Promoting Cultural Health Competence in Nursing

By Lani Hollenbeck, RN, BSN,C

Situation

According to the August 2003 Kaiser Commission on Medicaid and the Uninsured, more than 46 million people - more than 17 percent of the U.S. population - speaks a language other than English at home. The Kaiser Commission report provides many examples of how lack of language access negatively affects access to and quality of health care.

As a registered nurse (RN) in the Special Diagnostic Center at Children’s, many of my interactions with limited English proficient (LEP) patients and families have been frustrating, leaving me feeling that my communication and teaching were inadequate and wondering how I could improve my skills and interactions. Many of my nurse colleagues have shared with me that they experience similar feelings. The results of Children’s 2005 employee satisfaction survey as well as the Special Diagnostic Center’s problem scores confirm that lack of cultural health competence is seen as a barrier to providing excellence in patient care. Cultural health competence is defined as understanding the values and views of those in other social classes and ethnic groups.

Background

“Providing culturally safe care is necessary for excellent nursing care. The nurse/patient interaction is the core of such excellence; it enables openness, trust, and acceptance so that nursing care is facilitated” (Pasco, Morse and Olson, 2004). Consequences of inadequate health competence include poor health status, lack of knowledge, lack of understanding, and underused of preventative services.

Coffman, Shellman and Bernal (2004) evaluated the effectiveness of the Cultural Self-Efficacy Scale (CSES) for assessing nurses’ confidence and skills in caring for patients from culturally diverse backgrounds. They used literature searches and questionnaires to evaluate the uses, methods, and findings of the CSES. According the authors, “The . . . CSES is an important assessment tool as today’s nurses need to be increasingly sensitive as a result of the growing diversity of the population. Research indicates that nurses lack cultural self-efficacy, cultural information, and cultural experience. This lack of experience often results in nurses subjecting their clients to ethnocentric attitudes, inappropriate communication, inaccurate diagnoses, and ineffective interventions.” Their study supports ethnicity exposure, coursework, and educational experiences to increase nurses’ self-efficacy in delivering culturally competent care.

Comerford-Freda (2004) identifies patient education as one of the most important responsibilities of nurses and nurse midwives but acknowledges that appropriate and comprehensive patient education has become increasingly difficult to provide. She suggests that the challenges may be the result of the influx of clients from various cultures, confounded by lack of time, a dearth of educational materials at appropriate readability levels and/or in languages other than English, and lack of reimbursement for patient education. The author discusses cultural competence as affecting patient education, principles of education, methods of teaching, readability, ethical issues, and informed consent.

Majumdar, Browne, Roberts and Carpio (2004) conducted a randomized controlled study assessing the effectiveness of cultural sensitivity training on knowledge and attitudes of health care providers as well as satisfaction and health outcomes of patients from minority groups with health care providers who received training. They concluded that a cultural sensitivity program improved knowledge and attitudes among health care providers as well as health care outcomes for their patients.

The above literature identifies that cultural competence is integral to providing safe and excellent nursing care and reinforces the importance of recognizing our own limits and biases as nurses when caring for patients. It is imperative that we appreciate the need for cultural understanding and the nuances of cultural health in order to work effectively with families. The literature summaries identify that nursing participation in education about cultural health competence will enhance communication and patient interaction.

Assessment

Based on my literature review, I see two major challenges facing nurses at Children’s around the issue of education in cultural health competence:

• Many nurses may not understand the potential impact that cultural health competency education could have on the quality of their communication and interactions with limited English proficient (LEP) patients and families.
• Nurses’ ability to access resources already in existence is not valued and therefore is underutilized.

Recommendation

Personal education plan

Children’s nursing department promotes excellence in patient care through innovation and education of staff. This mission was foremost in my thoughts in developing a cultural competence education plan for the Special Diagnostic Center, the patient care area where I work. After reflecting on how I could develop a plan for myself and my unit, I knew I wanted to include

• participation in self-assessment exercises
• utilization of on-line learning resources
• observation and one-on-one exercises
• reading books and watching movies about cultures different from my own

Most important, I decided I needed to be proactive, creative, and accountable for my own learning. My personalized self-learning plan for increasing my own accountability has included visiting grocery stores in the Cedar Riverside area that sell culture-specific foods, and reading books rich in cultural and ethnic flavor. I met with Nancy Vang, a member of Children’s Interpreter Services, who enlightened me by sharing her story of marriage and childbirth in Hmong culture. I also took advantage of MNA education reimbursement funds in 2006 to attend Children’s annual Cultural Competence Conference as well as the Sigma Theta Tau nursing honor society’s research days focusing on nursing research in foreign countries. Children’s web-based learning courses provided me with powerful and easy tools to use in my self-education plan.

