With 40% of the U.S. population currently consisting of either immigrants or first-generation Americans, and with people of color actually outnumbering Caucasians in some parts of the country, it’s imperative that health care facilities provide cultural competence training for their nurses, to ensure that all patients receive quality care. After all, nurses are on the front lines of patient care and are often the first professionals that patients encounter when they enter the health care system. Fortunately, there are a variety of training options your organization can choose from to help your nursing staff develop these essential cross-cultural skills.
What should a cultural competence training program include? It should discuss overall organizational cultural competence as well as focus on the specific population groups and/or health issues that are relevant to the community your facility serves. It also should address the linguistic access needs of patients with limited English proficiency, as outlined in the National Standards on Culturally and Linguistically Appropriate Services (CLAS) in health care, developed by the Office of Minority Health (OMH) in 2000.
“It’s important to [start with] a broad overview,” says Valera Hascup, MSN, RNC, CTN, CCES, director of the Transcultural Nursing Institute in the Department of Nursing at Kean University in Union, N.J. “If the organization primarily serves a specific population, such as Latinos, then it can target that group or subgroups to discuss more specific care.”
According to Josepha Campinha-Bacote, PhD, MAR, APRN, BC, CNS, CTN, FAAN, president and founder of Transcultural C.A.R.E. Associates in Cincinnati, an effective training program should address the three themes of the CLAS standards: organizational, clinical and linguistic competence. Prior to the development of the CLAS guidelines, most cultural competency training focused on organizational issues of cultural diversity. But a well-rounded program also should help clinicians with diagnostic issues, such as identifying health conditions specific to certain ethnic patient populations or conducting skin assessments for patients with skin of color.
Cora Muñoz, PhD, RN, professor of nursing at Capital University in Columbus, Ohio, and co-author of the book Transcultural Communication in Nursing, begins her presentations with a frank discussion about organizational racism. “We have to look at ourselves because we have biases,” she says. “Sometimes we aren’t even aware of them, but they impact the way we provide care.”
Muñoz backs up such statements by citing the Institute of Medicine’s 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which found that bias, prejudice and stereotyping on the part of health care providers may contribute to minority patients receiving lower quality care than Caucasians. “A good training program needs to have such knowledge passed on,” she emphasizes.
Options for providing cultural competence training include using an existing training program that can be adapted to your organization, hiring a consultant to develop a program specifically for the institution, creating your own in-house training program, or a combination of all three. Here’s a look at the pros and cons of each approach.
Why reinvent the wheel when there are so many effective cultural competency training programs that have already been developed by experts? Some of the more widely used programs include those offered by the Cross Cultural Health Care Program, Management Sciences for Health, and the Center for Cross-Cultural Health, to name just a few (see “Resources” sidebar). A new and particularly exciting option is the soon-to-be-released Culturally Competent Nursing Modules (CCNMs), which will be launched in February.
Respected cultural competency models that can be found in the nursing literature include those developed by Andrews and Boyle, Campinha-Bacote, Giger and Davidhizar, Leininger, Purnell and Spector.
Train-the-trainer programs, such as the Cultural Competence Leadership Fellowship sponsored by the Health Research & Educational Trust and others, are considered one of the most effective formats for providing cultural competence education. The main reason is that this type of program enables an organization to reach many individuals.
The primary benefit of using an established program is that it has been proven effective. Additionally, many of these programs provide a consultant as part of the package to explain the program and how to implement it.
Campinha-Bacote recommends sticking with existing programs, such as the aforementioned ones, that have a strong track record of effectiveness. It is also important to spend the necessary time needed to research the various programs to determine which one best fits your organization’s needs. For instance, some programs may emphasize cross-cultural communication skills while others may center on building community partnerships or addressing clinical issues.
Muñoz focuses on racial and ethnic health disparities when she gives presentations on cultural competence and transcultural nursing to health professionals. “I train physicians and nurses, so I look at the impact of cultural competence on direct patient care,” she explains. Muñoz also recommends making sure that the program you use contains information that is sound and evidence-based.
The main disadvantage of using an existing program is that it will have to be modified to fit your organization. But as Muñoz points out, many of these programs were designed to be adapted. Plus, the consultant can work with you to help make the necessary adjustments.
A cultural competence consultant/trainer offers an objective perspective, something that is difficult to obtain from within your organization. An outside consultant can direct your organization in assessing its needs, design a program that incorporates those needs and help guide its implementation, says Hascup. This is a particularly good option for organizations that lack an in-house individual with expertise in cultural competency issues.
While a national consultant can be very knowledgeable, a local consultant knows the community and the populations your facility serves.
In either case, the trainer should have expertise in both clinical and organizational issues, with credentials from a reputable national or international credentialing body. A history of research and/or publications in the area of cultural competency is important. The individual should demonstrate a history of continuing growth in this field, because it continues to evolve, says Campinha-Bacote. Outstanding interpersonal skills, a genuine passion for the subject and an ethics/values and personality fit with your institution round out the qualifications, she adds.
Because of her academic perspective, Muñoz prefers trainers who are doctorally prepared. When seeking a consultant, she advises, find out the number of training sessions the person has conducted on a local, state and national level. Also, ask if he/she has been involved in developing curriculum on a national level. More importantly, ask if the trainer has firsthand experience working with minority communities. The trainer does not necessarily have to be a racial or ethnic minority, Muñoz explains, but should have extensive experience working with minority populations.
Norma Martinez Rogers, PhD, RN, FAAN, associate professor in the School of Nursing at the University of Texas Health Science Center at San Antonio, suggests asking the consultant for client references that you can contact.
The benefit of developing your own cultural competency training program from scratch is that your training department knows your organization’s culture best and therefore has a good grasp of what approaches will be most effective. The disadvantage is that the individual responsible for this task may lack experience and/or expertise in cross-cultural health issues. That’s why the experts we talked to recommend using a cultural competence consultant to guide and direct the process even when creating an in-house program.
Conducting an organizational cultural assessment is a critical first step. As Campinha-Bacote puts it, “Some organizations don’t know what they don’t know.”
Doing an assessment helps determine the strengths and weaknesses of staff in regard to cultural competency, and this information can be used to help design an effective training program, says Hascup. Other experts recommend conducting an assessment both before and after implementing the formal training, to determine how much the nurses have learned. It can also serve as a benchmark down the line.
Additionally, Martinez Rogers, who is president-elect of the National Association of Hispanic Nurses, recommends conducting periodic evaluations and an assessment as part of the orientation process for nursing staff. She also emphasizes the importance of including patients in the assessment process. Several good cultural assessment tools are readily available, including some created for or used by the training programs on our resources list.
No matter which training option a health care facility chooses, experts agree that buy-in from administration is essential for the program to be effective. “The top players need to be committed to the concept of cultural competency, because it is their attitude that will filter down to the staff,” says Hascup.
A hospital with committed leaders armed with a cultural assessment and an arsenal of proven-successful training tools is well on its way to being able to provide effective cultural competency training for its nursing staff.
And what is the final word of advice? “If you do not have a program, start one. If you have one, enhance it, because cultural issues are alive and well and constantly changing,” says Campinha-Bacote, who notes that she has tweaked her training model four times in the 15 years since she created it.
She points to new developments that have emerged in recent years, such as a greater emphasis on linguistic issues because of the CLAS standards and changes in the way hospitals use interpreter services. Therefore, a training program developed in the 1990s may be inadequate to address today’s cultural competency issues. “Most importantly,” Campinha-Bacote concludes, “cultural competence is a journey, not a destination.”