that allows you to reunite with God after death. Believes in reincarnation and so the environment around dying people must be peaceful. The presence of family and a priest during the end of life is preferable. After death, the body is washed and not left alone until cremated. Euthanasia is forbidden. Often vegetarian and the right hand is used for eating (26). 

Islam

Belief in God and the prophet Abraham. Prayer is required five times daily. Observe Ramadan, a month of fasting and abstinence during daylight (children and pregnant women are exempt from fasting). Autopsies should only be performed if legally necessary. Must eat clean, halal, food and excludes pork, shellfish, and alcohol. Female patients require female healthcare providers. Abortion is prohibited (26). 

Jehovah’s Witness

Belief destruction of the present world is coming and true followers of God will be resurrected. Do not celebrate birthdays or holidays. Believe death is a state of unconscious waiting. Euthanasia prohibited. Refuse blood and blood products. Abortion is prohibited. Pregnancy through artificial means (IUI, IVF) is prohibited (26). 

Judaism

Belief in an all-powerful God and varying levels of interpretation/observance of laws and traditions. Cremation is discouraged or prohibited. Prayer is important for the sick and dying, after death the body is not left alone. Must eat kosher foods, excludes pork. Amputated limbs must be saved and buried where the person will one day be buried. Abortion is allowed in certain circumstances (26). 

Protestant

Christian faith formed in resistance to Roman Catholicism. Autopsy and organ donation are acceptable. Euthanasia is not acceptable. No restrictions on diet or traditional Western medicine treatments (26). 

Roman Catholicism

Christian faith is steeped in tradition and observance of sacraments. Clergy is present at the end of life for the sacrament of Last Rites. Avoid meat on Fridays during Lent. Mass and Communion on Sundays is an obligation and they may require a clergy member visit during hospitalization. Abortion and birth control (other than natural family planning) are prohibited. Artificial conception is discouraged. Newborns with a grave prognosis need to be baptized (26). 

In order to better practice cultural competence in nursing and improve the quality of care given that respects a patient’s faith and religious boundaries, one should focus on:  

• Understanding basic differences and preferences with various religions and providing training for staff.  
• Encouraging family to participate in health decision-making where appropriate.  
• Providing interpreters where needed. 
• Promoting an environment that allows for clergy, healers, or other religious figures of comfort to visit and participate in care if desired.  
• Providing dietary choices that are considerate of religious dietary preferences.  
• Recruiting staff that are minorities or of various religions.  
• Respecting a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or decline of treatments even if it conflicts with staff members’ own beliefs (26). 

Age

As the Baby Boomer generation ages, there is a growing number of older adults in the U.S. In 2016, there were 73.6 million adults over age 65, a number which is expected to grow to 77 million by 2034. As of 2016, 1 in 5 older adults reported experiencing ageism in the healthcare setting (24). As the number of older adults needing healthcare expands, the issue of ageism must be addressed. For providers looking to improve cultural competence in nursing practices, it is vital that ageism is addressed, as it flies under the radar. Ageism is defined as stereotyping or discrimination against people simply because they are old. Ways in which ageism is present in healthcare include:  

• Dismissing a treatable condition as part of aging. 
• Over-treating natural parts of aging as though they are a disease. 
• Stereotyping or assuming the physical and cognitive abilities of a patient purely based on age. 
• Providers being less patient, responsive, and empathetic to a patient’s concerns or even talking down to patients or not explaining things because they believe them to be cognitively impaired. 
• Elderly patients may internalize these attitudes and seek care less often, forgo primary or preventative screenings, and have untreated fatigue, pain, depression, or anxiety.  
• Signs of elder abuse may be ignored or brushed off as easy bruising from medication or being clumsy (24). 

There are many reasons why ageist attitudes in healthcare may occur, including:  

• Misconceptions and biases among staff members, particularly those that have worked with a frail older population and assume all elderly people are frail.  
• Lack of training in geriatrics and the needs and abilities of this population. 
• Standardizing screenings and treatments by age may help streamline the treatment process but can lead to stereotyping. 
• Changing this process and encouraging an individual approach may be resisted by staff and viewed as less efficient. 

In order to combat ageism and make sure healthcare is appropriately informed to provide respectful, equitable care:  

• Healthcare professionals can adopt a person-centered approach rather than categorizing care into groups based on age. 
• Facilities can adopt practices that are standardized regardless of age. 
• Facilities can include anti-ageism and geriatric-focused training, including training about elder abuse. 
• Healthcare providers can work with their elderly patients to combat ageist attitudes, including internalized ones about their own abilities (24). 

Veterans

Veterans are a unique population as they face many health concerns unique to the conditions of their time in service. Much of veteran health care is provided through the Veteran Affairs (VA) facilities, a nationalized form of healthcare involving government-owned hospitals and clinics and government-employed healthcare professionals. Again, the purpose of this course is to educate providers on how to practice cultural competence in nursing; however, let’s introduce the disparities found within this population by utilizing a few statistics.

• 1 in 5 veterans experience persistent pain and 1 in 3 veterans have a diagnosis related to chronic pain (8).  
• Approximately 12% of veterans experience symptoms of PTSD in their lifetime, compared to 6% of the general population and 80% of those with PTSD also experience another mental health disorder such as anxiety or depression (8). 
• More than 1 out of every 10 veterans experiences some type of substance use disorder (alcohol, drugs), which is higher than the rate for non-veterans (8).  
• In 2019, around 9% of homeless adults were veterans (28).  
• Veterans account for 20% of all suicides in the U.S., despite only about 8% of the U.S. population serving in the military (8).  
• Disparities also exist within the veteran population and veterans who are a minority race or female experience these issues at an even higher rate.
  
