THIRTEEN
Health Care Institutions: General Overview, Inquiry, Action, and Innovation
with contributions from Carolyn Bloch, Stephen R. Marrone, and Jeanette Velez
Because few nurses have had formal preparation in transcultural nursing at entry into practice and because not all nurses will pursue additional higher education, the health care institution (HCI) assumes a great responsibility for assuring the public that nurses are prepared to provide culturally congruent care and that the care is appropriately rendered.
SNAPSHOT SCENARIO
Onnie: Once I took care of a refugee from somewhere in Africa who had a car accident near the hospital. She appreciated my care and never complained, so I must have done something right.
Maury: Over the years, I’ve taken care of more diverse patients than I could keep track of and I’ve never had a problem I couldn’t handle. More and more nurses ask me how to handle cultural situations. Do I really need one more in-service about something I already know enough there is to know about? In-services about new pieces of equipment are more important.
Cassie: I’ve had some casual encounters and conversations with cultural people outside the hospital. I feel equipped to care for anyone who’s cultural.
Everett: Well, everyone has a culture. Values, beliefs, and practices vary within and between cultures and extend beyond just ethnicity or some other broad label.
Emilio: My family emigrated three generations ago. I remember stories passed down from my grandparents about the hardships, challenges, obstacles, and opportunities encountered when first traveling here. I feel I can empathize with the new immigrant experience. My ancestors were immigrants. Everyone was an immigrant at one time.
Gladys: That’s really a narrow perspective. My ancestors included indigenous groups, slaves, indentured servants, and immigrants. From a global perspective, people are moving more rapidly than ever before and bring varied cultural histories, experiences, values, beliefs, and lifestyles that should be explored individually with patients in order to provide patient-centered care.
Maggie: Yes, criteria for Magnet® status as well as accreditation mandates emphasize patient-centered care, diversity, and cultural competence. This includes cultural competence staff education for all employees.
Ethel: Ethically, cultural competence in health care and the workplace is a right, not a privilege.
Laura: Yes, legal issues also substantiate that cultural competence is a “must,” not a “should” in practice and the workplace. Culturally and Linguistically Appropriate Standards (CLAS) is one example. Another example includes lawsuits indicating that a nurse, employee, or patient had adverse consequences or suffered damages incurred from culturally incongruent actions, inactions, negligence, or omissions.
Olga: I’m tired of being the token spokesperson and translator concerning any patient or family member who speaks Russian. Being taken for a token is burdensome, inaccurate, and perpetuates stereotypes. I moved from a small village in Lithuania when I was a small child and immediately learned English at the neighborhood church school. Sometimes other nurses expect me to answer questions about elderly Orthodox Jewish patients from the former Soviet Union who had been Holocaust survivors. The nurses just don’t understand that language does not equate with culture. All nurses and employees need cultural competence in-services on a regular basis to cover different topics.
Cara: Language and communication is one of the many dimensions of culture. A complete cultural assessment is essential to ascertain the cultural values, beliefs and practices that are important to that person. It’s also important to make mutually derived decisions and take action. For example, Dr. Madeleine Leininger, founder of transcultural nursing, proposed three action modes of culture care: preservation and/or maintenance; accommodation and/or negotiation; and repatterning and/or restructuring.
Wanda: Listening to everyone’s comments makes me wonder how much I really know or don’t know about cultural competence when caring for patients, interacting with family members, or working with others who may be culturally different from me. I wonder if I compromised quality of care or patient outcomes through cultural incompetence. I wonder if I caused cultural pain to my coworkers. I wonder what this hospital can do to help employees develop cultural competence.
“Throughout the world, an emerging consensus is that cultural competence is an essential component of accessible, socially responsive, and fiscally efficient quality health care” (1, p. 60). HCIs are in a unique position not only to encourage but also to expect ongoing and optimal cultural competence development and culturally congruent patient care (see Figure 13.1). Expectations must be partnered with structured, high-quality educational opportunities and incentives for enhancing cultural competence development that are motivated by true commitment for optimal cultural competence rather than by accrediting agency mandates. Because cultural competence is defined as a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective) and involves transcultural self-efficacy (TSE; confidence) as a major influencing factor, high-quality opportunities must be carefully planned and coordinated to integrate these components. The term learning process emphasizes that the cognitive, practical, and affective dimensions of TSE and transcultural skill development can change over time as a result of formalized education and other learning experiences.
FIGURE 13.1 Health Care Institutions
Although informal interaction within the HCI can provide contact with other cultures that can have valuable and positive learning outcomes, especially if supplemented with appropriate formalized educational experiences, unguided interactions can unintentionally perpetuate stereotypes and misperceptions. One common misperception is that one member of a particular cultural group is the authority or example for all aspects of the group’s values, beliefs, and practices; hence, stereotyping may ensue. Another common misperception is that being a member of a minority group automatically makes one the authority on cultural competence for minority group(s) and on the process of promoting cultural competency development in others. Contrary to this unfounded belief, scholars support that all individuals, regardless of cultural background and identity, need formalized preparation in transcultural nursing—at least on the generalist level (2–10). Preparation on the generalist level emphasizes broad transcultural nursing principles, concepts, theories, and research study findings to care for clients of many different cultures (11). Accrediting organizations have also addressed the need for formalized cultural competence education for all students, professionals, and/or staff members and for the need to create culturally competent health care organizations (12–20).
