Authors

1. Ubogaya, Karolina FNP-BC, RN
2. Alfred, Millicent FNP-BC, RN
3. Chen, Xing FNP-BC, RN
4. Wint, Diana FNP-BC, RN
5. Worral, Priscilla Sandford PhD, RN

Abstract

Review question/objective: What culturally-focused interventions are most effective in increasing the satisfaction of adult Asian patients in the acute hospital setting?

Background: Cultural competence has gained global attention as a focus to improve quality and mitigate or eliminate racial and ethnic disparities in health care.1 The globalization of migration flows over recent decades has increased the multicultural diversity of our societies. The total number of migrants worldwide for all ethnic groups has increased from 75 million in 1965 to 214 million in 2010.2 As a result of increasing migration, virtually all European countries are becoming ethnically and culturally more diverse. Canada, the United States (USA), Australia, and New Zealand display the greatest readiness to adapt their societies to diversity and have introduced multicultural policies to address the needs of migrants and their descendants. While these countries do focus on minorities' needs in employment, housing, social integration, and law enforcement, they are not focused heavily on minorities' needs in health care systems.1 Over time, societies evolve in response to the needs of the majority population, but are not as readily culturally responsive to health care needs of newcomers and ethnic minorities. The medical work force is still relatively unprepared for giving care to the immigrant population world-wide.2 Globally, healthcare organizations are challenged in providing culturally competent, evidence-based care to migrant and ethnic minorities. Those challenges are related, but not limited, to nutrition, pain, religion, ethics, and the multicultural health care workforce.2

In the USA, the Asian population grew faster than did any other racial minority group between 2000 and 2010, and is expected to increase from 4.8% in 2010 to 9.2% in 2050.3,4 Given this trend, cultural competence in nursing care for individuals, families, groups, communities, and institutions has had an increased focus in recent years. The United States Department of Health and Human Services Office of Minority Health defines culture as "integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups."5(p.8)

Cultural competence can be defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations."6(p.11) In an effort to eliminate some of these challenges and to improve patients' satisfaction, healthcare facilities are employing culturally diverse staff to bridge the cultural gaps and to improve the overall quality of care. Additionally, there is a need for cultural competence training for staff and providers, in order to identify cultural beliefs that positively impact the patient's experience. Some hospitals are providing interpreter services in an effort to communicate effectively and address patients' needs and concerns while bridging the gaps in cultural diversity and improving patient satisfaction.6

Patient satisfaction is multifaceted and a very challenging outcome to define.7 Patient satisfaction can be viewed as an attitude, a person's general orientation towards a total experience of health.7 Satisfaction is achieved when the patient's or client's perception of the quality of care and services that they receive in the healthcare setting is positive, satisfying, and meets or exceeds their expectations. Psychosocial factors, including pain and depression, are also known to contribute to patient satisfaction scores.7

Level of satisfaction data can be collected in various ways, including telephone interviews, email and computerized surveys, postal surveys, personal interviews, and focus groups. Standard questionnaires such as the Picker Patient Experience Questionnaire-15 (PPE-15), Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and Victorian Patient Satisfaction Monitor (VPSM) are in regular use in the United Kingdom (UK), USA, and Australia, respectively.8 In Wong et al.9 the PPE-15 was adopted for measuring patient satisfaction in Hong Kong hospitals. The PPE-15 includes 15 items with either three or four possible responses: yes, always; yes, sometimes; no; and not relevant. In the USA, HCAHPS is used as a survey instrument and data collection method for measuring patients' perceptions of their hospital experience and overall patient satisfaction, with scores ranging zero (low) to ten. The VPSM has six survey questions addressing access and admission, general patient information, treatment and related information, physical environment, complaints management, and discharge follow-up. In the UK, the VPSM is used for a national patient survey, with scores ranging between three and four on a scale zero (low) to five.10 A recent VPSM report found Asian patients are less satisfied with their hospital care.10 National HCAPHS results in the USA found that ethnic minority patients tend to have scores between seven to eight, while the general USA patient population scores range between nine to ten.11 Several HCAHPS surveys reviewed in New York and California recognized that Chinese patients' satisfaction surveys had scores no higher than eight on the zero to ten scale.

New York City has the largest growing Asian population of any city in the USA.12 As a result, increased numbers of Asian patients with limited English proficiency (LEP) are at greater risk for ethnic and cultural disparities while seeking medical care.13 Traditionally, healthcare satisfaction has been lower among the Asian population as compared to other racial groups. This raises the question of whether satisfaction survey scores below the desired nine or ten are equally or more influenced by cultural perspective than by anything missing in the patient's care.

An initial search of the literature identified six articles that evaluated the satisfaction of Asian patients' experience during their hospital stay. There was an indication that patient satisfaction is negatively impacted by multiple factors, such as patients' belief that less care is provided to them based on the number of patients their nurse is caring for, as well as the inability for patients' family to stay with them at the bedside.11,12Patient satisfaction scores were low for patients who believed there was a lack of cultural communication and a lack of interpreters to communicate effectively.13,14,15 A seminal study in Hong Kong, the first cross-sectional survey study for Asian patients, found the average global satisfaction scores for public and private hospital care were 7.3/10 and 7.8/10, respectively.9 Liou et al.13 found that a lack of communication, respect, and patient engagement in provider-patient relationships negatively impact patient satisfaction.

To better focus initiatives for hospitalized adult Asians, it is critical to understand the determinants of culturally and linguistically appropriate hospital services for this population.8,11 A number of culturally-focused interventions have been assessed, including bilingual providers, interpreter services such as remote simultaneous medical interpreting (RSMI), providing hospital wide training in cultural competency for staff, and enhancing the nurses' responsiveness to clinical needs. In addition, patient education, pain management and call bell response time have been studied in the USA. While many of these interventions have demonstrated some level of effectiveness, no one intervention or set of interventions has demonstrated transferrable or consistent effectiveness in increasing patient satisfaction among adult Asian patients admitted to acute care hospitals. No systematic reviews (SR) were found in CINAHL, PubMed, the Cochrane Library, or the Joanna Briggs Institute Library regarding interventions to improve patient satisfaction among hospitalized adult Asian patients. A systematic review on the effectiveness of culturally-relevant interventions in increasing satisfaction of hospitalized adult Asian patients' satisfaction may add important evidence-based information for improving the hospital experience for this population.