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Case Exemplar: Linking Strategies—Spotlight on Employee Orientation Programs to Enhance Cultural Competence
with contributions from Cynthia Karczewski
A well-planned employee orientation program (EOP) should: (a) substantively emphasize cultural competence throughout most content areas; (b) provide strategies and incentives for nurses to implement culture-specific care directly in their assigned unit or setting; and (c) intrinsically motivate nurses to actively engage in the ongoing quest for optimal developing cultural competence in self and in others.
SNAPSHOT SCENARIO
Several staff educators meet at a local conference on cultural competence development. Contemplate their viewpoints and statements.
Mandy: Now that accrediting agencies mandate cultural and linguistic competence education as part of initial and ongoing staff education, there is no choice but to include it in the orientation.
Minnie: Yes, we will need to minimize the other employee orientation content and squeeze in a separate workshop about culture and interpretation services if we don’t want to exceed our week-long full-time orientation program. That should meet the requirements.
Stan: At my institution, we have a standard 50-minute video about culture that all employees watch at the general orientation session. Then we have a standard 50-minute narrated PowerPoint that all the registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) get at the nursing staff orientation. The phone numbers for the approved interpreter service providers are distributed on a handout along with a listing of patient teaching brochures available in different languages. Fact sheets about Hispanics, Asians, and Blacks supplement the 30-minute lecture given by a nurse born somewhere in South America. All our nursing staff meet the standards because they are required to score at least 70% on the postlecture quiz about all the cultural facts. The RNs score highest and the NAs frequently need to take the test over a few times. The NAs aren’t happy about the extra time on culture but standards must be met.
Blaise: At a conference last week, I was impressed by one institution’s presentation about a comprehensive employee orientation program designed to provide the foundation for an ongoing staff development series. The focus was on developing optimal cultural competence. The underlying philosophy was that in order to achieve optimal patient, workplace, and organizational outcomes, cultural competence education needed to be ongoing and that everyone should always be seeking to reach from his or her personal starting point to the pinnacle or reaching for a higher personal potential.
Dawn: Yes, I attended that presentation also. The presenters included some staff nurses who shared how the orientation and subsequent in-services included specific, immediately relevant examples, noting patient and nursing outcomes that varied based on culturally congruent versus culturally incongruent actions. I was impressed by the positive nursing staff outcomes such as motivation, commitment, job-embeddedness, and satisfaction. The program was based upon the standards by international organizations such as the Transcultural Nursing Society, resources from the National Center for Cultural Competence and Office of Minority Health, and other evidence-based literature. The program included guest presenters who were recognized experts in cultural competence through their research, publications, presentations, and/or specialized educational preparation.
Wanda: How does one substantively incorporate cultural competence within an employee orientation program? Where should we begin?
What feelings and thoughts do each of the characters in the Snapshot Scenario evoke? Why? How could each scenario positively or negatively influence optimal cultural competence development among staff members?
Although employee in-service (EI) programs (staff/employee education) can provide numerous ongoing opportunities for promoting cultural competence development, it is the employee orientation program (EOP) that can make the greatest impact. This is true for three reasons: (a) the main function of the orientation program is “education”; (b) the primary role of the employee is “learning” to apply old and new professional knowledge, skills, and attitudes in a new organizational culture and setting; and (c) the orientation program provides the foundation and framework for employees’ work expectations and all future employee in-services. During the orientation, the expectations and values of the health care institution (HCI) are conveyed within the immediate context of the employment setting. HCIs that convey, expect, and support optimal cultural competence initially during the EOP set the standard at this high-quality level. If optimal cultural competence is highly valued by the HCI, employees will become enculturated into the organizational environment. Optimal cultural competence can also be supported by being criteria for annual evaluation, promotion, salary gain, and annual recognition. Conveying that minimal level performance is not looked upon favorably by the HCI motivates employees to continually seek to enhance cultural competence development, actively assess culture within the workplace, and implement decisive action plans to provide culturally competent patient care and facilitate multicultural workplace harmony.
The main purpose of this chapter is to describe a process of visibly integrating cultural competence throughout an existing EOP. Employee education is best facilitated through a collaborative partnership in cultural competence education and professional development between nurse educators, administrators, other professional nurses, 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 subsequent employee in-service (staff education) programs build upon the foundations established via a well-planned EOP. For example, a well-planned EOP should: (a) substantively emphasize cultural competence throughout most content areas; (b) provide strategies and incentives for nurses to implement culture-specific care directly in their assigned unit or setting; and (c) intrinsically motivate nurses to actively engage in the ongoing quest for optimal developing cultural competence in self and in others (see also Chapters 13 and 15).