Learners will be most motivated and interested in learning if immediate benefits to career goals and daily professional responsibilities are clearly evident and learning goals are realistic (21–27) (see Table 7.2). With increased globalization and the changing demographics and characteristics within and between cultural groups, it is unrealistic to expect that nurses will become specialists in caring for (or working with) all of the many different cultural groups that they may encounter. To become a specialist in one or more select cultural groups requires a series of specialized transcultural courses and concentrated fieldwork at the graduate level (4, 5, 7, 11, 28). Although this type of formalized education occurs in an academic setting, the HCI has an important role in facilitating nurses’ advanced degrees and/or advanced certifications. The HCI may provide incentives (flexible scheduling, promotions, released time, tuition reimbursement, forgivable loans, certified transcultural nurse certification fee and expenses) for nurses to become advanced practice nurses as transcultural nurse specialists. Transcultural nurse specialists will be valuable resources within the HCI and the surrounding cultural community (6, 7, 28, 29).
It is realistic to expect that all nurses have the basic or generalist transcultural nursing skills needed to provide care for culturally diverse and different clients. It is also reasonable to expect nurses who have been prepared as generalists to participate in ongoing educational programs designed to expand their learning with direct application to specific, targeted priority cultural groups in the surrounding communities. The advanced certificate program in cultural competence offers a unique, flexible, formalized graduate level or continuing education learning opportunity for nurses and other health professionals to expand their cultural competence education, develop cultural competence projects for implementation and evaluation in a variety of health care settings, and network with other health care professionals from near and far places (see Chapter 7) (30). By providing incentives such as tuition reimbursement, professional recognition, and monetary bonuses for advanced certificates, degrees, and certifications, the HCI will actively create a climate in which culturally competent practice and innovations will flourish and grow.
Because few nurses have had formal preparation in transcultural nursing at entry into practice and because not all nurses will pursue additional higher education, the HCI assumes a great responsibility for assuring the public that nurses are prepared to provide culturally congruent care and that the care is appropriately rendered. Unfortunately, heightened patient acuity levels; the nursing shortage; poor nurse retention; inadequate staffing; varying culturally diverse patient populations; managed care; changing health care systems, legislation, and policies; and limited resources create numerous, ongoing challenges for HCIs. First, patient care activities often must compete with educational programs. Second, providing ongoing education programs for nurses passing through a revolving door system of changing positions, units, agencies, and shifts presents obvious obstacles for synthesized learning connections that build upon previous learning. Third, the disheartened morale and dissatisfaction of many nurses drains valuable energy and motivation integral to learning. Finally, the number of nurses formally prepared in transcultural nursing, at the undergraduate or graduate level, who are actively employed in an HCI and who can adeptly develop their own and others’ cultural competence is grossly inadequate. Although the American Association of Colleges of Nursing (AACN) has now increased attention on the inclusion of cultural competence throughout baccalaureate and graduate nursing education (10, 12–18), many HCI nurses currently employed missed this accreditation change. Additionally, nurses prepared via diploma or associate degree programs (or foreign-educated) do not fall under AACN accreditation guidelines. Although state/regional, national, and other accrediting agencies in the United States have now included cultural competence and cultural diversity as expectations, defining cultural competency and knowing exactly “what is adequate” varies. The lack of sufficient, consistent evidence-based cultural competence education throughout nursing and other health care professions is also experienced globally, and international organizations advocate and expect cultural competence education and practice based upon evidence-based best practices (10, 29, 31–41). Consequently, nurses’ (and other health care professionals’) exposure to formal (and informal) cultural competence education has not been expected or standardized; therefore, it is questionable, unknown, and/or inconsistent. New guidelines, prepared via a two-step process with input from nurses around the world (9, 10, 42) have the potential to make a difference; however, systematic inquiry, action, and innovation require implementing the guidelines with swift, easy transition to the grassroots level of everyday practice, education, policy, and research. HCIs have an important role in this transition. The 10 guidelines for the practice of culturally competent nursing care are:
1. Knowledge of cultures
2. Education and training in culturally competent care
3. Critical reflection
4. Cross-cultural communication
5. Culturally competent practice
6. Cultural competence in health care systems and organizations
7. Patient advocacy and empowerment
8. Multicultural workforce
9. Cross-cultural leadership
10. Evidence-based practice and research (9)
Endorsed by the International Council of Nurses (ICN) and the American Academy of Nursing (AAN), the guidelines have been shared with over 130 nurses associations around the world (10) and well-received by other health care professionals, thereby enhancing the possibilities for high-quality outcomes via an interprofessional teamwork approach.
Although the removal of obstacles and challenges is one obvious solution, it is beyond the scope of this book to tackle all of these issues. The author contends that offering strategies and incentives for ongoing cultural competence development (part of professional development) combined with tangible patient, personal, and professional outcomes will positively affect nurse’s satisfaction and morale, thereby improving nurse retention and further enhancing patient care. Nurse educators, executives, and leaders in the HCIs are empowered to make a tremendous difference by promoting, facilitating, and evaluating cultural competence development. Each individual nurse, nurse educator, executive, or leader is empowered to make a positive difference; however, the greatest impact will be achieved through a coordinated, holistic group effort that thoughtfully weaves together relevant high-priority educational programs, unit-based initiatives, and supplementary resources.
