FIFTEEN
Case Exemplar: Linking Strategies—Spotlight on Employee In-Service Education to Enhance Cultural Competence
with contributions from Patricia Bartley-Daniele and Karen Kennedy
Capitalizing upon both intrinsic and extrinsic motivators will optimize learning outcomes, transcultural self-efficacy (TSE), and the delivery of culturally specific patient care.
SNAPSHOT SCENARIO
Consider the following employees’ thoughts and attitudes about cultural competence staff in-services, their possible impact on optimal cultural competence development in self and others, cultural competence with patients and in the workplace, and implications for staff educators.
Sally Spectator: I just like to sit back, watch, and listen. I purposely selected a staff educator who lectures and talks fast. Some of the other in-service educators make participants talk and interact with each other. Some of them even do small group or role-play activities and mix up the groups with people who don’t know each other.
Vinnie Video: I purposely selected the mandatory cultural competence workshop 2 update via the 50-minute video. The other options include a live presenter who makes participants talk and interact as part of the in-service.
Rosie Dozey: I work the night shift right before attending the staff in-services. I sit in the back and usually find myself dozing on and off. But, I’ve now completed all the cultural competence in-service segments required for medical–surgical nurses at my hospital.
Tom Tardy: I always seem to be late getting to the in-service, because I’m late getting my medications out, finishing my documentation, and giving a hand-off report. When I get to the in-service, I start to jump right in and ask questions but my coworkers get annoyed because the staff educator just explained what I’m asking about. Now I just keep quiet but sometimes I don’t really understand the cultural case scenarios because I missed the background work. Fortunately I still get credit for attending the in-service.
Patti PowerPoint: It’s great that I can just breeze through the PowerPoint slides for cultural competence in-services 5, 6, and 7. I like all the pictures of the different countries. It gives me new vacation ideas. I can also flip back through the slides to make sure I answer 80% of the post-test questions correctly. I love all these in-services!
Filomena Facts: Oh, no, another cultural competence in-service. I just can’t remember any more facts about one more culture. Just look at that handout, filled up with lots of stuff that’s not necessary. Why do I need to know about cultural beliefs and implications related to disposal of an umbilical cord and afterbirth? I’m working in geriatrics!
Lana Later: All these cultural competence in-services will come in handy later on if I ever meet a diverse patient. We’re all the same here.
Una Unconnected: This hospital cultural competence in-service is just so unconnected from the realities of my urgent care center.
Olivia Overconfident: I’ve been a nurse caring for culturally diverse patients for over 20 years. I know all there is to know about dealing with diversity. I’ve managed fine, even though this wasn’t emphasized in my nursing program.
Clyde Clock: I don’t have time for all these in-services about stuff that is nonessential. Who has time for cultural competence?
Debra Doubtful: I doubt that cultural competence really makes a difference. I doubt this in-service will do anything to make my nursing practice more fulfilling. I doubt this young staff educator can teach me anything new.
How many of these employees are engaging in active attendance? In optimal cultural competence development? Has this occurred in your employee in-services? Have you had a problem with active participation and achievement of desired outcomes? How did you visualize each of these characters in terms of demographic characteristics? Why?
Providing culturally competent care is essential to a patient’s well-being and recovery. Leininger (1) defines culturally competent nursing care as “the explicit use of culturally based care and health knowledge in sensitive, creative and meaningful ways to fit the general lifeways and needs of individuals or groups for beneficial and meaningful health and well-being or to face illness, disabilities or death” (1, p. 84). Examples of culturally competent care include “striving to overcome cultural, language and communication barriers; providing an environment in which patients from diverse cultural backgrounds feel comfortable discussing their cultural health beliefs and practices in the context of negotiating treatment options; and being familiar with and respectful of various traditional healing systems and beliefs” (2, p. 8). In order to accomplish culturally competent care with culturally diverse patient populations and employees, the health care institution (HCI) must be truly committed to promoting and facilitating cultural competence development among all employees. Ongoing cultural competence education via employee in-services is an important mechanism toward achieving this goal.
