SEVENTEEN New Priorities: Challenges and Future Directions Whatever inquiries, actions, and innovations are done (or not done) today will influence the future. Through coordinated group efforts, the goals of culturally congruent health care and multicultural workplace harmony may be achieved. SNAPSHOT SCENARIO* Following a multidisciplinary conference plenary session titled “Enhancing Cultural Competence, Diversity, and Inclusiveness in Practice, Education, and Research,” several health professionals contemplate the speaker’s challenge to take immediate inquiry, action, and innovation within one’s own professional setting. Consider the following thoughts and dialogue: Ute Uno [silently thinks]: I’m only one person. I’m struggling to keep up with all my work responsibilities in my dual clinical practice-clinical professor position. We’re so short on faculty that I’m teaching an extra course this semester. What could I ever do to enhance cultural competence throughout the curriculum, workplace, and clinic? It takes more than one person.” Penny Pronto: We can’t do everything at once, or immediately solve all the problems interfering with optimal development of cultural competence, diversity, and inclusiveness, but we can do something now to make it better. Every little bit will add up to make a big difference. Rita Lott: I was wondering so much about how to effectively design, implement, and evaluate strategies for cultural competence education that I decided to allocate one day a month to reading new journal articles concerning this topic. Each article gave me new insight, ideas, and ways to avoid mistakes and optimize outcomes. I realized that unintentionally faculty and staff actions and inactions might actually isolate and hurt diverse learners, patients, families, and coworkers, leading to unmet needs and contributing to stress and dissatisfaction. I’ve also been searching about how I might prevent other new faculty and colleagues in practice from making cultural mistakes without making them feel patronized or inadequate. Willie Webb: Some hospitals, professional associations, and universities have formalized mentoring programs for new employees. Every new professional is paired with an experienced mentor. The roles of mentor and protégé are delineated in writing to clarify purposes, goals, expectations, boundaries, limits, anticipated outcomes, and duration. Sometimes there are also combined small group meetings with several new protégés and mentors. This enhances dialogue, mutual bonding from shared experiences, and role modeling. Of course, once the formalized mentoring time period is over, it usually evolves into an informal mentor–protégé relationship with mutual exchange of information and shared expertise. Like in all good professional mentor-protégé relationships, change is expected and desired. One benefit of a formal mentoring program is that everyone is interconnected and empowered within the web of inclusion rather than feeling alone, lost, tangled up, and trapped within a web of confusion. Ronda Researcher: As an experienced qualitative researcher, I would be interested in mentoring novice qualitative researchers. I’m also interested in expanding and enhancing my program of research by creating a collaborative partnership outside my discipline to build upon the cultural competence research already conducted in nursing. That is new to me and I would benefit from mentoring. Norma Numbers: As a quantitative researcher who has implemented several single site and multisite pre-test, post-test design studies using the Transcultural Self-Efficacy Tool (TSET), I would be pleased to collaborate. Perhaps we can design a multimethod study using the TSET–Multidisciplinary Healthcare Provider (MHP) version to measure transcultural self-efficacy perceptions prior to and after an interdisciplinary cultural competence training program sponsored by the neighborhood university medical center. A qualitative component to the study would yield valuable data to enrich overall understanding. Roland Model: I would also appreciate an opportunity to expand my professional role, as well as learn more about qualitative research and how the results could help provide additional support for the underlying assumptions of the Cultural Competence and Confidence (CCC) model. Alfa Stats: Yes, testable assumptions of the CCC model have been mainly substantiated via quantitative approaches using the TSET; however, results from the Cultural Competence Clinical Evaluation Tool (CCCET) and qualitative studies have also supported the model. The design of the TSET and CCCET involved a detailed process, including review by content validity experts and psychometric experts. Consistently, high Cronbach’s alpha scores provided evidence of their psychometric quality. Future testing with different populations in various geographic settings and disciplines will add to the growing body of evidence for the psychometric quality and applicability of the questionnaires across disciplines. Tim Coach: It sounds like we have many resources and ideas among ourselves already. The TEAM acronym can be used to emphasize and synthesize two important points you all just mentioned. For example, “theory, evidence-based best practices, action, and measurement” are important and “together everyone achieves more.” We can all