Transculture in Nursing

Question: Discuss about the Assessments of Cultural Competence Initiatives Available in your Organization. Answer: Introduction The increase in racial and ethnic diversity in countries is bringing in opportunities as well as challenges for health care providers. They are constantly under pressure to deliver culturally competent care and this can be achieved by developing cultural competence skill in health care professionals. Cultural competence is the ability to deliver health care services to meet the social, cultural and linguistic needs of diverse group of people. To promote health and well-being of patients, health care providers need to respond to diverse values and health belief of patients (Huey et al., 2014). However, conflict situation or negative health outcome may arise when health care staffs fail to manage the socio-cultural difference and health beliefs of patient. Hence, the assessment of cultural competency within health care system is needed to improve the quality of care and eliminate racial and ethnic disparities in care. The goal of health care organization should be to create a culturall y competent environment. This is possible by having key elements in health system such as defined values and principles of cross-cultural interaction, conducting cultural competency assessment to develop the ability to manage diversity and assimilate cultural knowledge and integrate them in daily practice (Ring, Nyquist, Mitchell, 2016). With this challenges present in health care to respond to the needs of culturally diverse patient, the purpose of this report is to analyze the cultural competent initiative available in a health organization in Saudi Arabia and assess how they respond to the needs of culturally diverse group. It will help to gain idea about current challenges in Saudi Health care system and their preparedness to promote culturally competent care. Detail of health care organization This report is focused on examining the cultural competent initiative in King Fahad Military Medical Complex (KFMMC) of Saudi Arabia. The KFMMC hospital is located in Dhahran city of Saudi Arabia with 350 beds and 5000 employees. It was founded in 1989 and has different specialties like accident and emergency care, intensive care unit, operating room, cardiac center, physiotherapy, haemodialysis center, internal medicine, ophthalmology and many others. Other specialized department includes kidney transplant, nephrology, specialty clinics and kidney transplants. The rapid changes in economical, technological, social changes and customer-related demands have an impact of the nature and quality of care and KFMMC is highly reliant on international workforce. Presence of diverse cultural group can create risk in delivering health care and lead to medical error (Inocian, 2015). Hence, to eliminate this barrier in effective care practice, the purpose of KFMMC is to carry out comprehensive c ultural competence assessment to determine the level of knowledge about Saudi Cultural aspect in workforce and evaluate whether they practice in a culturally sensitive way or not. Rationale for cultural competence initiative in hospital of Saudi Arabia Cultural diversity presents the major challenge to health care workforce of Saudi Arabia. As patients and heath care staffs come from different linguistic and cultural background, it often leads to conflict. Staffs recruited in Saudi Arabian healthcare system are mainly non-Saudi who come from different parts of the world and they are unaware of the culture and beliefs of Saudi Arabian citizens. This factor makes care process inadequate and leads to misunderstanding which has an impact on therapeutic relationship as well as interaction with patients. Similar challenge is also experience by clinicians and nurses in King Fahad Military Medical Complex. Hence, due to the resultant mix of culturally and linguistically diverse health care staffs and patient in hospital, KFMMC felt the need to evaluate and assess the cultural awareness knowledge of nurses and other staffs. The problem of inadequate cultural awareness in health care setting can be addressed if health care organization takes steps to educate health professionals about all aspects of Saudi culture to minimize conflict and improve the quality of care and similar strategy is also proposed by the management of KFMMC hospital (Karout et al., 2013). The complexities in health care system can cultural competency have been studied by various researchers. One such analysis of research literature by Karout et al., (2013) revealed the experience of Saudi women admitted in private hospital of Saudi Arabia. Muslim cultural life, values and beliefs are different from other cultural groups and this creates a misfit in ethical codes of practice. Diversity in the clinical context leads to inconsistency in the expectation of care and delivery of care. There are certain Muslim practices such as concern for modesty, evil-eye and food taboos which non-Muslim nurses are not aware about and it is the responsibility of current health care system to provide in-service education to the staffs to enhance the quality of culturally competent care. Another example of cultural disparity is that breast cancer incidence is rising but the breast cancer screening rate is low in Arab women. This is because of Arab womens attitude and beliefs prevented them f rom adopting health preventive behavior. The interview with this group of patients revealed that fear or embarrassment was the reason why