Certain factors within the HCI may support cultural competence development, while yet other factors may restrict its development. This chapter proposes some strategies for systematic inquiry into already existing facets of the HCI, while also suggesting strategies for developing new initiatives. This chapter aims to: (a) uncover, discover, and explore educational opportunities (within HCIs) for promoting cultural competency; (b) describe action-focused strategies for educational innovation; and (c) present ideas for evaluation (and reevaluation) of educational innovation implementation. Figures, tables, “Innovation in Cultural Competence” exhibits, TSET Research Exhibits, and the “Educator-in-Action” vignette provide supplementary information to expand upon narrative text features. Major emphasis is placed on self-appraisal and determining educational priorities and goals.
How many nurses and other health care professionals in your workplace have had formal entry-level preparation in transcultural nursing and cultural competence? Post-entry-level formalized preparation (e.g., advanced certificates, continuing education, transcultural nursing certification, and/or college-degree courses)? What concepts, content, skills, theories, or teaching–learning strategies were used? When were courses taken? How were they connected to other courses and transformed into immediate and ongoing application in the workplace?
SELF-ASSESSMENT
What factors within your HCI support optimal cultural competence development? What factors within your HCI restrict optimal cultural competence development?
Similar to the process of cultural competency development in academia (see Chapter 7), promoting cultural competency in the HCI requires considerable, sincere effort that must begin with self-assessment. Systematic self-assessment evaluates the various dimensions that can impact upon the educational process and on the achievement of educational outcomes (43, 44). Figure 13.2 depicts a systematic assessment within the HCI setting. Here, self-assessment refers to assessment of the individual staff nurse, nurse manager, nurse educator, nurse executive, administrator, and the organization. Readers are encouraged to refer to Chapter 7 for an in-depth discussion about self-assessment and Table 1.2 about dimensions of cultural values and beliefs. A user-friendly Self-Assessment Tool–Health Care Institutions (SAT–HCI) is available in the Cultural Competence Education Resource Toolkit (45). The SAT–HCI may be used individually and/or in groups; the SAT–HCI may be used alone or in conjunction with other toolkit items (see instructions in Preface). Finally, self-assessment should conclude with a listing of strengths, weaknesses, gaps in knowledge, goals, commitment, desire, motivation, and priorities.
As mentioned in Chapter 7, comprehensive understanding, skill, and desire are essential but not enough to effectively make a positive difference in cultural competence development. The author believes that resilient TSE (confidence) is the integral component necessary in the process of cultural competence development (of self and in others). TSE is the mediating factor that enhances persistence in cultural competence development despite obstacles, hardships, or stressors. Resilient TSE perceptions embrace lifelong learning in the quest to become “more” culturally competent and in the quest to assist others (learners and colleagues) to become more culturally competent.
Within the HCI there are many stressors or obstacles; therefore, it becomes increasingly important that individual staff nurses, nurse managers, nurse educators, nurse executives, administrators, and the organization develop and maintain resilience, motivation, commitment, and persistence for endeavors that foster cultural competence. It is proposed that individuals (and the organization) with resilient TSE perceptions persist in their endeavors to be active transcultural advocates or promoters of cultural competences in all dimensions of the HCI and professional practice. Table 13.1 provides a guide for appraising values, beliefs, and actions and for determining whether or not one is an active role model in cultural competence development within the HCI or if there are factors restricting cultural competence development. A user-friendly Active Promoter Assessment Tool–Health Care Institutions/Professional Associations (APAT–HCIPA) is available in the Cultural Competence Education Resource Toolkit (45). The APAT–HCIPA may be used individually and/or in groups; the APAT–HCIPA also may be used alone or in conjunction with other toolkit items (see instructions in Preface). It is proposed that the “actions taken to promote cultural competence development” is what makes one an active role model. Active role models influence cultural competence development in others by presenting opportunities for vicarious learning and via forms of persuasion (honest and judicious encouragement and feedback). By providing ongoing opportunities for high-quality mentoring, the HCI can enhance the power of modeling on self-efficacy appraisal and development of nurses at all levels within the HCI. The power of mentoring on nurses’ professional development, satisfaction, quality of patient care, and retention has been well documented (7, 46–63). E-mentoring is a strategy that can effectively connect nurses, mentors, and preceptors despite the barriers of distance, work schedules, and other responsibilities (26, 27, 62, 63).