Future plans include a visit to the new Midtown Global Market (Lake and Chicago) and attending the Minneapolis-St. Paul International film festival with nursing colleagues. My overall comfort level with cross-cultural topics and interactions has increased, giving me the confidence to participate in a poster presentation and attend the Sigma Theta Tau International Leadership Academy. My anxiety in working with LEP families has diminished, and I look forward to working with families whose culture is different than my own.

Education at the unit level

At the unit level, I discussed my concerns with the nurse manager of Special Diagnostics. I gave her an outline of best practice literature that identified the value patients could receive from having caregivers trained in cultural health competency, and I advocated for introducing a teaching-learning component on health competency into our unit culture.

My manager supported this initiative: we have shared a cultural competency power-point presentation with colleagues and developed a unit-based cultural competence learning manual accessible to all staff. The manual provides information on racial and ethnic disparities in health care, care provider resource tools, and peer-reviewed research articles demonstrating the value of cultural competency education and its impact on nursing practice. Staff meetings included a brief time for colleagues to share information with others on cultural topics and norms as we learned new information. Intercultural sensitizer exercises, such as those identified by author Rena C. Gropper in her book Culture and Clinical Encounter can be used as a basis for discussion.

More suggestions

Additional suggestions for growth in cultural competence include:

Expand your horizons. Give yourself permission to learn something new and different about another person. Enroll in a Spanish for health care workers class. Attend cross-cultural conferences and workshops. Children’s 6^th Annual Conference on Cultural Competence in Pediatrics: Children’s Health and Culture, will be offered April 13, 2007 at the St. Paul Heart and Lung Conference Center. This year’s theme is Culture and Child Rearing. Watch for flyers coming soon, or contact Elsa.Batica@childrensmn.org for more information.

Pause to reflect. Think about times when you haven’t felt comfortable during interactions with people from a culture different from your own. Could these be opportunities for personal growth? Consider a self-development plan. Contact Boris Kalanj, director of Cultural Care and Interpreter Services at Children’s, for help with a self-assessment, at Boris.Kalanj@childrensmn.org The Intercultural Development Inventory (IDI) is an instrument that measures a person’s likelihood to act competently in cross-cultural situations.

Utilize interpreters for your patients. If your patient/family is LEP, it is okay to use an interpreter for yourself to better understand your patient’s needs. Learn how to use interpreters effectively. Learn how to use the telephone language line if an in-hospital interpreter is not available. Familiarize yourself with Children’s translated patient/family education materials, available on StarNet. Use translated written materials. If you identify a topic that does not have an education sheet in the language you need, fill out a request form for translation or use the link from StarNet to the Multilingual Health Resource Exchange.

Have fun in learning. There is a wealth of books and movies that can be used to learn about different cultures. My favorites include the movie Hotel Rwanda, and the books The Joy Luck Club and The Kite Runner. Other recent popular films that can expand your worldview include Smoke Signals, Whale Rider, Monsoon Wedding, and Eat Drink Man Woman. Visit an ethnic-specific food store or restaurant. Ethnic restaurants within walking distance of the St. Paul campus include Cossetta’s and Chico Chica, and there are several along Grand Avenue, including Pad Thai and Barbary Fig. In Minneapolis, a short walk through Abbott Northwestern and over a skyway leads to Midtown Global Exchange with a wealth of ethnic food and shops; Eat Street (Nicollet Avenue from Grant to Lake) has more than fifty restaurants from all over the world.

Conclusion

In conclusion, I feel that the recognition and promotion of education is an important tool to help nurses develop cultural health literacy skills. Individual nurses and nursing units adopting the above interventions will no longer identify lack of educational access to cultural literacy tools as a barrier to learning, and will be more comfortable and more competent in interacting with patients and families who have limited English proficiency.

Lani Hollenbeck, RN, BSN,C, is a staff nurse in Special Diagnostics at Children’s.

Coffman, J, Shellman, J., Bernal, H. (2004). An integrative view of American nurses’ perceived cultural self-efficacy. Journal of Nursing Scholarship 36(2), 180-185.

Comerford Freda, M. (2004). Issues in patient education. Journal of Midwifery Women's Health 49(3). Retrieved May 3, 2005 from http://www.medscape.com/viewarticle/478283

Kalanj, B. Director, Cultural Care and Interpreter Services, Children’s Hospitals and Clinics of Minnesota. Personal communication, May 17, 2005.

Majumdar, B., Browne, G., Roberts, J., Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal of Nursing Scholarship 36(2), 161-166.

Pasco, C., Morse, J., Olson, J. (2004) Cross-cultural relationships between nurses and Filipino Canadian patients. Journal of Nursing Scholarship 36(3), 239-246.

Vang, N. Staff interpreter, Cultural Care and Interpreter Services, Children’s Hospitals and Clinics of Minnesota. Personal discussion, April 2006.