Nursing Center - Journal Issue

Abstract

Home healthcare and hospice clinicians face many challenges in the complex healthcare system caring for patients and their families in the home environment. One of those challenges is providing culturally competent care for an increasingly diverse population. This article will highlight free, easily accessible, online resources to assist clinicians and organizations to assess organizational and individual cultural competence and provide many resources for cultural competency education programs.

Introduction and Significance

Nurses are at the frontline of patient care and are often the first professionals that patients and their families encounter when they enter the healthcare system. Given that 40% of the U.S. population currently consists of either first-generation Americans or immigrants, and in some parts of the country people of color outnumber Whites (Carol, 2007), it is imperative for nurses to be able to deliver culturally competent care. Home healthcare clinicians, especially those in organizations without a medical library, must be able to access resources to help them do this.

Figure. No caption a... - Click to enlarge in new window

Figure. No caption available.

Cultural competence, as defined by Campinha-Bacote (2007), is a process in which the nurse strives continuously to achieve the availability and ability to effectively work within the cultural context of an individual, family, or community. Developing cultural competence is an ongoing journey that is part of the lifelong learning that is a core value of registered nurses. Giger et al. (2007) observed that cultural competency is a dynamic process that involves respecting one another's difference and not allowing our own biases to influence the care we provide. It essentially requires the knowledge, skills, and understanding of all diverse groups.

Nursing, as a patient-centered, caring profession, is committed to meeting the holistic needs of all patients and families across all settings. This is particularly true of home healthcare and hospice clinicians, who help patients in their home environment and traverse a very complex healthcare system. As our population becomes increasingly more diverse, the profession will need to develop ongoing skills to meet those needs. Becoming culturally competent is our moral and ethical commitment to our patients, families, and communities.

Narayan (2010, p. 246) stated, "Because of the ever-growing diversity of patient and staff populations, cultural competence and linguistic competence are critical elements of effective home healthcare agencies and essential attributes of administrators and staff." If your home healthcare agency accepted these three new clients, would your clinicians be able to provide culturally competent care to them?

* Baby J was born 4 weeks premature with Hirschsprung's disease. She is the first child of Russian parents. The father, who is in the United States for graduate study, speaks fluent English. The mother's English is limited. The baby had bowel surgery and has been discharged with a temporary colostomy. Her parents are very worried about caring for her properly.

* Mrs. K is a 73-year-old Indian Hindu who does not speak English. She has been discharged from the hospital following a stroke and is living with her son and daughter-in-law. The daughter-in-law has given up a postdoctoral position to care for her mother-in-law. Mrs. K also has hypertension, which may be aggravated by her preference for traditional spicy Indian food. She needs assistance with dressing and feeding herself. The home healthcare clinician realizes that she will need to discuss end-of-life issues with the family.

* Mr. S is a retired surgeon who has come to the United States from Korea with his wife to live with his daughter and son-in-law. He is deaf, so he has not been able to learn to speak English or read lips in English. However, he can read it. He has diabetes and is receiving home care for a chronic wound. He also has hypertension and is capable of managing his medications.

The Institute of Medicine (2011) report, The Future of Nursing: Leading Change, noted that the health challenges facing the nation have shifted and observed that those challenges include a more diverse population. Minority groups are expected to become a majority by 2042. "Diversity exists not only among us, but also within various ethnic and racial groups with respect to country of origin, primary language, immigrant status and generation, socioeconomic status, history, and other cultural features" (p. 48).

National Standards for Cultural Competence

The U.S. Department of Health and Human Services' (HHS) Office of Minority Health (OMH) responded to the need to ensure that all people entering the healthcare system receive equitable and effective treatment in a culturally and linguistically appropriate manner with development of the National Standards on Culturally and Linguistically Appropriate Services (CLAS; HHS OMH, 2001). These standards were proposed as a means to correct inequities that exist in the provision of health services and to make these services more responsive to the individual needs of all patients/consumers. The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups. However, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services. Ultimately, the aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans.