do something individually and collectively to make a positive difference together. Let’s start developing an action plan. Currently, the process of cultural growth and change (cultural evolution) is strongly influenced by rapid growth in worldwide migration and changes in demographic patterns, marking a new and challenging era for health professionals. More than ever before, health professionals will be expected to provide culturally congruent care to many diverse “culturally different” patients and families. This new era demands a focused, committed, and transformational change that prioritizes optimal cultural competence development through innovative actions guided by systematic inquiry, empirical findings, and conceptual models. This new era necessitates optimism, resilient confidence, and a visionary plan with a prioritized focus. A first priority is to comprehensively understand the process of becoming culturally competent, recognizing that optimal cultural competence is a multidimensional lifelong learning process rather than a final product. Limited research focused on understanding this “learning” uncovers the need to more fully understand the complex process before jumping ahead and implementing randomized and disconnected teaching interventions. Learning is more than an accumulation of cognitive, practical, and affective skills; learning, persistence for learning, motivation, and skill performance are strongly influenced by psychological factors. Gaining insight into the learner’s perceptions will be an essential component in identifying the learner’s strengths, weaknesses, gaps, and needs. In this book, the CCC model was presented as an organizing framework for examining and understanding the multidimensional factors involved in the process of learning and developing optimal cultural competence in self and in others. TSE (transcultural self-efficacy, meaning the perceived confidence for learning and performing transcultural skills among culturally different patients) is a major influencing factor. The model emphasizes that the cognitive, practical, and affective dimensions of TSE and transcultural skill development can change over time as a result of formalized educational and other learning experiences. Optimal cultural competence is at the core (core value or goal) and has been added to the new illustrated model as a visible reminder of its significance. The process of developing optimal cultural competence involves seven steps: self-assessment; active promotion; systematic inquiry; decisive action; innovation; measurement; and evaluation, with continual movement, development, and interaction between all steps implying ongoing inquiry, action, and innovation (see Figure 3.3). The seven steps were incorporated throughout this book and Toolkit and are easily applicable across all settings. In addition, the TSET was proposed as a valid and reliable tool for measuring and evaluating changes in TSE perceptions within the cognitive, practical, and affective domains. Through the ongoing use of the TSET and the associated CCCET, researchers can further appraise the underlying assumptions and relationships proposed in the model. The model is flexible and easily adaptable as interprofessional collaborative research across global communities yields additional data to further expand the depth and utility of the model. A second priority is to creatively design, implement, evaluate, and modify empirically supported teaching–learning strategies that effectively weave together the main threads of professional life (academia, health care institutions [HCIs], and professional associations) into a resilient fabric that can effectively meet changing climates and unforeseen challenges of the future. Chapters 7 to 16 of this book suggested strategies for inquiry, action, and innovation within each aspect of professional life; however, educational research remains inadequate in evaluating learner needs and outcomes. The TSET was proposed as a tool for assisting educators in identifying inefficacious learners (those who are “at risk” for avoiding transcultural skills), identifying supremely efficacious learners (“at risk” for inadequate preparation and performance of transcultural skills), and developing diagnostic-prescriptive teaching interventions; ongoing research with the TSET and CCCET will expand psychometric knowledge and practical application. This chapter suggests some empirical directions for further inquiry, based on the major areas highlighted in this book. The suggestions are not meant to be exhaustive, but are offered with the intent to stimulate new ideas and invite health professionals to explore new paths in the winding journey toward developing optimal cultural competence in self and in others. FUTURE DIRECTIONS Theoretical Framework More studies using constructs, assumptions, and relationships from the CCC model should be conducted across a wide range of settings and health disciplines. Many underlying assumptions about the model had been supported empirically in the preliminary studies (1–5); subsequent research around the world has added to the growing body of evidence concerning the CCC model (6–12) (see Chapters 3 and 4 for details). Studies in progress using the TSET and the CCCET will provide data to substantiate, modify, or expand the CCC model and its