Online Journal of Cultural Competence in Nursing and Healthcare Volume 6, Number 1 (2016) Cultural Competence in Taiwan Health Care and Society: Rationale for and State of the Science

Taiwan is a multicultural and multiethnic society. In addition to its Han Chinese heritage, many cultures and societies influence Taiwanese. As Taiwan’s immigrant population continues to grow, the need for culturally competent health care providers capable of addressing the needs of its diverse ethnic, racial, and multicultural society is becoming more evident. Many Western societies have adopted culturally competent research, education, and clinical practices; however, cultural competence remains a new concept in Taiwan. Little information is available on the cultural competency of the health care providers in Taiwan and particularly nurses who provide direct care to patients. In this paper, justification for and the current knowledge about cultural competence in Taiwan’s heath care system are presented. Insights into Taiwanese health care providers’ cultural competence might provide guidance for future implementations of cultural competence in-service trainings or integration into designing nursing curricula to improve patient outcomes and health care quality. Lin & Mastel-Smith 111 www.ojccnh.org Online Journal of Cultural Competence in Nursing and Healthcare Volume 6, Number 1 or the fifth ethnicity. Most of these so-called “New Residents” are either foreign laborers or foreign female spouses from Mainland China and Southeast Asian countries such as Indonesia, the Philippines, Thailand and Vietnam. A reported 45,000 foreign women are married to Taiwanese men (National Immigration Agency [NIA], 2012) with approximately one out of five marriages involving foreign brides. The practice of marrying foreign brides started in the 1980s in rural Taiwan (Hsia, 1997) and created a special social phenomenon in farming and fishing communities, particularly among the lower middle classes. In addition, because of the shortage in low-level tech laborers and long-term health care providers, the Taiwanese government recruited foreign workers to fulfill industrial needs and caregivers for children and older adults with chronic illnesses and disabilities. Approximately 430,000 foreigners work in construction or serve as caregivers (Council of Labor Affairs [CLA], 2012). These changes in population and social structure dramatically shifted Taiwan’s demographic landscape and created a multicultural environment that necessitated transcultural nursing and health care policies. Huang (2012) pointed out that good health care policies need to satisfy both the providers and those who are served, which include Indigenous Taiwanese and New Residents. Health care providers must be culturally sensitive and competent when caring for clients from diverse ethnic groups. Immigrants, for example, face the challenges of living in a new environment and therefore suffer the most from health related problems (Aponte, 2009). The lack of or insufficient knowledge about the cultural background of foreigners, especially foreign female spouses and low-level laborers and caregivers might explain why there is a higher prevalence of suffering, both physical and psychological, among these groups (Hou, Chen, & Lu, 2008; Liu, Chung, & Hus, 2001). Culturally competent health care for diverse populations has received little attention in Taiwan (Wu & Yen, 2012; Huang, 2012; Perng & Watson, 2012). Lack of formal education and training for Taiwanese health professionals might limit their ability to provide culturally appropriate health care services (Hung, Yang, & Yen, 2011). A better understanding of cultural competence among Taiwanese nurses could establish a foundation for developing strategies to improve, cultivate and foster culturally competent health care and services provided to culturally and ethnically diverse patients. Such knowledge might also trigger governmental and administrative agencies to regulate and/or provide mandates or guidelines on culturally competent health care. Review of Literature An intensive search of nursing and social sciences literature was performed dating from 2001 through 2011. Relevant literature was located using electronic scholarly and popular databases such as The Cumulative Index for Nursing and Allied Health Literatures (CINAHL), Web of Science, PUBMED, Educational Resources Information (ERIC), and Taiwanese National Central Library Database of Thesis and Dissertation. Search terms included “cultural competence” and “Taiwanese nurses” and searches were limited to the previous ten years to capture most current research. Searching for “cultural competence” resulted in 4641 hits on PubMed, which was narrowed down to 730 hits when the keyword “nurses and cultural competence” were used. Only 15 articles; however, were produced when using the keywords “nurses” and “cultural competence in Taiwan”. Searching for “cultural competence” resulted in 822 articles using CINAHL, 169 articles on “nurses and cultural competence”, and reduced to four articles when combined with “Taiwan”. An additional 18 articles were obtained from sources in Taiwan, which could not be accessed via database in the United States (US), as well as from references listed in cited articles. Lin & Mastel-Smith 112 www.ojccnh.org Online Journal of Cultural Competence in Nursing and Healthcare Volume 6, Number 1 Culture and Cultural Competence Defined Culture is a shared system of values, beliefs, traditions, behaviors, as well as verbal and nonverbal patterns of communication that may differentiate a group with similar characteristics from others (Giger & Davidhizar, 2008; Purnell, & Paulanka, 2008; Leininger, 2002). These values and beliefs have a significant impact on how individuals access and interact with health care providers and services (Spector, 2009). Understanding the impact of culture on an individual’s perceptions of health is the basis of cultural competence in health care and practice. Cultural competence is defined by the US Office of Minority Health ([OMH]; Office of Minority Health, 2012) as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.” The concept of transcultural nursing care was pioneered by Leininger in the 1950s, which stemmed from her belief that the understanding of cultural diversity related to health and illness was an essential component of nursing knowledge (Leininger, 2002). Its aim is to encourage quality nursing care to patients from diverse cultural backgrounds and to decrease health care inequality and disparities among minority racial and ethnic groups. The standards for culturally competent practices in health care are based on social justice which emphasizes fair and adequate access to health care for all (Douglas et al., 2009). Culturally congruent and competent health care results in improving health and well-being for people worldwide (Jeffreys, 2010) and impacts health care outcomes and quality (Betancourt, Green, Carrillo, & Park, 2005). Nursing professionals in the US acknowledged their responsibility and the challenges in preparing a nursing workforce that reflects this diversity and which is capable of providing culturally competent care. Consequently, accrediting bodies such as the Commission on Collegiate Nursing Education (CCNE: CCNE, 2008) and the Accreditation Commission for Education in Nursing (ACEN: ACEN, 2013) mandated that academic nursing programs should demonstrate that graduates are capable of providing culturally competent nursing care at basic and advanced practice levels. The American Academy of Nursing Expert Panel on Global Nursing and Health and The Transcultural Nursing Society (TNS; Douglas, et al. 2009) established twelve standards for culturally competent nursing care, which provided a road map for applying transcultural nursing in health care. Culturally competent care is therefore becoming a standard agreed upon by health care professionals in the US. Such standards, however, are neither common nor advocated for in Taiwan, which is in stark contrast to the ethnic diversity of its population. Health Status among Taiwanese Minority