• For example, veteran women are twice as likely to experience homelessness than veteran men (28).  

The causes of these troubling issues for veterans are multifaceted. Some of it relates to the nature of work in the U.S. Military and increased exposure to trauma (particularly with those involved in combat), and some of it relates to the care of veterans and their mental health during and after their service.  

• 87% of veterans are exposed to traumatic events at some point during their service (8). 
• Current data suggests fewer than half of eligible veterans utilize VA health benefits.
  
• For some this means they are receiving care at a non-VA facility and for others it means they are not receiving care at all. 
• Care at civilian facilities means healthcare professionals who may not have a full understanding of veteran issues (12).  
• Less than 50% of veterans returning from deployment receive any mental health services (23).  

All service members exiting the military are required to participate in the Transition Assistance Program (TAP), an information and training program designed to help veterans transition back to civilian life, either before leaving the military or retiring. The program is evaluated annually for effectiveness and currently includes components about skills and training for civilian jobs and individual counseling regarding plans after exit.  

• Adding or strengthening components of TAP surrounding mental health care and utilization of VA healthcare services would be beneficial and could help reduce disparities. 
• Changing the military culture surrounding mental health to strengthen and mandate training and usage of debriefing for active duty military could be beneficial as well. 
• Incentivizing the usage of the VA healthcare system for routine preventative and mental healthcare would help reach more veterans who may be in need. 

Additional training for healthcare professionals working within the VA with an emphasis on cultural competence and mental health disorders would ensure high quality of care for veterans utilizing their services.

Mental Illness & Disability

Disabilities are emerging as an under-recognized risk factor for health disparities in recent years, and this new recognition is a welcome change as more than 18% of the U.S. (15) population is considered disabled. Disabilities can be congenital or acquired and include conditions that people are born with (such as Down Syndrome, limb differences, blindness, deafness), those presenting in early childhood (Autism, language delays), mental health disorders (bipolar, schizophrenia), acquired injuries (spinal cord injuries, limb amputations, change in hearing/vision), and age-related issues (dementia, mobility impairment).  

Public health surveys vary from state to state, but most categorize a condition as a disability based on the following: 1) blindness or deafness in any capacity at any age, 2) serious difficulties with concentrating, remembering, and decision-making, 3) difficulty walking or climbing stairs, 4) difficulty with self-care activities such as dressing or bathing, 5) and difficulty completing errands, such as going to an appointment, alone over the age of 15 (19).  

Health disparities affecting people with disabilities can include the way they are recognized, their access and use of care, and their engagement in unhealthy behaviors. In order to practice cultural competence in nursing, understanding the disparities that those with disabilities face is essential.

• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (19). 
• People with disabilities are less likely to receive needed preventative care and screenings (15). 
• Only 78% of women with disabilities were up to date with their pap test, while over 82% of non-disabled women were up to date with this preventative screening (19). 
• People with disabilities are at an increased risk of chronic health conditions and have poorer outcomes (15). 
• 27% of people with disabilities did not see a doctor when needed, due to cost, as opposed to only 12% of non-disabled peers (19). 
• 21% of children with disabilities were obese, compared to 15% of children without disabilities (19). 
• People with disabilities are more likely to engage in unhealthy behaviors such as cigarette smoking and lack of physical exercise than people without disabilities (15). 
• During Hurricane Katrina, 38% of the people who did not evacuate were limited in their mobility or providing care to someone with a disability (19). 

Much of the health differences between those with and without disabilities can be attributed to social factors like education, employment (finances), and transportation which significantly affect access to care.  

• 13% of people with disabilities did not finish high school, compared to 9% of non-disabled peers. 
• Only 17% of people over the age of 16 with disabilities were employed, compared to nearly 64% of non-disabled peers. 
• Only 54% of people with disabilities had at-home access to the Internet, compared to 85% of people without disabilities. 
• 34% of people with disabilities reported both an annual income <$15,000 and access to transportation, compared to 15% and 16% respectively for people without disabilities. 
• Fewer than 50% of people with disabilities have private insurance, while 75% of people without disabilities have private health insurance. 
• Even for those insured, 16% of people with disabilities have forgone care due to cost, compared to only 5.8% of insured people without disabilities (19). 

If access to necessary preventive and acute health care is to be increased for those with disabilities, much must be changed in regard to the social determinants affecting this population. Policy change on a community, state, and federal level will be needed to provide the social and economic support these people need. Potential solutions include:  

• Streamline and standardize the process of identifying people with disabilities so they can be eligible for assistance as needed. 
• School programs that help people with disabilities graduate and find jobs within their ability level.  
• Community participation in making sure transportation, buildings, and facilities are accessible to all. 
• Make internet access a basic and affordable utility, like running water and electricity. 
• Address the inequities in health insurance accessibility and coverage. 
• Provide social and economic support programs for parents of children with disabilities and provide transitional support as those children become adults (15). 

Conclusion

In short, cultural competence in nursing means that although a provider may not share the same beliefs, values, or experiences as their patients, they understand that in order to meet the patient’s needs, they must tailor their care delivery. Nurses are patient advocates, and it is on them to ensure that they are providing equitable and inclusive care to all populations. 

However, cultural competence in nursing is ever-changing and it is the responsibility of the provider to stay up-to-date in order to offer the best experience for all patients.

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