This chapter describes the process of designing, implementing, and evaluating an employee in-service (EI) program to enhance cultural competence. EI education is best facilitated through a collaborative partnership in cultural competence education and professional development between nurse educators, other professional nurses, administrators, and other health professionals. The ongoing accessible opportunities for cultural competence education at the HCIs offer tremendous possibilities for optimal cultural competence. This is especially true if in-service programs are built upon the foundations established via a well-planned employee orientation program that: (a) substantively emphasized cultural competence throughout all content areas; (b) provided strategies and incentives for nurses to implement culture-specific care directly in their assigned unit or setting; and (c) intrinsically motivated nurses to actively engage in the ongoing quest for developing cultural competence in themselves and in others. Extrinsic motivation refers to motivation that focuses on the goal-driven reasons—for example, rewards or benefits earned when performing an activity (3). Intrinsic motivation indicates one’s own pleasure and inherent satisfaction derived from a specific activity (3). Capitalizing upon both intrinsic and extrinsic motivators will optimize learning outcomes, TSE, and the delivery of culturally specific patient care (see Chapter 13).
Two illustrative case exemplars from two different HCIs, supplemented by detailed illustrations, are threaded throughout the chapter, demonstrating easy application for a variety of unit-based or site-based settings. Evaluation of EI components, including formative and summative evaluation strategies, conclude the chapter.
EI: DESIGN, IMPLEMENTATION, AND EVALUATION
EI design, implementation, and evaluation should be a systematic and well-planned process. This involves time, energy, money, commitment, collaborative partnerships, and a systematic plan. Figure 15.1 presents an 11-step process that can guide EI development. The two case exemplars (perioperative nursing and bone marrow transplant [BMT] unit) illustrate how this process can be adapted by other staff/employee nurse educators interested in developing diagnostic-prescriptive employee in-service programs for nurses and other licensed and unlicensed health care personnel. The EI exemplars were designed for nurses already working in an HCI; however, the case exemplars have applicability for other health care personnel as well as other patient populations and settings. Additionally, the exemplars illustrate how the in-service can be implemented as a component of a larger, full-day in-service program (e. g., Nursing Educational Day) or as a separate, shorter, unit-based in-service.
FIGURE 15.1 Employee In-Service (EI) Education: Design, Implementation, and Evaluation Process HCI, health care institution; CE, continuing education.
The first phase of the process might appear to be “design,” but there is really a predesign phase. This involves four steps: assess the current situation, review the literature, outline ideas, and solicit support. Each step is described individually and within the context of the EI case exemplars.
Step 1—Assess Current Situation
What characteristics and relevant factors about employees and clients are routinely assessed for in your institution? What is the profile of your employees and clients? What other characteristics and affective factors should be assessed? When was the last time you and your agency conducted a systematic assessment concerning cultural competence and EI?
An employee in-service program should be designed for a specific situation and have empirical support. The first step is to systematically assess the current situation, including staff profile variables, retention rates, prior exposure to formal and informal cultural competence education, client profile variables, frequent clinical and cultural issues/problems, staff support and motivation, administrative support, and the existing HCI resources (see Chapters 13 and 14).
In both of the EI case exemplars, the following assessment information supported the need for a unit-based/site-based cultural competence in-service program:
1. Absence of prior unit-based/site-based cultural competence education programs.
2. Increase in the cultural diversity of clients.
3. Renewed administrative interest in cultural competence education throughout the HCI.
4. Mismatch between the diversity of nurses and patient population.
5. Varying levels of motivation, interest, and commitment of nurses to cultural competence education.
6. Awareness that culture-specific care of patients could enhance patient clinical outcomes and prognoses.
7. Identification of actual and/or potential clinical problems directly and/or indirectly influenced by culturally incongruent versus culturally congruent care specific to the unit/site.
Based on systematic appraisal, what data trends, strengths, weaknesses, and gaps can you identify in your setting and HCI? What priorities would you recommend? Why? What components of existing EIs are working well? Why? What EI components are not working well? Why? What is missing?