FIGURE 13.2 Self-Assessment in the Health Care Setting
TABLE 13.1 Self-Assessment: Active Promoter of Cultural Competence Development in the Health Care Institution
Promoter | Values, Beliefs, and Actions | Promoter |
Yes | Views cultural competence as important in own1 life and shares beliefs with others.2,3 | No |
Yes | Views cultural competence as important in staff’s education, professional development, and future practice and shares view with others. | No |
Yes | Views own role to include active involvement in promoting cultural competence development among staff members and shares view with others. | No |
Yes | Routinely updates own knowledge and skills to enhance cultural competence and shares relevant information with others. | No |
Yes | Attends professional events concerning cultural competence development and shares positive and relevant experiences with others. | No |
Yes | Views professional event participation concerning cultural competence development as important in staff members’ ongoing continuing education, professional development, and future practice and shares view with others. | No |
Yes | Offers incentives to encourage staff members’ participation in professional events. | No |
Yes | Maintains professional partnerships focused on cultural competence development and shares positive and relevant experiences with others. | No |
Yes | Maintains membership(s) in professional organizations whose primary mission is cultural competence development and shares positive and relevant experiences with others. | No |
Yes | Views memberships in professional organizations/associations (whose primary mission is cultural competence development) as important in staff’s continuing education, professional development, and future practice and shares view with others. | No |
Yes | Offers incentives to encourage others’ participation in memberships in professional organizations/associations committed to cultural competence development. | No |
Yes | Recognizes actual and potential barriers hindering the development of cultural competence and initiates strategies to remove barriers. | No |
Yes | Implements strategies to encourage staff’s development of cultural competence. | No |
Yes | Evaluates strategies implemented to encourage staff’s development of cultural competence. | No |
1Own refers to individual staff nurses, nurse manager, executive, administrator, educator, or organization
2Active promoter/facilitator actions are indicated by italics
3Other members of the health team include professional and unlicensed health care providers
In addition, one needs to evaluate if the HCI is truly committed to the goal of cultural competence development and culturally congruent patient care for the right reasons. The right reasons mean guided by altruism, ethics, and patient advocacy rather than being motivated by accrediting body criteria that mandate evidence of cultural competence among employees and culturally competent health care among diverse client populations. This needs to be considered, because the relatively recent addition of cultural competence criteria by accrediting agencies correlates with many HCIs scrambling to produce evidence of cultural competence, especially when previously cultural competence was invisible, superficial, and/or unimportant. This applies for both minimum accreditation standards (standard accreditation) as well as for the more prestigious Magnet status designation (see Exhibit 13.1). One approach is to examine whether the HCI actively embraced cultural diversity and had cultural competence as a goal paired with opportunities for staff development prior to accrediting agencies’ criteria mandating cultural competence. Actively embracing cultural diversity includes multiple, intensive strategies designed to recruit, retain, and encourage educational and career advancement among culturally diverse nurses, especially from groups underrepresented in nursing practice and nursing leadership. Tragically, cultural diversity within the nursing profession does not mirror the U.S. population; nurse leaders from underrepresented groups are even less visible (54, 56–58, 64–73). (The critical topic of enhancing cultural diversity within nursing is enormous; readers are referred to the current literature on nurse recruitment, retention, and professional advancement.)
EXHIBIT 13.1
Overview of the Magnet Recognition Program® and Cultural Competence
Stephen R. Marrone, EdD, RN-BC, NEA-BC, CTN-A
Associate Professor of Nursing
Long Island University
Harriet Rothkopf Heilbrunn School of Nursing
Brooklyn, NY
Adjunct Assistant Professor of Nursing Education
Teachers College Columbia University
Executive Program for Nurses
New York, NY
The American Nurses Credentialing Center (ANCC) Magnet Recognition Program is a quality designation that recognizes nursing excellence within health care organizations. Based on the American Nurses Association Nursing Administration Scope and Standards of Practice (1), Magnet designation recognizes organizations that create and sustain a culture of nursing excellence, exemplary professional practice, and a positive work environment and disseminate nursing best practices throughout the global arena (2, 3). The first Magnet designation was awarded in 1994. Today, approximately 7% of registered hospitals in the United States have achieved ANCC Magnet recognition (4). Currently, there are 401 Magnet-designated hospitals in 45 U.S. states and the District of Columbia, as well as four international sites: Australia, Lebanon, Saudi Arabia, and Singapore.
A complementary program titled Pathway to Excellence® was developed by the ANCC as a quality designation for hospital settings of any size as well as long-term care facilities. Pathway Practice Standards are based on expert nurse input, best practices, and scientific evidence that support the qualities of a positive practice environment (5). The first Pathway to Excellence designation was awarded in 2006. Today, 114 hospitals and long-term care facilities in 28 U.S. states and one international site, Singapore, have achieved ANCC Pathway to Excellence designation. Cultural competence and inclusion are essential elements of both the Magnet Recognition Program and Pathway to Excellence that support exemplary professional practice and the creation of a positive work environment.
The vision of the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association (ANA), is that Magnet-designated health care organizations will serve as a fount of knowledge and expertise for the delivery of nursing care within the context of global issues in nursing and health. The Magnet Recognition Program is based on the findings of original research conducted in 1983 by the American Academy of Nursing (AAN) Task Force on Nursing Practice in Hospitals. The Task Force was commissioned to identify and describe the variables that created and sustained practice environments that promoted quality nursing care and positive patient outcomes (2). The attributes that exemplify nursing excellence are known as the 14 Forces of Magnetism and serve as the conceptual framework for the Magnet Recognition Program. The 14 Forces of Magnetism are: (1) quality of nursing leadership, (2) organizational structure, (3) management style, (4) personnel policies and procedures, (5) professional models of care, (6) quality of care, (7) quality improvement, (8) consultation and resources, (9) autonomy, (10) community and the health care organization, (11) nurses as teachers, (12) image of nursing, (13) interdisciplinary partnerships, and (14) professional development; these are integrated throughout the Magnet model (2, 3).