The principles and activities of culturally and linguistically appropriate services should be integrated throughout a healthcare organization and undertaken in partnership with the communities being served. The 14 CLAS standards are organized by themes: culturally competent care (Standards 1-3), language access services (Standards 4-7), and organizational supports for cultural competence (Standards 8-14). Accreditation and credentialing agencies such as The Joint Commission, the National Committee for Quality Assurance, and professional organizations use these standards to assess providers who say they offer culturally competent services and to assure quality for diverse populations.

Cultural Assessment

The National Center for Cultural Competence (NCCC; Georgetown University Center for Child and Human Development, 2011) provides a variety of resources to organizations, trainers, families, and communities. It includes several policy briefs, guides, and checklists that discuss the importance of policies, structures, procedures, and practices to support cultural and linguistic competence, as well as a wealth of publications and personal stories related to cultural competence. The promising practices section of the Web site highlights both promising and evidence-based practices that are commensurate with the conceptual frameworks and definitions of cultural and linguistic competence embraced by the NCCC. Content also includes interviews, PowerPoint presentations, and planning tools for service delivery systems for children with special healthcare needs and their families, consumer and family advocacy agencies, and training programs.

Several online self-assessment tools for cultural competence are offered that provide a vehicle to measure outcomes for personnel, organizations, and the community at large. The Cultural Competence Health Practitioner Assessment (CCHPA, 1999-2004) is intended to enhance the delivery of high-quality services to culturally and linguistically diverse individuals and underserved communities and to promote cultural and linguistic competence as an essential approach for practitioners in the elimination of health disparities.

The Assessment of Organizational Cultural Competence was developed by the Association of University Centers on Disabilities (AUCD) Multicultural Council (2004). The instrument assists organizations to assess their progress toward cultural competence at the organizational and individual level by identifying areas of strengths and areas for possible improvement. The assessment is designed to be administered to staff of all levels and includes questions about the individual's perception of the organization's cultural competence. The intent of the instrument is not to give an organization a "score," but to provide information about where the organization may be on a continuum in moving toward cultural competence.

The instrument consists of three sections: Assessment of Organizational Cultural Competence, Respondent Information, and Assessment of Individual Cultural Competence. The first section can be individualized to the organization by inserting the appropriate information in the blanks provided and by allowing respondents to skip those functions that do not pertain to the organization. The last section is solely for the respondent's use to monitor his or her growth in this area. The assessment takes approximately 20 min to complete.

Conducting a Cultural Competence Self-Assessment, developed by Andrulis et al. (n.d.), is an innovative approach to assessing organizational cultural competence. The tool augments the Georgetown University Child Development Center's Cultural CompetenceContinuum (2004). It can be used by a variety of healthcare providers to conduct organizational assessments of their cultural competence.

The assessment's questions are arranged by the four cornerstones of cultural competence: a healthcare organization's relationship with its community, the administration and management's relationship with staff, interstaff relationships at all levels, and the patient-provider relationship. The tool enables organizations to score their responses and identify their place on "a five point spectrum of cultural competence, ranging from inaction to a fully realized 'learning' organization" (Provider's Guide to Quality & Culture, n.d.).

This tool can be used as a formal organization-wide review instrument. Its format requires actively engaging a broad spectrum of staff and encourages the use of focus groups with patients. The tool can be very helpful in providing a healthcare organization with the opportunity to evaluate what it does well in providing care to culturally diverse populations, where the organization's weaknesses lie, and how to develop a plan for improving its services.

Provider Education

The Joint Commission developed Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (2010) to provide recommendations and practice examples that address various issues including language, culture, health literacy, other communication barriers, mobility needs, and the concerns of lesbian, gay, bisexual, and transgender (LGBT) patients. The document is organized by main points along a continuum of care. Topics include admission, assessment, treatment, end-of-life care, and organization readiness.

The roadmap also includes relevant Joint Commission standards, additional resources and links to supplemental information, model policies and tools to meet the needs of the organization's patient populations, recommendations for performance improvement, and guidelines for staff education and information to inform policy. The patient-family-centered document is reproducible with permission for use in noncommercial, educational purposes.