Illustrative case exemplars, supplemented by detailed illustrations, are threaded throughout the chapter, demonstrating easy application for a variety of unit-based or site-based settings. Evaluation of EOP components, including formative and summative evaluation strategies, conclude the chapter.
EOP: INTEGRATING CULTURAL COMPETENCE
Visible and substantive integration of cultural competence in an existing EOP should be a systematic and well-planned process. This involves time, energy, money, commitment, collaborative partnerships, and a systematic plan. Figure 14.1 presents a seven-step process that can guide EOP revision. The two case exemplars (general hospital orientation and school nurse orientation) illustrate how this process can be adapted by other staff/employee nurse educators interested in developing diagnostic-prescriptive employee orientation programs for nurses and other licensed and unlicensed health care personnel. The EOP exemplars were designed for newly hired nurses within two different settings; however, the case exemplars have applicability for other health care personnel as well as other patient populations and settings.
FIGURE 14.1 Employee Orientation Program (EOP): Ongoing Revision Process for Optimal Cultural Competence
The beginning steps of the process involve systematic assessment of: (a) employee characteristics; (b) client characteristics; and (c) existing EOP. Assessment of the HCI is omitted here because it is assumed that the HCI interested in revising EOP to enhance cultural competence has already completed a detailed, systematic assessment (see Chapter 13 and Jeffreys Toolkit 2016 Items 16, 19, 21) (1). Each beginning step is described individually followed by a case exemplar that synthesizes assessment results.
Step 1—Assess Current Employees and Clients
What characteristics and relevant factors about employees and clients are routinely assessed in your institution? What is the profile of your employees and clients? What other characteristics and affective factors should be assessed?
Assess Employee Characteristics
An EOP should be designed for a specific employee population and have empirical support. The first step is to systematically assess both employee profile characteristics and affective factors. Profile characteristics include age, ethnicity, race, gender, socioeconomic background, religion, primary (first) language, educational background, prior cultural competence education, and prior work experience. Affective factors include cultural values and beliefs (CVB), transcultural self-efficacy (TSE), and motivation (see Chapters 1, 3, and 13). Additionally, assessing the interaction of variables for the presence or absence of multicultural workplace harmony or conflict is recommended (see Chapter 2).
Assess Client Characteristics
An EOP designed for specific client examples reflective of patient populations and clinical problems will have most relevance to orientees and can have the most benefits for patient populations by reducing health disparities among targeted populations. Assessment should include client profile variables, frequent clinical problems/issues, and frequent cultural problems/issues (see Chapter 13, Table 13.2).
Step 2—Assess Existing EOP
Although every HCI has some sort of EOP guided by accreditation-mandated and agency-mandated components, and most HCIs have at least the minimum level of cultural competence education mandated by accrediting agencies, too few HCIs actively advocate for optimal cultural competence. Assessment of the existing EOP for optimal cultural competence includes careful scrutiny of accreditation-mandated components, agency-mandated components, other general components, cultural competence components, strategies and techniques, diversity of examples, measurement plan, and evaluation. Obviously, mandated components must remain; however, they can be revised to be more reflective of cultural diversity and cultural competence education if needed. Other general components should be appraised for relevance in the overall orientation and benefit to employees, HCI, and clients as well as relevance to cultural competence development. Existing cultural competence education components should be evaluated for placement within the EOP, connection to other components, depth, evidence-based content, appropriateness and relevance, and equality of emphasis in relation to other components. Examining the repertoire of teaching–learning strategies and techniques should take into account employee characteristics as well as the importance of learner-centered, reflective approaches with immediate relevance to the adult learner as recommended in the literature (2–6). Three important questions are: (a) To what extent are case examples representative of diverse patients, diverse employees, and diverse clinical issues? (b) What types of examples are currently used? and (c) How do case examples develop or hinder cultural competence development in the workplace? Finally, assessment of the measurement plan and evaluation should be thoroughly reviewed, including any formative and summative evaluations of previous EOP.
When was the last time you and your agency conducted a systematic assessment concerning cultural competence within the EOP?