The ANCC Magnet model provides a framework for excellence in nursing practice within the context of global issues in nursing and health care and includes five interrelated model components: (1) Transformational Leadership, (2) Structural Empowerment, (3) Exemplary Professional Practice, (4) New Knowledge, Innovations, and Improvements, and (5) Empirical Outcomes (3). Each model component is supported by one or more Force(s) of Magnetism. Cultural competence of health care practitioners in meeting the diverse needs of individuals, groups, populations, and organizations is a thread that is woven throughout the ANCC Magnet model (2, 3).
Transformational Leadership requires that senior leadership create the vision for the future and also the requisite systems, processes, and environment to achieve that vision (2, 3). The intent of this model component as it relates to cultural competence is to transform organizational philosophy values, beliefs, and behaviors in order to lead health care teams and organizations at large toward meeting the demands of changing demographics and diverse patient and community needs. Sources of Evidence for Transformational Leadership include the strategic planning structures and processes used in nursing to improve organizational effectiveness and efficiency, and quality outcomes that are responsive to the population in the service area. Transformational Leadership is supported by Quality of Nursing Leadership (Force #1) and Management Style (Force #3).
Structural Empowerment includes establishing and maintaining an organizational infrastructure that creates an environment within which strong professional practice flourishes and where organizational mission, vision, and values are actualized in order to achieve outcomes that are relevant to the organization (2, 3). Sources of Evidence for Structural Empowerment focus on how nursing and the overall organization address the health care needs of the diversity of populations in the service area by establishing partnerships for practice, education, research, and policy development. Specific to cultural competence and inclusion, Structural Empowerment includes establishing dynamic, mutually beneficial relationships and partnerships among community organizations to improve patient outcomes and the health of the communities served. This is accomplished through the organization’s strategic plan, structure, systems, policies, and programs. Structural Empowerment is supported by Organizational Structure (Force #2), Personnel Policies and Programs (Force #4), Community and the Health Care Organization (Force #10), Image of Nursing (Force #12), and Professional Development (Force #14).
Exemplary Professional Practice is considered the true essence of a Magnet organization (2, 3). The goal of this model component is to establish a strong professional practice environment through the application of new knowledge and evidence that is grounded in the comprehensive understanding of the role of nursing and the influence of nursing on the health outcomes, satisfaction, and engagement of patients, families, and communities, and the effectiveness of interprofessional health care teams. Evidence supports that workforce diversity, an inclusive working environment, and culturally competent health care services are critical to the delivery of safe, culturally and linguistically appropriate, quality care (6, 7, 8).
Sources of Evidence for Exemplary Professional Practice address how nurses develop, apply, evaluate, adapt, and modify the Professional Practice Model (2, 3). Since the patient/family/community is the center of the Practice Model, culturally competent organizations advance and sustain a governance infrastructure that promotes equity through policy, practices, education, and allocated resources that support the delivery of culturally and linguistically appropriate health care services (6, 9, 10). Sources of Evidence for Exemplary Professional Practice associated with cultural competence relate to (a) how the organization identifies and addresses disparities in health care for diverse patients, (b) how nurses use resources to meet the needs of diverse patients and families, (c) how the organization promotes a nondiscriminatory environment for both consumers and the workforce alike, (d) how the organizational climate supports workplace advocacy concerning diversity-related conflicts and issues, and (e) how nurses use internal and external experts such as community leaders and professional/interprofessional organizations to improve the practice environment. Exemplary Professional Practice is supported by Professional Models of Care (Force #5), Consultation and Resources (Force #8), Autonomy (Force #9), Nurses as Teachers (Force #11), and Interdisciplinary Relationships (Force #13).
New Knowledge, Innovations, and Improvements promotes the redesign and reconceptualization of new models of care, the utilization and application of existing evidence, the generation of new evidence through scientific inquiry, and the dissemination of notable contributions to the science of nursing and the worldwide health care community (2, 3). Sources of Evidence for New Knowledge, Innovations, and Improvements highlight the organizational structure and processes used to evaluate existing nursing practice based on evidence. As such, culturally competent organizations are positioned to expand the body of transcultural nursing and health care knowledge through discovery of new knowledge, application of evidence, practice integration, and outcomes evaluation that are meaningful to the organization and consumers represented in the service area. New Knowledge, Innovations, and Improvements is supported by Quality Improvement (Force #7).
Empirical Outcomes reflect the influence and impact that nursing and nurses have on patient, family, community, workforce, organizational, and consumer outcomes. Empirical Outcomes are integrated throughout each Magnet model component and essentially answer the question: What difference have you made? Outcomes are dynamic and require continuous attention in order to identify areas of improved performance and areas in need of additional effort. Magnet organizations are expected to mentor and lead the provision of quality, culturally competent patient care and to create environments that contribute to the health of the workforce and global community (2, 3). Culturally competent organizations use quantitative benchmarks that serve as a report card and demonstrate nursing excellence related to promoting culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. Empirical Outcomes are supported by Quality of Care (Force #6).
