Core Concepts in Cultural Competence

map of Somali

Romani, the adjective; Romani, plural noun; or Roma, singular noun, are the preferred terms when referring to people commonly and incorrectly known as Gypsies. Gadje (or gazho) is the plural term referring to non-Roma. An individual Romani household is a familia consisting usually of three generations of six to fifteen relatives. Families are male dominated, with a group of male elders within the familia being the major decision makers. Romani women are often not included in the decision making process and generally have a much more subordinate role.

The Roma originated in India and migrated to Europe by the 15th century. A large Romani migration to the United States occurred, from Russia via Argentina in the 19th and 20th centuries. The Romani language is derived primarily from Sanskrit. Education and technology have not traditionally been considered important. Many older Roma are not literate.

Roma are generally a nomadic people. They have traditionally adopted the dominant religion of the area in which they live. They also maintain beliefs in the supernatural, omens and curses and may carry charms, amulets and talismans in their pockets for safety, good luck and to prevent illness. Romani female healers, called drabarni or drabenhgi, prescribe traditional healing rituals and cures. The Romani people tend to use the Gadje health care system only in crisis situations when there is an acute and/or unresolved condition for which folk medicine has failed.

Most Roma make a concerted effort to remain socially isolated and invisible. In the United States Roma often present themselves as members of one of the other minority groups in the U.S., due to concerns about the “impurity” of outside cultures and to the long history of prejudice and misconceptions about their culture.

The Roma have a strict taboo code that classifies all outsiders as soiled or unclean. "Wuzho" (pure) and "marimé" (pollution or impurity) are important Romani concepts. To maintain purity, Roma are required to follow strict sexual mores. They must wash their hands after touching the lower body before touching the upper body. Separate soap and towels are used on the upper and lower parts of the body and they must not be allowed to mix. Dishes may not be washed in a sink used to wash clothing. Roma believe that polluting actions will result in illness. To return to a state of purity, cure, and good health one must conform to or correct the marimé social behavior.


This case story discusses how a Nurse Manager begins to approach helping the hospital in which she worked and the nursing staff become more culturally competent.

Challenges of a New Mandate

By 7:00 am, Jacqueline Strong is already in her office, preparing for the day to come. As a Clinical Nurse Manager on a busy pediatric unit at Kendrick Hospital, she is in charge of patient care and training. She also chairs a hospital committee for Cultural Competence. Last month, the Board of Trustees unveiled its 10-year Strategic Plan. Objective #3 mandates that the entire hospital, from an individual to an organizational level, must demonstrate the ability to provide culturally competent care. Helping achieve this goal has become another one of Jacqueline’s responsibilities.

Prior to the Board’s development of the Strategic Plan, Kendrick Hospital conducted an organizational self-assessment of cultural competence. Staff in different departments were asked to complete anonymous self-assessments in cultural competence. Jacqueline was quite concerned when she looked at the nursing responses. She knows that the department has a long way to go.

For many years, Kendrick Hospital has served a blue collar, Irish Catholic neighborhood on the edge of Chicago. Many of the nurses are from this neighborhood (many of them grew up here) and hospital staff and patients have enjoyed a feeling of close camaraderie. They have also taken particular pride in Dr. Jamieson, a nationally known oncologist who was recruited to develop a satellite oncology program to be affiliated with the larger Metro Healthcare Center. Recently, a number of Romani patients have been coming to Kendrick. They frequently ask for Dr. Jamieson, even if the problem for which they are seeking help is not cancer. While perceived by some as loud and demanding, the Romani patients seem to have an admirable ability to negotiate the system, obtaining the information they need and getting appointments with the physicians they wish to see.

Jacqueline's dilemma

Jacqueline is concerned, however, because the nurses have little to no experience with members of other cultures. Just yesterday, for example, Christy Fitzgerald, a young, enthusiastic, usually cheery nurse came into her office, her voice filled with frustration. She protested that she “could not get her work done with that Gypsy girl.” Christy said that least 10 of the girl’s relatives were in her room at all times, while many others “camped out” in the hall and waiting room. When Christy entered the room, one of the older men “demanded” to know why they hadn’t seen Dr. Jamieson. When Christy attempted to give the child a sponge bath, several of the women insisted in staying and watching her. As she proceeded, they clearly became angry. Christy couldn’t understand what they were saying, but their loud and agitated voices made it clear they wanted her to stop. Later, she tried to butter some of the girl’s toast, and again she was stopped. Christy thinks she saw one of the girl’s relatives pocketing some of her medications. She told Jacqueline that she has heard that Romani patients have a reputation for stealing, though she can’t imagine why they’d be stealing antibiotics. She thinks just being at the hospital is stealing, in a way, because they clearly have no insurance. Christy thinks the Gypsies lie, too. After all, one of the family members told another nurse that they were Hispanic and that’s clearly not true. And it’s been hard to get anything done. When the doctor told the girl’s mother that, with her permission, he’d like to use a new medication on her daughter, the mother just wouldn’t make up her mind. Christy also thinks the family is at fault because they waited so long before bringing the girl into the hospital. The girl wouldn’t have gotten this sick if they’d brought her in right away. As Christy talked, it became clear to Jacqueline that Christy has been approaching this Romani patient and her family entirely from her own perspective, without attempting to understand the family’s views and beliefs.

Jacqueline knows that she will need to have a long talk with Christy. As chair of the Cultural Competence Committee she will have to provide training for all of the nurses. While the Romani patients present the most immediate need, Jacqueline wants the nurses to learn more generally about how to work with people from diverse cultures. In addition, she is coming to realize that the hospital is not a welcoming place for Romani patients. She recognizes that changes will need to be made at the institutional level, to allow Romani patients to feel more comfortable there.

Interventions at all levels

Jacqueline decides to approach the problem at two levels. First, she holds a series of in-services for the nurses, using Christy’s experiences with her Romani patient as a starting place for the first one. Jacqueline knows that developing a culturally competent staff will take more than these seminars, and that knowledge does not immediately translate into attitude and behavior change. But she feels this will be a start. She plans also to consider the possibility of asking the Romani elders whether they would be willing to act as “faculty”, talking with the nurses about their culture and beliefs. She would ideally like this to happen in their homes, but knows that she will have to approach this idea gently, as members of the “gadje” community are generally seen as presenting an impure and potentially dangerous influence on the Romani community.

Simultaneously, Jacqueline and other members of the Cultural Competence Committee writes a proposal that she presents to the hospital’s executive committee. They would like to develop a special program for Romani patients. This program would involve providing rooming-in accommodations for the larger family groups, special sanitary precautions (disposable plateware and eating utensils; two washcloths and bars of soap; careful attention to Romani concerns); and training to physicians and nurses regarding the importance of communicating with elders and refraining from touching surfaces in the rooms of Roma; sensitivity to the fact that Romani elders may not read and accommodations for this; flexible billing programs to allow Romani patients to pay their bills over time; and appropriate mores for communicating with members of the opposite sex.

Things to consider about this case

There are several issues to consider about this case. You will explore these issues more fully in the learning activities.

  • What challenges do medical facilities face when trying to become more culturally competent?
  • What kinds of assumptions do providers sometimes make about people from other cultures?
  • What factors may cause providers to relate to patients in a biased manner?


What to do next

Now that you have read the case, go to the lecture section to gain a better conceptual understanding of the issues related to Cultural Competence.