Step 2—Review Literature
Once the organizational climate seems favorable to supporting the educational endeavor, moving forward to conduct a literature review is recommended. (In contrast, if the organizational climate is unfavorable or ambivalent, a literature review documenting strong rationale for the educational endeavor is indicated.) A review of the nursing, medicine, other relevant disciplines, and education literature should be conducted. Materials should be reviewed for gathering background information about proposed clinical topics, culturally diverse patients, patient outcomes, cultural competence education strategies, evaluation methods, in-service and continuing education, and potential resources. Choice of a relevant conceptual framework can be valuable to provide structure and organization. For example, in the two case exemplars, the Cultural Competence and Confidence (CCC) model and the measurement of TSE perceptions provided the underlying framework for strategy design and evaluation. When reviewing literature concerning cultural competence education strategies, determining strategy strengths, limitations, and appropriateness of fit to the targeted population can help sort through various possibilities. Attention to the strategy’s measurement and evaluation of outcomes is integral to determining selection and/or adapting strategies reported in the literature. One must be aware, however, that there is no panacea that one in-service program will solve all problems and help prepare every nurse to become culturally competent. Realistically weighing the possible benefits against the risk of doing nothing can help in the decision-making process. Realistically acknowledging that one cultural competence education in-service or continuing education program can be the starting point for future cultural competence development is important.
In the case exemplars, the in-service planners had previously compiled literature on cultural competence; however, an updated review of the nursing and health professions literature was necessary. Additionally, review of cultural competence education strategies, measurement and evaluation, psychology literature on motivation, and current clinical information on the specialized target areas were conducted systematically. Published journal articles and books were reviewed and organized into specific categories, expanding the current literature files and making future retrieval and updates easy.
When was the last time you conducted a review of the literature concerning cultural competence education strategies, EI programs, staff education, and organizational cultural competence? What books, book chapters, websites, journal articles, dissertations, and other scholarly resources can help you plan, prioritize, implement, and evaluate EIs?
Step 3—Outline Ideas
Beginning with a focused, manageable topic is a necessary, critical step. Attempting to collapse too much information, skills, and affective learning within a brief in-service will overwhelm the learner, dilute content, and result in superficial or minimal application in the actual clinical setting, thus defeating the intended purpose of achieving culturally congruent care and of promoting lifelong, ongoing cultural competence development among staff nurses. Planning a series of short in-services may meet the needs more appropriately and satisfactorily with nurses who are pulled in many directions in a busy unit and with other health care professionals who are pulled in many directions throughout the HCI.
The next step is outlining major areas and filling in details to expand the working outline. Major areas to include are:
• Problem, need, significance, and rationale
• Background literature
• Target population
• Purpose
• Objectives
• Project activities, timeline, and potential impact on target population
• Measurement and evaluation
• Budget
• Feasibility
In the case exemplars, data from the preliminary appraisal of the HCI, unit, staff, and client profile (step 1) strongly supported the need for a cultural competence in-service program. Furthermore, the background literature strongly documented the need for culture-specific care among perioperative patients and BMT patients. The broad goal was to enhance cultural competence among staff nurses. Exhibit 15.1 presents the purpose, target population, educational objectives, and activity components in an easy-to-read format. Brainstorming resulted in a list of possible activity and content components. Reviewing the list for feasibility eliminated some strategies. Finally, prioritizing the remaining components provided an outline of ideas that could be a starting point for soliciting support.
What ideas do you have for enhancing cultural competence through employee in-services? What topics, target populations, settings, time frames, objectives, formats, and activities are most feasible? Why? Which are the most prioritized? Why? Which idea(s) will you pursue first?
Step 4—Solicit Support
Although soliciting support can seem time-consuming, the benefits of having conceptual and instrumental support commitments are invaluable and help build alliances and partnerships. Although both are important here, soliciting a significant amount of instrumental support commitments is an essential precursor to preparing an EI program proposal.