The Institute of Medicine (6, 9) reports that changing demographics of health care consumers demands that health care organizations redefine and redesign health care delivery systems based on the key principles of patient-centeredness and equity in order to meet the health and wellness needs of a rapidly growing racial and multiethnic health care population. Health care organizations that have been successful in achieving Magnet designation and redesignation have well-articulated and integrated interprofessional diversity and inclusion programs across the continuum of care. Culturally competent health care organizations provide consumers with effective, understandable, and respectful care provided in ways that fit with their cultural value and beliefs and in the consumer’s preferred language (10). Best practice supports the creation of the “chief diversity officer” role and an interprofessional “Diversity Council” to lead all diversity- and inclusion-related organizational initiatives. The roles of the chief diversity officer and Diversity Council would be to advise the chief executive team in the development of strategies that support diversifying the organization’s workforce, to review organizational policies and standard operating procedures, recruitment practices, patient education materials, and care practices that may have an adverse impact on one or more consumer groups within the service area. In addition, the diversity officer and Diversity Council provide oversight for establishing written criteria for hiring external candidates and promoting internal candidates; develop policies that address discrimination, conflict management, and grievance resolution processes and incorporate them into the patient bill of rights; and educate staff as mediators in cross-cultural conflicts (11).
The Magnet Recognition Program recognizes health care organizations that demonstrate sustained excellence by creating an exemplary professional practice environment that attracts and retains top nursing talent, embraces diversity and inclusion for patients and employees, and provides culturally competent health care services. Initial ANCC Magnet designation is granted for a period of 4 years. Organizations must successfully redesignate every 4 years and demonstrate continued excellence, improvements, innovations, and quality patient outcomes particularly related to nurse-sensitive indicators, nurse empowerment, workforce engagement, and a healthy work environment, in order to maintain Magnet status. Magnet organizations provide the springboard for nursing and nurses to lead change, redesign health care, and advance health locally, regionally, nationally, and globally.
REFERENCES
1. American Nurses Association. (2009). Nursing administration: Scope and standards of practice. Silver Spring, MD: American Nurses Association.
2. American Nurses Credentialing Center. (2014a). Magnet Recognition Program®. Retrieved from http://www.nursecredentialing.org/magnet/program overview/new-magnet-model
3. American Nurses Credentialing Center. (2014b). Magnet Recognition Program® application manual. Silver Spring, MD: American Nurses Association.
4. American Hospital Association. (2014). Fast facts on US hospitals. Retrieved from http://www.aha.org/research/rc/stat-studies/fast-facts.shtml
5. American Nurses Credentialing Center. (2012). Pathway to Excellence® application manual. Silver Spring, MD: American Nurses Association.
6. Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
7. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/Reports/2010/the-future-of-nursing-leading-change-advancing-health.aspx
8. Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., Tucker, D., & Long, L. (2007). Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. Journal of Evidence-Based Healthcare, 5, 208–253.
9. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
10. Office of Minority Health. (2013). National standards for culturally and linguistically appropriate services in health care: A blueprint for enhancing and sustaining CLAS policy and practice. Washington, DC: U.S. Department of Health and Human Services.
11. Marrone, S. R. (2013). Organizational cultural competence. In L. Purnell & B. Paulanka (Eds.), Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F. A. Davis.
A second approach is to consider the question: “If the accrediting agency removed cultural competence from their evaluative criteria, would the HCI and its employees still allocate the same amount of time, money, and energy toward cultural competence development or would cultural competence be less valued?” These two major considerations are important because nurses exist within the organizational culture of the HCI and are greatly influenced by the opportunities, values, and expectations provided by the HCI (1, 7, 54, 72, 74–76). Organizational cultures truly committed to cultural competence exert positive influence on nurses’ values, commitment, satisfaction, and motivation (77). Furthermore, organizations that actively reach out to culturally diverse patients, nurses, and communities provide a wealth of opportunities and benefits to all. An important goal is to aim for optimal cultural competence, rather than merely “passing” accreditation criteria (i.e., the achievement of minimum standards) (see Preface, Chapter 1, and Chapter 17).
Motivation behind nurses’ participation in cultural competence development in-services, continuing education, and/or workshops may not be ideal. For example, a nurse who attends a workshop because it is required for continued employment, salary increase, promotion, and/or transfer is extrinsically motivated by superficial or personal reasons, rather than intrinsically motivated by altruism, the desire for professional and personal growth and development, and improved patient care. Consequently, multidimensional learner characteristics will need to be evaluated before the design of any educational interventions. Typically, educators within the HCI have been and continue to be challenged with providing high-quality educational programs for nurses and other health professionals who represent cultural, educational, and career diversity (1, 7, 28, 29, 76, 78–90). Developing strategies to shift extrinsic motivation to intrinsic motivation is one challenge for the HCI sincerely committed to developing cultural competence at high levels of excellence (optimal cultural competence) (see Chapter 15). The author contends that optimal cultural competence is hindered unless individuals are intrinsically motivated; resilient TSE (confidence) will positively influence intrinsic motivation and persistence at optimal cultural competence development of self and others.
To what extent are individual staff nurses, nurse managers, other health professionals, executives, administrators, educators, and the organization active promoters/facilitators of optimal cultural competence development? To what extent are HCI employees and administrators intrinsically motivated to actively engage in optimal cultural competence development? What strategies are implemented consistently? What can be changed, enhanced, or added?
EVALUATION IN THE HEALTH CARE INSTITUTION
When was the last time you and your agency conducted a systematic assessment concerning cultural competence across all levels and settings?