they did not go for mammogram. This problem can be addressed by culturally appropriate intervention and awareness program. Hospitals of Saudi Arabia like KFMMC need to pay more attention to the cultural competent skill of nurses and clinician to develop the understanding of Arab culture, beliefs and practices (Donnelly et al., 2013). The concept of an ideal culture can be understood by the quantitative phenomenological study which explored the perception of Saudi women in cultural diversity in heath care team. The biggest problem reported by the participants was related to linguistic diversity as the difference between English spoken nurse and Arabic speaking patients was leading to problem in communication. Second theme arising from the study was religious diversity issues where women were not comfortable in uncovering their body parts to non-Muslim service providers. Furthermore, there was also value and belief conflict as women participants were not satisfied with care as it overlooked their traditional values on health practices. Therefore, this experience suggest that health care workforce may struggle in providing culturally appropriate care to diverse population groups and this may affect the quality of care delivered. As lack of religious and cultural knowledge is a major barrier in efficient nursing care , it has become paramount for hospitals of Saudi Arabia to assess cultural competence of their workforce and training nurse to culturally competent health care practice. Nursing education programme will also have to strengthen their curricula by including cultural competency concept in quality care. Nurses and other staffs need to be conversant with Saudi Expression, terminology, belief and values to engage in appropriate care practices (Karout et al., 2013). Components of cultural competence assessment profile The cultural competence assessment profile is a set of analytic framework and indicators for examining cultural competence in health care service in hospitals. Use of such profile is effective in internal assessment of cultural competence at the hospital. It may involve quality review, performance monitoring and compliance with set cultural competence standards at the hospital. The major components of an assessment profile for the hospital include the following: Domain of cultural competence and focus areas- The main domain involved in cultural assessment includes organizational values, staff development, and governance, planning evaluation, hospitals infrastructure and interventions. Organizational values can be judged by the attitude and commitment towards culturally competent care and the main focus areas under this domain will be leadership role, data regarding cultural competence and level of flexibility in the organization. Governance domain can be assessed by looking at policies used at hospital to deliver culturally competent care. Planning process for cultural competence at the hospital can be judged by the presence of short-term and long-term policy and system to track level of cultural competence. Furthermore assessment of culturally competent oral and written communication will help to understand whether culturally appropriate communication process is present or not. Tracking training content and commitment is also an important d omain to evaluate if staffs have the skill to deliver culturally competent care service. Another important focus area is the process of care planning and treatment that is delivered in a culturally competent manner (Shen, 2015). Indicators of cultural competence- Indicators are any measureable characteristics that determine the level of cultural competence in a hospital. Structural indicators are related to factors used to assess organizations preparedness to cultural competence. Example of this indicator may include culturally appropriate setting, infrastructure, financial resource, governance and administrative system present at the hospital. Similarly process indicators give an idea about activities and procedures at the hospital that reflects culturally competent care. Output indicator is the positive or negative outcome of policies in a multi-cultural and multi-lingual work environment. Other indicators may include provisions of care and response to care in culturally competent manner (Linkins et al., 2017). Assessment of cultural competence initiative KFMMC is a recognized for the quality of care provided and it is under the government agency. Like KFMMC, there are other 15 military hospitals across the country and KFMMC provides primary and advanced health care in the city of Dhahran. The nursing workforce in this hospital are mainly expatriate coming from countries like U.K., Australia, Malaysia, Middle East countries, South Africa and North America. The entire nurse irrespective of their nationality need to get registered with Saudi Commission for Health Specialist to practice in the country and the registration is renewed every three years. The major problem seen in Military Hospitals in Saudi Arabia includes increased reliance on expat nurse, however not paying attention to psychosocial and communication competency to deal with Saudi patients. Due to this problem in health care system, the goal of KFMMC was to arrange for a cultural competence initiative at the hospital to enhance psychosocial and communication skill in their workforce (Aldossary, 2017). The main objective behind the KFMMCs cultural competent initiative was to analyze the experience of patient and nurse in psychosocial and communication