Magellan Health Services, recognized for its comprehensive integrated programs that address behavioral health needs across the entire continuum of care, developed a Cultural Competency Resource Kit (2007) that is especially valuable for multidisciplinary providers who care for clients with primarily psychosocial issues. Particularly helpful are the links to guidelines and standards such as the American Psychological Association's Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychology; the Department of Health and Human Services' CLAS; the Substance Abuse and Mental Health Services Administration's (SAMHSA) Cultural Competence Standards in Managed Care Mental Health Services; and the National Association of Social Workers' Standards for Cultural Competence in Social Work Practice. In addition, the resource kit makes available organizational competency assessment measurement tools, a sample cultural competence action plan and template, cultural and linguistic definitions, links to Web resources, and an extensive list of cultural competence-related books.

Also available on the Magellan introduction page for the resource kit is a link for "Cultural Competence Information Sheets" (Magellan Provider, n.d.). These sheets provide concise summaries of cultural competence-related information that can be incorporated into PowerPoint for training purposes or posted on organizational bulletin boards. The sheets cover cultural competence tenets and stereotyping, list some of the facets of culture, define cultural competence, and address its individual impact.

The Centre for Culture, Ethnicity, & Health (CEH, 2011) Web site provides succinct tip sheets to assess and improve cultural competence and the framework used to measure it. Content includes an introduction to cultural competence, a discussion of how to determine organizational values placed on cultural competence, and suggestions for equipping staff with the knowledge, attitudes, and skills needed to deliver culturally competent services. The site also addresses how to ensure that programmatic and operational plans that address cultural competence issues are tracked.

Stanford School of Medicine (2011) eCampus Geriatrics provides a vibrant Web site to assist in creating and disseminating a high-quality, peer-reviewed geriatrics curriculum for a multicultural population. In partnership with the Collaborative on Ethnogeriatric Education and the U.S. Department of Veterans Affairs, they have identified the major ethnic groups of older adults in the United States and have developed individual modules on 13 ethnicities. The modules describe the commonalities for each ethnic group, identify learning objectives, give general history and demographic information, address access to care, present case studies, and provide additional references and links to useful Web sites.

Additionally, the section on culturally competent care offers specifics on sources of knowledge related to cultural patterns of health risk and assessment. The learning resources section of each module offers detailed instructional strategies, important cultural terminology, a glossary, and comprehensive strategies for interviewing elders from diverse backgrounds.

The American Association of Colleges of Nursing (AACN, 2011)Tool Kit for Cultural Competence in Master's and Doctoral Nursing Education provides a wide array of resources to assist faculty in preparing culturally competent graduate students for practice and research. However, it can easily be used by home healthcare and hospice clinicians and leaders. The tool kit includes numerous resources and examples of references as well as classic work that includes models and theories to guide culturally competent nursing care in a safe and holistic manner to meet patient needs and expectations. Information on clinical mnemonics, cross-cultural communication, curricular resources, comprehensive research on cultural competence, and various excellent Web sites are available.

Diversity Rx is a project of the Tides Center (2011). Its purpose is to improve the accessibility and quality of healthcare for minority, immigrant, and indigenous communities. The searchable resource database is user friendly and allows one to search by resource type, topic, keywords, target population, and date of publication.

A CLAS-TALK Listserv, a diversity blog, Webinars, and videos are also available. The videos, in both Mandarin and English, were developed to assist Chinese American seniors to overcome cultural, language, and navigational barriers so that they may communicate effectively with their adult children, caretakers, healthcare providers, and the U.S. healthcare system. "Cultural Competence 101," under the topics tab, introduces the concepts, principles, and practices of CLAS in healthcare settings.

The HHS's Health Resources and Services Administration(n.d.) provides a plethora of resources to promote cultural language and health literacy. Documents available include:

* "Cultural Competency Model for African Americans,"

* "Providers Guide to Quality and Culture,"

* "Cultural and Linguistics Competency Policy Assessment," and

* "Addressing Cultural and Linguistic Competency in the Health Care for Homeless Setting"

The Web site offers valuable information categorized by race/ethnicity, gender, special populations, age, and research and education. A free online course "Unified Health Communications: Addressing Health Literacy, Cultural Competence, and United English Proficiency" allows the learner to go at his or her own pace. It is offered to healthcare professionals and students to improve patient-provider communication. The five-module course may be taken in 5 hours and deals in a sensitive manner with cultural differences that affect the way patients navigate the health system. It also addresses low health literacy and bridges knowledge gaps that can prevent patients from adhering to prevention and treatment protocols. "Unified Health Communications" can also accommodate low English proficiency with its effective use of tools that do not rely on the written or spoken word.