Following the template for systematic evaluation in the academic setting (see Chapter 7), evaluation in the HCI begins with examining how visible (or invisible) cultural competency development is actively present: (a) overall within the institution; (b) specifically at the individual unit (site) level; and (c) via outside connections to supplementary resources. A systematic evaluative inquiry should also be guided by two additional questions: (1) To what degree is cultural competence an integral component within the HCI? and (2) How do all the cultural components fit together? (see Figure 13.3) A thorough evaluation of what currently exists (Jeffreys Toolkit 2016 Item 21) serves as a valuable precursor to informed decisions, responsible actions, and new diagnostic-prescriptive innovations targeting staff (and administrator) development and improved patient care outcomes in the overall goal of achieving optimal cultural competence. The following sections address major areas for inquiry, action, and innovation within the HCI.
Institution
Careful perusal of the HCI’s philosophy, mission, and purpose may lend valuable insight into the HCI’s worldview (perspective) on resources, resource allocation, profit goals, cultural diversity, cultural competence development, targeted patient populations and objectives, employee empowerment, nursing profession, decision making, and organizational priorities (Jeffreys Toolkit 2016 Item 21, Part 1). For example, a nonprofit HCI, whose mission statement and philosophy attest to providing culturally congruent health care to culturally diverse individuals despite ability to pay, provides some beginning, favorable information concerning the desire to achieve cultural competence. However, without sufficient resources or strategies to: (a) develop cultural competence of health care providers; (b) create culturally specific professional care actions; and/or (c) evaluate strategy outcomes, positive goal achievement is unlikely. Close inspection at the institutional level must also assess whether cultural competency development is emphasized substantially, equally, and symmetrically throughout the HCI beyond philosophy, mission, and purpose to such areas as new employee orientation, in-service education, learning strategies, newsletter and publications, library, website, bulletin boards, special events, and committees (see Chapters 14 and 15). Unfortunately, budget constraints, staffing shortage, and hospital restructuring has resulted in decreased HCI resources for new employee orientation, in-service education, and continuing education (53, 76, 91–97). Sample innovations that are particularly important to the development of cultural competence are presented in the “Educator-in-Action” vignette and can also be used to guide inquiry. Several major areas are described here.
FIGURE 13.3 Systematic Inquiry for Decision, Action, and Innovation: Health Care Institutions
New Employee Orientation
New employee orientation has the potential to initially introduce and reinforce the HCI’s philosophy and purposes, specifically those concerning cultural competence development. Achievement of cultural competence must expand beyond meeting minimum levels of proficiency in clinical practice (product outcome view) to expecting ongoing efforts aimed at optimal cultural competence development in self and others (process view). Nurse educators at new employee orientations have the potential to make a tremendous difference by introducing, emphasizing, fostering, and nurturing cultural competence development throughout the new employee orientation (see Chapter 14). Emphasizing ongoing education as a professional commitment to lifelong learning has the potential to raise motivation for learning. By presenting learning goals and outcomes with long-term broader professional and personal benefits rather than as merely employer expectations, occupational tasks, or job requirements, the emphasis will be on professional expectations, standards, and excellence. Emphasis on autonomy, accountability, self-regulation, and ethics is consistent with professional standards and expectations (98) and can serve as intrinsic motivators (97, 99). In contrast, mandatory workshops without connections to professionalism limit outcome results (100, 101). Linking new employee learning with unit-specific examples and connections with other HCI resources and supplementary resources illustrates an easily accessible pathway to continue on the journey of cultural competence development paved by the HCI’s instrumental and philosophical support for cultural competence endeavors. For example, case study discussion and reflection transform passive classroom orientation into active, multidimensional, and synthesized learning (7, 25, 44, 52, 86, 102–105). Such multidimensional strategies should aim to optimize learning in the affective domain (7, 25, 74, 105). Supplementing learning with computer-based learning programs, online continuing education programs, web-based programs, satellite TV programs, videotapes, simulation programs, and podcasts are other innovative options discussed in the literature (25, 53, 78, 83, 106–115).
As adult learners, new employees’ motivation will be heightened with direct application and explicit ties to the unit (site) level (see Chapters 14 and 15). Partnering follow-up learning activities on the unit (site) level provides opportunities for applying general principles to specific patient situations. Assessing learner characteristics (including TSE perceptions) and pairing learners with experienced mentors or preceptors who can serve as role models and offer encouragement will enhance cultural competence development. Self-efficacy perceptions will be greatly enhanced with models who display effort and perform tasks successfully rather than those who complete the task effortlessly (116, 117). Preparing preceptors adequately includes the use of techniques to enhance cultural competence learning, higher order thinking (118), and affective learning (74).
Physiological indices such as manifestations of stress and anxiety also interfere with confidence and learning (116). Typically, the stress of a new job, new orientation, and perhaps a new career (for graduate nurses) exists during orientations, thereby creating additional challenges. Although nurse residency programs or postgraduate training programs for new graduate nurses may present positive solutions, financial constraints and scarce human resources present limitations (55, 63, 107). Sufficient supports for graduate nurses during the transitional process may include mentors, preceptors, prolonged general and unit-based orientation, review of reality shock phenomena and strategies for successful coping, positive professional socialization opportunities, and ongoing support beyond the orientation and probation period (49–51, 53, 54, 119). Similarly, well-planned transitional interventions beginning with tailored orientation programs are strongly recommended for internationally recruited nurses (58, 120–124) and inactive nurses returning to work (53, 125).