performance, identify the barriers that affect their performance and then plan strategies to make them culturally competent (Aldossary, 2017). They considered initiating the cultural competence program from health care professionals due to the rise in cultural misunderstanding between patients and expatriate health care provider. This problem is most likely to lead to poor quality of care, increased patient satisfaction with care and rise in ethical dilemmas within the hospital. This will ultimately have an impact on the reputation of the hospital and to avoid this issue cultural competence assessment was necessary to evaluate current responsiveness to patients needs and preference and take relevant corrective action as far as possible (Almutairi, 2015). This initiative was started by identifying the factors that challenges nurses and clinicians in carrying out their responsibilities. This challenge was mainly related to communication problem such as language difference, cultural difference and low health literacy between patients and care providers. The health care workforce could have surpassed these challenges if they were given institutional support such as cultural competence training and seeking help from interpreters. However, the hospitals of Saudi Arabia have failed to provide support to staffs leading to experience of prejudices and ethnocentrism in practice (Inocian, Atallah, Moufleh, 2017). The positive aspect is that KFMMC recognized the importance of culturally appropriate care and they took the responsibility to arrange a culture competence assessment and training program at their institute. The culture of Saudi Arabia is a combination of Arabic and Islamic influence and peoples lifestyle highly revolves around the Islamic cultural values. They follow Islamic obligations as well as Arabian community traditions and customs. The problem for health care workforce is aggravated due to the rise in the number of expatriate health care professionals and little attention on expanding their knowledge about Saudi culture. The first priority of cultural assessment was to assess the language proficiency of nurses and other staffs. All were found toe proficient in English, but the patient were not proficient in English and they mostly used Arabic language. This linguistic difference might lead to health and safety issues in care. Furthermore cultural competence assessment also revealed work related violence in health care. The gap in cultural and language awareness among expatriate health professionals often put them in risk situation while giving instruction to patients or during ma nagement of patients with different ailments (Almutairi, 2015). Hence, KFMMC identified two major problem during cultural competence assessment at their institute and that was linguistic and communication barrier in practice. They realized the fact that if health care providers are given the necessary knowledge about cultural customs of Saudi Arabia, then it will empower their workforce to address misunderstanding among colleagues and patient and enhance the quality care. They are planning to address this problem faced by nurses by conducting extensive training to develop the linguistic and cultural competency skill of staffs according to the cultural values of Saudi Arabia. To initiate the cultural competence initiative at the hospital, special attention should be given to nursing problems and their complexities in the hospital. This is because Saudi Arabian citizens are highly influence by Islam culture and nursing workforce in Saudi Arabia is mostly foreign in origin. If nurse are aware of different dimensions of culture, it may help them in linking the culture with patients and avoiding any conflicts arising due to cultural misunderstanding. Hence, hospitals of Saudi Arabia should pay special attention to developing the skills of nurse in grasping the cultural attributes of patient. There is a need to enhance the knowledge related to cultural values of Saudi citizen to deliver respectful and holistic care. Cultural shock confronts nurses and staffs in Saudi Arabia in a significant way and this issue should be immediately addressed to prevent risk of errors. Lack of cultural sensitivity may have an influence on the care-giving process and so emphasizi ng on staff development in the area of cultural competence is an important responsibility for hospitals (Inocian, 2015). Main feature of cultural competence initiative Given is the list of steps followed to assess cultural competence of staffs at the hospital- Evaluation of cultural competency skill of staffs- An internal survey was done to assess the psychosocial and communication aspects of care at the hospital. The members involved in this initiative consulted the culturally and linguistically appropriate service (CLAS) guidelines to carry to access skills of staffs and it was measured by a Cultural Competency Assessment tool for Hospitals (CCATH). According to CLAS guideline, there areas that can be evaluated are culturally competent care, availability of language access service and organizational support for cultural competence. This assessment will be a roadmap to judge the health disparities present within the health care system and act accordingly (Weech-Maldonado et al., 2012). The main elements evaluated through this cultural competence initiative were as follows: Workforce diversity and level of training at the hospital- The first step for managers of KFMMC was to assess the workforce diversity at the hospital. There is shortage of