"Cultural & Spiritual Sensitivity-A Learning Module for Health Care Professionals" was developed by the Pastoral Care Leadership and Practice Group of Health Care Chaplaincy, New York, NY (2009). It is based on the earlier work of Rev. Susan Wintz and Rev. Earl Cooper. The tool is a self-learning module designed to address the issues of cultural and spiritual diversity, provide the means to understand one's own cultural and spiritual heritage and beliefs, develop the ability to provide culturally and spiritually sensitive approaches to care, and identify appropriate interventions, particularly for patients with serious or terminal illness.

Using a multidisciplinary and holistic approach, it begins with a self-assessment tool that is essential in assisting learners with identifying their own cultural and spiritual heritage and beliefs prior to beginning the learning module, which includes excellent information on spirituality, spiritual well-being and distress, cultural sensitivity, and competence. It provides insightful approaches to respecting diverse beliefs, very clearly written multicultural healthcare tips and practice, case studies, and a myriad of resources. A post-test competency validation evaluation identifies critical elements and aids in development of an action plan if needs are identified.

The Toolkit for Cross-cultural Collaboration(Awesome Library, 2010) was developed through "a study of collaboration styles of African American, Hispanic American, Asian American, Native American and Anglo American communities." It is designed to help administrators and community leaders become more culturally aware and therefore more effective at collaborating successfully. By discussing barriers to cross-cultural collaboration, it provides methods for assessing and improving communication patterns and cultural competence on an organizational and individual level. An extensive introduction provides stark examples of differential at-risk behaviors and outcomes for ethnic minorities. A bias in terminology explanation gives insight into finding an appropriate term for the nonminority population to use.

Also included are the stages of intercultural sensitivity, how to use comparisons of cultural patterns, communication of those patterns and assumptions, and a summary of normative communication styles and patterns. A section on myths that prevent collaboration across cultures provides insight into ways to begin to break down myths and the lack of understanding we have regarding other cultures.

The California Endowment's (2003)Principles and Recommended Standards for Cultural Competence Education of Health Care Professions is one of the many educational resources and publications by the Endowment designed to develop and strengthen the ability of healthcare professionals to serve diverse populations. These principles and standards were designed to accompany CLAS Standards to assist healthcare professionals in their efforts to provide culturally appropriate education. (The resources are available in AACN, 2011.)

The document contains principles and recommended standards for cultural competence education and training of healthcare professionals, standards for evaluating cultural competence learning, and standards relating to the qualifications of cultural competence. There are several appendices that share comprehensive information such as a glossary of terms, policy statements and standards, and several excellent models of culturally competent care. A list of 33 video and CD-ROM resources that identifies cost, intended audience, length of program, content, author, and how to access them is included. There is also a list of 67 useful Web sites with detailed descriptions of their value and purpose. Sources include state and federal governmental agencies, universities, and healthcare agencies.

Conclusion

Baldwin (2010, p. 163) discussed the need to computerize clinical home healthcare documentation to "complement the mobile nature" of the home healthcare clinician. In addition to facilitating record documentation, laptops provide home care clinicians with the ability to access online resources to enable them to practice cultural competence. For cultural competence training initiatives to advance, there needs to be a clear understanding of the terms and definitions used at both the individual and the organizational levels. Successful cultural competency education initiatives that impart knowledge from these online resources should have a lasting impact on an organization's staff. Ideally, this staff development will lead to permanent changes in staff knowledge, skills, and attitudes, resulting in the provision of optimal care, regardless of a client's cultural background (Chun, 2010). Home care clinicians are well positioned to use the resources that have been highlighted in this article.