To what extent is cultural competence visible or invisible within your employee orientation program? What else could be done? (Check Chapter 14 for more details and case exemplars.)
Unit (Site) Level
Although accountability for cultural competence development and culturally congruent health care delivery is a shared responsibility of individual staff nurses, nurse educators, and nurse managers, the nurse manager is ultimately responsible for holding staff accountable for developing and maintaining competencies (76, 108). Delineating clear expectations and penalties for noncompliance, offering supportive strategies and rewards for developing competence, initiating corrective measures when necessary, and acknowledging positive achievements optimizes the achievement of successful outcomes and minimizes the risk of noncompliance (76). Again, emphasizing the importance of cultural competence development as a lifelong commitment to professional development and the enhancement of patient care reminds nurses of their individual responsibility to uphold professional standards and guidelines. Thus, the shifted emphasis on individual professional accountability attempts to stimulate and nurture intrinsic motivation, thereby replacing the potentially, previously held, predominant influence of extrinsic motivators with true motivation and commitment (see Chapter 15).
Objectively appraising the daily routines, rituals, and activities specific within the unit (setting) and within the context of cultural competence and culturally congruent patient care as desirable outcomes requires time, expertise, and dedication. Table 13.2 presents select activities with cultural competence application common across a variety of settings (Jeffreys Toolkit 2016 Item 21). Because culturally congruent patient care begins with accurate, sensitive assessment of an individual patient’s cultural values, beliefs, practices, and behaviors, it is essential that the initial health history interview and physical examination incorporate cultural components visibly and substantially. First, inspection of the demographic form and health history interview (institution- or unit-specific) should be free of bias and reflect key cultural assessment areas particularly relevant for the setting or unit. For example, are patients (a) invited to self-identify with ethnic group affiliation(s) as an open-ended question; (b) asked to select one or more ethnic group affiliation options including an open-ended fill-in; (c) instructed to pick one category only; or (d) assigned a category by the admission nurse, physician, receptionist, or admission intake staff member? Examining whether health history forms include details about folk medicine practices, home remedies, spiritual rituals, and non-Western health practices should also appraise if questions are presented equally with questions about Western medicine, and whether questions are presented first, last, integrated, or as an afterthought. Appraising forms within the context of the broad definition of diversity (diversity of diversity) that goes beyond religious group affiliation, ethnicity, or race (see Chapter 1) and openly invites honest sharing of information is an important first step. Subtle, culturally incongruent and insensitive messages may often be unintentional or unconsciously incompetent; however, they can hinder communication and assessment. Second, information forms are only meaningful if nurses (and other health professionals) have the appropriate knowledge, skills, values, and confidence to use them appropriately with diverse patients and to document findings clearly.
TABLE 13.2 Select Activities With Cultural Competence Application
Activity | Cultural Competence Application |
Health History Interview | • Systematic cultural assessment is incorporated within the health history interview. • Interview form reflects key cultural assessment areas that are particularly relevant for setting or unit. |
Physical Exam | • Physical exam assessments and documentation are adapted to meet cultural needs and biophysical differences. • Physical exam form is free of cultural biases and includes physical assessment areas that are particularly relevant for setting or unit and for numerous different cultural groups. |
Change of Shift Report Hand-Off Report | Cultural-specific care actions are discussed: • Preservation or maintenance • Accommodation or negotiation • Repatterning or restructuring |
Patient Record | Cultural-specific care actions are documented: • Preservation or maintenance • Accommodation or negotiation • Repatterning or restructuring |
Patient Care Plan Patient Teaching Plan Patient Discharge Plan | Cultural-specific care actions are planned, implemented, and evaluated: • Preservation or maintenance • Accommodation or negotiation • Repatterning or restructuring |
Patient Care Conferences | • Topics focus on cultural competence development. • Clinical topics include relevant case exemplars representing culturally diverse patients. |
Walking Rounds | • Incorporate culturally congruent approaches for introductions, communication, and physical exam. |
Staff Meetings | • Incorporate culturally appropriate strategies for culturally diverse staff • Address issues and topics to enhance cultural competence • Promote multicultural workplace harmony • Promote culturally congruent patient care • Include resources with cultural expertise as needed |
Multidisciplinary Communication and Collaboration | • Incorporate culturally congruent approaches for introductions, communication, and designing cultural-specific care actions. |
Unit-Based In-Service Education Cross-Training Education Discipline-Specific or Specialty Area Staff Education | • Topics focus on cultural competence development. • Clinical topics include relevant case exemplars representing culturally diverse patients. • These utilize multidimensional teaching–learning strategies that incorporates cognitive, practical, affective dimensions and transcultural self-efficacy. • Relevant journal articles and other resources are available. • Relevant information is posted on the staff bulletin board or in a communication book or blog. |
Patient Teaching Materials | • Include literature and resources specific to the consumer’s ethnicity, religion, preferred language, lifestyle, gender, sexual orientation, socioeonomic status, geographic location, developmental level, educational level, health literacy and e-health literacy levels, and health needs. Educational materials include culturally congruent and culturally relevant illustrations, photos, graphics, models, colors*, and so on. *Colors may have different meanings within and between cultures. For example, a red pill could be “bad luck”; the use of certain gestures or facial expressions may have different meanings, and so on. |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