health care workforce in Saudi Arabia, so international health professionals and nursing staffs are mainly recruited at hospitals of Saudi Arabia. They come from countries like U.K., U.S., Australia, Malaysia, Middle East countries and many others. This reflects that the multi-lingual and multi-cultural environment is present at the hospital. It can lead to a crisis situation unless and until properly planning is done to manage culturally diverse workforce and patients (Al Hosis, Plummer, O'Connor, 2012). The training domain for culturally diverse workforce was evaluated by the human resource practice at the hospital. Their recruitment and retention activities were judges to find how they put extra effort in pursuit of a culturally appropriate work culture. Ideal retention strategies might have included creating a supportive work environment for international workforce, maintaining the work-life balance and providing opportunities for flexibility in the job process. However, this aspect was missing and training needs for expatriate staffs was ignored. To override this issue, the plan was to provide in service training to all staffs and modify the staff training curriculum to develop the skills required for culturally competent clinical care. However, just conducting training programs may not serve the purpose unless and until the impact of training program is assessed by the effectiveness of staffs in meeting the cultural needs of patients in care. It might be possible that people fro m diverse cultural background may resist in accepting service or care protocols and they may be vulnerable to cross-cultural conflicts. Hence, experienced cultural competence training staff may help in resolving conflicts and handling grievances, legal and ethical issues in care (Weech-Maldonado, 2012). Assessment of cultural competence skill of staff- After making a profile of workforce diversity, individual profile was made in terms of age, nationality, length of service and educational qualification. This would help to measure skill and performance on different parameters. Secondly, the cultural competency was assessed by their ability and attempt to learn key word and colloquialisms of the Arabic language used by patients and by their manner of communication with patients and family members. They were also interviewed for the effect of their own cultural background and prejudices in their performance. If they had ever got an interpreter, it was judged whether they could utilize this opportunity effectively or not. If staffs are found to be highly competent in this area, their competency will be further developed by bringing adaptive changes in them to better serve the diverse cultural group of patients and family members. Another strategy was to assess cultural competence accord ing to age, gender, education, nationality and length of service to determine whether skills occurs due to individual weakness or due to lack of organization preparedness for culturally competent care (Inocian, Atallah, Moufleh, 2017). This assessment strategy would help to gain an understanding of the improvement needed to support expatriate staffs to recognize Saudi Culture and enhance cultural competence. The challenges and issues in care would help to design the health service at the hospital in accordance with the needs of patient and connect with patients in an appropriate manner (Koh, Gracia, Alvarez, 2014). Assessment of patient-provider communication at the hospital- Managing any type of illness in a multicultural environment is difficult due to the communication barrier seen between patients and health care professionals. Health care staff has the responsibility of conveying complex information to the patient as well as managing their emotions. However, different cultural beliefs, health-related values and customs affect how a patient perceive treatment and diagnosis process. Similarly, difference between health beliefs of clinicians and nurses from patients also has an impact on the delivery of care and health outcome. Cultural incompetency often contributes to disparities in health care. Hence, cultural competence is the strategy to eliminate disparities and improve the quality of care. Patient-provider communication is the most important factor in culturally competent care and communicating with awareness and knowledge about socio-cultural factors helps to efficiently manage care p rocess (Brown et al., 2016). To evaluate level of patient-provider communication at the hospital, the method and approach of communication between patient and health staffs was assessed. The assessment process identified gap in communication as most of the staffs were from other countries and there was no provision for training them in culturally appropriate care. Hence, improvement was needed in patient-staff communication at the military hospital (Aldossary, 2017).To address this gap in service, the corrective action that is proposed is to arrangement for interpreter service and translated materials to pass on to those patients and staff who have low proficiency in English. This interpreter service will come handy in improving provider and staff communication with patients. In that case, there will also be a need to evaluate the quality of interpreter service to see how interpreter are effective in reducing gap in patient-provider communication. Another effective corrective action proposed is to translate writ ten materials like treatment instruction, consent form and prescription into the common language of the population (Weech-Maldonado, 2012). Assessment of supporting mechanism for culturally competent care- Supporting mechanism for culturally competent care implies the physical environment of the hospital and its link with supportive service. It may also involve application of tools to promote culturally relevant information on health beliefs and practices. The hospital was lagging behind in this area. Taking cues from past action and research on organizational strategy to reduce health disparities might help in modifying the physical environment of the hospital. In this context, the research by Weech-Maldonado et al., (2012) gives guidance regarding the process to develop a culturally competent environment in hospital setting. Supporting mechanism for culturally competent care is present in those hospitals that are committed to a system approach of change. System level cultural competency is achieved when congruent behavior and cultural competence policy is present within health care system. Adopting a system approach helps in easy integration of cultural competence practices throughout the hospitals. The initial step to adopting the system approach is to assess whether hospital structure and process is appropriate to meet the relevant needs of diverse patient group. The Cultural Assessment Tool for Hospitals CCATH) is an example of tools for organizational assessment. The main aim of this tool is to evaluate six areas at the hospital and they are- Role and function of leaders at the hospital Level of culturally competent training for staffs Strategy for management system and operations Engagement of local community in service Approach to patient-provider communication Presence of supporting mechanism at the hospital Plan for achieving cultural competence To achieve the objective of holistic cultural competence assessment, the strategy of military hospital is to prepare a checklist of strength and weakness of nurse based on assessment of their cultural competency skill and then analyzing the baseline data of workers to plan improvement areas. This will lead to positive outcome in care process and eliminate culture shock and language barrier in care (Purnell, 2014). The cultural competence initiative might lead to many positive outcomes for KFMMC. After conducting complete cultural assessment of health care staffs, their plan for improving communication skill in nurse in daily care were as follows: Having set standard of culturally competent care- The standards for the hospital is that they want to ensure that their staff members deliver respectful and effective care to patients compatible with their cultural beliefs and language spoken. Another set standard for them will be to implement strategies to retain culturally diverse staff by providing them supportive mechanism to overcome challenges in care process. Another standard is to make sure that all staff receives adequate training in culturally and linguistically appropriate care (Ring, Nyquist, Mitchell, 2016). Enhancing culturally competent care- Taking cue from cultural competence initiative in other health care organization, KFMMC hospital need to ensure that nurses approach patient in efficacious and courteous manner. This is the first step to establishing a relation with patients and any wrong notion or attitude should not be passed on to the patients. Secondly, they need to be given training linguistic skills and for KFMMC, the immediate need for nurse will be to learn basic Arabic language. They can start with interpreters and then handle patients singlehandedly once they learn to easily converse in local language of the country. Furthermore, to promote culturally competent care, it will be necessary for health care staffs to respect cultural practices and issue of Saudi patients (Lord, 2015). Apart from this effort health care staffs to inculcate culturally competent care in practice, the human resource manager of the hospital will also play an influential role in recruiting, sustai ning and managing a diverse workforce. They will ensure that all staffs entering the hospital are given the necessary information to follow the work culture of the hospital and create a patient-friendly environment at the hospital (Albougami, 2015). Increasing the provision for language access service- The cultural assessment of nurses and other staffs at the hospital revealed linguistic difference as a major problem and the hospital plan to arrange for programs and service to address linguistic difficulty faced by employees working at the hospital. Phenomenological study examining the experience of nurse in care also revealed nurse faced many difficulties in communicating with Arabian patients due to language difference and this was the reason why patients were not satisfied with their service. The lack of clarity in communicating post-discharged information lead to dissatisfaction in many patients (Almutairi, 2015). Considering this difficulty in hospitals of Saudi Arabia, the plan was to introduce language aid service for health care staffs where they to easily comprehend information and patient queries. Interpreter and multilingual staffs may help staffs and patient who have low command over English or Arabic language (Albou gami, 2015). Promoting organizational support for building a culturally competent work environment at the hospital- To ensure that cultural competence skills and initiative is maintained and sustained in the hospital, a well-written plan will be executed that clearly mentions all the operational level demands and