Step 3—Identify Trends
Sifting through the assessment results obtained will assist in identifying data trends, showcasing strengths, uncovering weaknesses and gaps, and establishing priorities. In the school nurse case exemplar, the following assessment information supported the need for a revised EOP that emphasized and integrated cultural competence education:
1. Absence of prior cultural competence education program.
2. Increase in the cultural diversity of children, families, and communities.
3. Mismatch between the diversity of nurses, children, and parents.
4. Varying levels of motivation, interest, and commitment of nurses to cultural competence education.
5. Awareness that culture-specific care of clients (children and parents) could promote children’s health, prevent illness, enhance clinical outcomes for existing health problems, and facilitate entry into the health care system.
6. Identification of actual and/or potential clinical problems directly and/or indirectly influenced by culturally incongruent versus culturally congruent care specific to the school setting.
7. Increase in multicultural workplace conflict, nurse dissatisfaction, high nurse transfer/attrition rates, complaints, and lawsuits.
8. The National Association of School Nurses identified the need to teach and learn about cultural competence and provide culture-specific care to diverse children (7, 8).
9. Renewed administrative interest in cultural competence education throughout the local school system.
Based on systematic appraisal, what data trends, strengths, weaknesses, and gaps can you identify in your EOP? What priorities would you recommend? Why?
Step 4—Review Literature
A review of the nursing, medicine, and education literature as well as that of other relevant disciplines should be conducted. Materials should be reviewed for gathering background information about proposed clinical topics, culturally diverse patients and nurses, patient outcomes, cultural competence education strategies, evaluation methods, employee orientation/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 school nurse case exemplar, the Cultural Competence and Confidence (CCC) model and the measurement of transcultural self-efficacy 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 adaptation of strategies reported in the literature. One must be aware, however, that there is no panacea that one EOP will solve all problems and help prepare every nurse to become culturally competent. Realistically acknowledging that the EOP can be the foundational starting point for future employee cultural competence development is imperative.
When was the last time you conducted a review of the literature concerning cultural competence education strategies, employee orientation programs, and organizational cultural competence? What books, book chapters, websites, journal articles, dissertations, and other scholarly resources can help you plan the EOP?
Step 5—Revise EOP
What components of an existing EOP are working well? Why? What EOP components are not working well? Why? What is missing?
When revising an EOP or any education in-service program, it is important to focus on the positive components that are already working effectively. Revising for the mere sake of doing something different without a well-founded, empirical, and/or conceptual rationale is wasteful and counterproductive. Keeping what works and tying this into revisions will be most productive. For example, if an already existing case exemplar on the use of a professional interpreter for a non-English-speaking patient has had positive feedback from EOP participants and has met the desired educational outcomes, then this case exemplar should be retained (and continually reevaluated). Identifying what about the case exemplar captivated the audience can provide helpful guidelines to designing similar case exemplars for other topics. If time and other resources (money, expertise) permit, another teaching–learning strategy can be added to further develop cognitive, practical, and/or affective learning in the particular area. For example, the 10-minute Charades Communication Game (9) can be piloted (see Exhibit 8.4).
Retaining accreditation-mandated and agency-mandated components is essential to maintaining accreditation and the operation of the particular agency. Finding creative, time- and cost-efficient ways of threading cultural competence, diversity, and multidimensional teaching–learning strategies throughout the EOP (with the intent of establishing a strong foundation for future employee in-services with integrated cultural competence) is challenging, yet quite rewarding if successful. Determining what is successful (what works, what doesn’t, and why) requires a thorough formative and summative measurement plan with timely evaluation of the results.
In the school nurse EOP, no formalized cultural competence education had been previously introduced; therefore, a formalized measurement plan and evaluation was also nonexistent. Consequently, the following revisions were proposed.
New School Nurse Orientation
The evidence-based, research-supported CCC model (10, 11) and valid, reliable corresponding questionnaire is proposed to guide the school nurse EOP, its implementation, and the evaluation of summative outcomes. The EOP includes self-assessment for each employee to determine one’s own cultural values and beliefs as well as if the employee is an active promoter of cultural competence development in the workplace (Jeffreys 2016 Toolkit Items 16, 19). The Transcultural Self-Efficacy Tool (TSET) will be given prior to the first class and again 3 months after orientation. It will be used to measure and evaluate participants’ confidence for performing general transcultural nursing skills among diverse populations.
Next, the EOP will introduce and reinforce the Office of School Health’s philosophy and purposes specifically concerning cultural competence development. The fairly recent focus on cultural competence education by the National Association for School Nurses and School Nurses International, along with relevant updated position statements, will be highlighted. The emphasis will be on professional expectations, standards, and excellence as well as on autonomy and accountability. Ongoing education will be emphasized as a professional commitment to lifelong learning. New employees’ motivation will be heightened with direct application in the school setting (see Exhibit 14.1).