While this step may seem similar to the assessment of support in step 1, it has many important differences. First, this step builds on the collaborative relationship initiated in step 1 that should then evolve (or be nurtured) into a collaborative partnership. A collaborative partnership can have varying degrees of direct or indirect supportive involvement but all could be potentially critical to the approval of an EI program and ultimately its success.
EXHIBIT 15.1
Title, In-Service/Continuing Education (CE) Purpose, Target Population, Educational Objectives, and Activity Components: Comparison of Two Case Exemplars
Title | |
Enhancing Cultural Competence In-Patient Teaching: Issues and Examples for Nurses Working With Diverse Bone Marrow Transplant (BMT) Patients | Perioperative Nursing: Promoting Cultural Competence |
In-Service/CE Purpose | |
To enhance staff nurses’ cultural competence in patient teaching among diverse BMT patients | To enhance perioperative nurses’ cultural competence |
Target Population | |
BMT staff nurses at a health care institution (HCI) | Perioperative registered nurses at a HCI |
Main Activity | |
A 1.25-hour unit-based in-service targeting culturally competent patient teaching | A 3-hour hospital-based continuing education (CE) program with 25 to 30 perioperative RN participants |
Educational Objectives | |
At the completion of the in-service, the learners will be able to: 1. Distinguish between different cultural competence terminologies 2. Differentiate between culturally congruent and incongruent patient teaching. 3. Discuss areas of concern with providing culturally congruent teaching 4. Incorporate cultural competence into patient teaching | 1. Discuss the phases of perioperative nursing and its relationship to quality health care 2. Describe key transcultural nursing concepts with direct application to perioperative nursing practice 3. Discuss the relevance of culturally competent perioperative nursing in the achievement of successful patient outcomes 4. Analyze the impact of Culturally Linguistic and Appropriate Services (CLAS) standards and its effect on health literacy and culturally congruent perioperative nursing care 5. Analyze the impact of medication reconciliation and culturally congruent nursing care 6. Summarize strategies to promote culturally congruent perioperative nursing care |
Activity Components | |
1. Administer the Transcultural Self-Efficacy Tool (TSET) 2. Lecture/discussion 3. Interactive PowerPoint presentation/discussion 4. Short case scenarios about culturally congruent and incongruent patient teaching 5. Reflection 6. Generate open conversation among staff nurses using probing questions about their concern and/or ideas regarding their provision of culturally congruent teaching with diverse patients 7. Dialogue and brainstorming on “how to incorporate cultural competence into patient teaching on the unit” | 1. Administer the TSET 2. Lecture/discussion 3. Interactive PowerPoint presentation/discussion 4. Small group work analysis of clinical scenarios: Health literacy, medication, reconciliation, ambulatory patient discharge 5. Reflection 6. Group leader summary of clinical scenarios’ themes 7. Guided synthesis summary to incorporate cultural competence into all phases of the perioperative process |
At this point of more formalized commitment to specific tasks, the anticipated timeline for the tasks should be mentioned. This gives more structure and organization. For instance, if the timeline is not realistic, it can be adjusted now before writing it in the proposal and setting oneself up for failure later in the implementation and evaluation phases. Before preparing a proposal, it is important to tease out what strategies are feasible and realistic and what would be more problematic. In this way, the presence or absence of support will result in a modified list of possible strategy components. Instrumental support cannot occur without conceptual support; however, conceptual support without instrumental support greatly limits the possibilities of EI success. Evaluating staff support for various components is crucial before entering the design phase (program preparation and approval).
The following examples are applicable to the EI:
• General objective of in-service (enhancing cultural competence) is approved by director of nursing education, clinical nurse educator, and nurse manager.
• Date and time for the in-service is negotiated and approved by director of nursing education, clinical nurse educator, and nurse manager.
• Several staff nurses agree to participate in the in-service and encourage their colleagues to participate.
• Nurse manager agrees to make announcements to encourage staff participation.
• Administrators commit to support release time for in-service planner/educator.
• HCI statistician agrees to actively assist with questionnaire processing and data analysis.
• Administrators agree to allocate funds for the continuing education (CE) application form, healthy snacks, and photocopying.