defines the responsibility to deliver culturally appropriate care. The assessment of activities in diverse group should be done regularly to monitor whether linguistic and cultural practices are incorporated by staffs in care or not. The internal audit will be beneficial in judging patient satisfaction level measured by staff and develop opportunities for performance enhancement of different clinical staffs at the hospital. While executing any new service at the hospital, the health care organization will review the local community profile such as cultural and demographic factors of the area. This will ensure that they are prepared to respond to the linguistics and culture of the hospita l. There is also plan for collaborative association with local communities to resolve conflicts and issues raised by the patient (Albougami, 2015). Eliminating the ethical barrier faced by nurses and clinicians at the hospital- There will be special focus on nurses responsibility in care as nurses spend the maximum amount of time with patients. This will be done after interacting with nurses regarding the external and internal barriers in care. External barriers may result due to communication difficulties occurring due to language difference and cultural difference between nurse and patient. Due to this barrier, newly placed international nurse in Saudi Arab hospital may find the job demanding and it may lead to stress and burnout. As this barrier has a negative impact both on nurses as well as patient, the plan is to make nurses aware of culturally competent policies and make them learn basic colloquial terms and Arabic language to converse with patients. They will also be provided support with interpreter service in the beginning. The advantage of removing external barrier is that it will help to remove internal barriers for nurse which results due to experience of cultural shock. Hence, support given to nurse with additional tools help to overcome instability in the job. Developing flexible attitude will help them to implement interventions according to cultural preference of patients and family members (Murcia Lopez, 2016). Creating opportunities for better understanding of patients- This can be achieved by improving existing system of staff-patient interaction at the hospital. Skill in interacting with patients will help in explaining serious disease and rationale for any treatment process to patients. There is rise in problem of staff-patient interaction in Saudi Arabia due to large number of foreign staffs in health service, little orientation on local traditions and health related beliefs of Saudi people. Problem also arises due to rise in number of expatriate consumer in health care of Saudi Arabia. Hence, the need to train and orientate health care staffs is significant for KFMMC. To make nurses aware of the importance of staff-patient interaction, it is necessary to include in their curriculum or training program the detail on orientation on medical humanities to broaden understanding of social traditions of patients. Regular training program will be arranged for staffs to make them aware of Arab ian colloquial language, health traditions and belief of Saudi citizens. It will help to correct and modify any misconception regarding patients (Ahmad et al., 2016). Conclusion The report presents the importance of culturally competent health care environment to provide holistic care to patients and highlights the cultural competence initiative at KFMMC in Saudi Arabia. The analysis of the challenges faced by nurses and clinicians practicing in health care setting showed that there is great disparity in health service due to rise in number of expatriate health care professionals and wide cultural difference between patient and care provider. KFMMC realized that cultural incompetency is leading to high level of patients dissatisfaction with service and it is hampering therapeutic interaction with patients. The presence of linguistically diverse workforce was also a reason for conflict and error in service. The rationale for the cultural competence initiative at the hospital is also understood from recent research based evidence investigating the barrier in health care service of Saudi Arabia. There are example of Saudi women perspective of breast cancer scre ening, their perception of incompatibility with service and other issues which reflects immediate action to enhance physical environment of hospital and develop cultural competence skill among staffs (Ahmad et al., 2016). With this rationale, KFMMC utilized a cultural assessment profile and framework to assess the health care practice, skill and procedure at the hospital. The cultural assessment profile of the hospital consisted of cultural competence domain of organizational values, policies, governance, hospital infrastructure, system support, tools, training and staffs skills and the main focus area of each domain was assessed. Furthermore, the hospital also included structural, process and output indicator to analyze the performance of hospital in delivering culturally appropriate care. The main objective behind the cultural competence initiative was to measure psychosocial and communication performance at the hospital and the program was initiated by collecting data on diverse workforce and nature of work at the hospital. Key problems and complexities arising at the hospital during health care delivery were monitored and systematic process of cultural assessment was followed. 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