utility across disciplines and settings. Quantitative and qualitative studies should be carried out using different groups of students, health professionals, and employees to compare similarities and differences based on gender, age, professional experience, ethnicity, race, religion, geographic region, and other demographic variables. How can you apply, adapt, test, implement, and evaluate the CCC model within your professional role now? In the future? What ideas for future application, adaptation, testing, implementing, and/or evaluating can you suggest to professional colleagues, researchers, educators, administrators, and policy makers? Qualitative Studies Although several multimethod studies and/or qualitative studies have already been conducted and guided by the CCC theoretical framework and/or the TSET (13–19), more studies are needed. Qualitative studies among different populations and settings will add to scientific knowledge by exploring such topics as the following: • “Lived experience” of learners’ changing transcultural perceptions • Perceived influence of select educational experiences on transcultural skills in the cognitive, practical, and affective dimensions • Perceived influence of changes in confidence levels and the impact on culturally congruent care, learning, and/or professional satisfaction • Perceived challenges and/or effective strategies for preventing and/or overcoming multicultural workplace conflicts through educational programs • “Lived experience” of promoting, facilitating, and nurturing transcultural learning and TSE in academia, HCIs, or professional associations What qualitative research questions and study designs can you contemplate that would add new and/or continued evidence for the underlying assumptions of the CCC framework, TSE, and optimal cultural competence development of self and of others? What study sample populations and settings would you select? Why? Quantitative Studies Future longitudinal, cross-sectional, or quasi-experimental studies (using the TSET exclusively or in combination with the CCCET) will help evaluate the effectiveness of select, sequential, integrated, scaffolded, and/or combined teaching interventions on outcome performances such as culture care competencies, knowledge, skills, patient satisfaction, positive patient outcomes, and confidence. Consistent with the renewed emphasis on lifelong learning, academic progression, and articulation (20–22), the quest for optimal cultural competence development is ongoing and lifelong and is a global priority for multidisciplinary health providers (22–24). Ongoing administration and psychometric testing of the various translated TSET versions and the TSET–Multidisciplinary Healthcare Provider (TSET–MHP) version will add to the growing body of evidence about the psychometric quality of the questionnaires. Thus far, the TSET has most often been used to: • Identify transcultural skills perceived as more difficult or stressful by learners • Identify at-risk learners (inefficacious or supremely efficacious/overconfident) • Develop a composite of learner needs, values, attitudes, and skills concerning transcultural skills • Evaluate the effectiveness of teaching interventions • Assess changes in self-efficacy perceptions over time More recently, some researchers also examined TSET scores in relation to patient satisfaction scores on national questionnaires like the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) used for hospital reimbursement in the United States (25), for train-the-trainer programs (26), or for employees in diverse job categories (18, 27). Other examples of newer TSET applications include researchers examining: (a) TSET data via expanded types of data analyses and statistical techniques (28, 29); and (b) TSET scores and item responses in relation to selected focus areas such as end-of-life care (30) and lesbian, gay, bisexual, transgender, and questioning (LGBTQ) workplace and patient-care issues (31) (see Chapter 4 and the Appendix). The replication and expansion of quantitative studies using the TSET will add depth to the existing knowledge base; addition of the CCCET, the Clinical Setting Assessment Tool-Diversity and Disparity (CSAT-DD), and other assessment tools will expand empirical knowledge concerning cultural competence behaviors in clinical practice settings, diversity, and disparities (19, 32) (see Chapters 4 and 6). Evidence-based educational innovations and ongoing research, guided by empirically and conceptually supported literature, can effectively guide the transformation necessary to prepare culturally competent health professionals who exceed minimum standards striving for and/or achieving optimal cultural competence. Several current quantitative studies target faculty who participate in workshops to enhance cultural competence throughout the curriculum. Such studies must also aim to reach beyond the minimal integration of cultural competence toward the optimal integration of cultural competence. Researchers should carefully consider which quantitative design and which quantitative measures are most suited for their study purpose and population, especially because funding agencies frequently stipulate the evaluation of outcomes using valid and reliable quantitative measures.
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