Transcultural Diversity and Health Care Chapter1 LARRY D. PURNELL The Need for Culturally Competent Health Care Cultural competence in multicultural societies continues as a major initiative for business, health-care, and educational organizations in the United States and throughout most of the world. The mass media, health-care policy makers, the Office of Minority Health, and other Governmental organizations, professional organizations, the workplace, and health insurance payers are addressing the need for individuals to understand and become culturally competent as one strategy to improve quality and eliminate racial, ethnic, and gender disparities in health care. Educational institutions from elementary schools to colleges and universities also address cultural diversity and cultural competency as they relate to disparities and health promotion and wellness. Many countries are now recognizing the need for addressing the diversity of their society, including the client base, the provider base, and the organization. Societies that used to be rather homogeneous, such as Portugal, Norway, Sweden, Korea, and selected areas in the United States and the United Kingdom, are now facing significant internal and external migration, resulting in ethnocultural diversity that did not previously exist, at least not to the degree it does now. As commissioned by the U.K. Presidency of the European Union, several European countries—such as Denmark, Italy, Poland, the Czech Republic, Latvia, the United Kingdom, Sweden, Norway, Finland, Italy, Spain, Portugal, Hungary, Belgium, Greece, Germany, the Netherlands, and France—either have in place or are developing national programs to address the value of cultural competence in reducing health disparities (Health Inequities: A Challenge for Europe, 2005). Whether people are internal migrants, immigrants, or vacationers, they have the right to expect the health-care system to respect their personal beliefs, values, and health-care practices. Culturally competent health care from providers and the system, regardless of the setting in which care is delivered, is becoming a concern and expectation among consumers. Diversity also includes having a diverse workforce that more closely represents the population the organization serves. Health-care personnel provide care to people of diverse cultures in long-term-care facilities, acute-care facilities, clinics, communities, and clients’ homes. All health-care providers—physicians, nurses, nutritionists, therapists, technicians, home health aides, and other caregivers— need similar culturally specific information. For example, all health-care providers engage in verbal and nonverbal communication; therefore, all health-care professionals and ancillary staff need to have similar information and skill development to communicate appropriately with diverse populations. The manner in which the information is used may differ significantly based on the discipline, individual experiences, and specific circumstances of the client and provider. Culturally competent staff and organizations are essential ingredients in increasing clients’ satisfaction with health care and reducing multifactor reasons for gender, racial, and ethnic disparities and complications in health care. If providers and the system are competent, most clients will access the health-care system when problems are first recognized, thereby reducing the length of stay, decreasing complications, and reducing overall costs. A lack of knowledge of clients’ language abilities and cultural beliefs and values can result in serious threats to life and quality of care for all individuals. Organizations © 2008 F A Davis and individuals who understand their clients’ cultural values, beliefs, and practices are in a better position to be coparticipants with their clients in providing culturally acceptable care. Having ethnocultural specific knowledge, understanding, and assessment skills to work with culturally diverse clients assures that the health-care provider knows what questions to ask. Providers who know ethnoculturally specific knowledge are less likely to demonstrate negative attitudes, behaviors, ethnocentrism, stereotyping, and racism. Accordingly, there will be improved opportunities for health promotion and wellness; illness, disease, and injury prevention; and health maintenance and restoration. The onus for cultural competence is on the health-care provider and the delivery system in which care is provided. To this end, health-care providers need both general and specific cultural knowledge to help reduce gender and ethnic and racial disparities in health care. World Diversity and Migration The world’s population reached 6.5 billion people in the year 2005 and is expected to approach 7.6 billion by 2020 and 9.3 billion by 2050. The estimated population growth rate is 1.14 percent, with 20.05 births per 1000 population, 8.6 deaths per 1000 population, and an infant mortality rate of 48.87 per 1000 population. Worldwide, life expectancy at birth is currently 64.77 years, with males at 63.17 years and females at 66.47 years (CIA, 2007). As a first language, Mandarin Chinese is the most popular, spoken by 13.59 percent of the world’s population, followed by Spanish at 5.05 percent, English at 4.8 percent, Hindi at 2.82 percent, Portuguese at 2.77 percent, Bengali at 2.68 percent, Russian at 2.27 percent, Japanese at 1.99 percent, German at 1.49 percent, and Wu Chinese at 1.21 percent. Only 82 percent of the world population is literate. When technology is examined, more people now have a cell phone than a landline: 1.72 billion versus 1.2 billion. Slightly over 1 billion people are Internet users (CIA, 2007). We currently live in a global society, a trend that is expected to continue into the future. According to the United Nations High Commissioner for Refugees, there is a global population of 9.2 million refugees, the lowest number in 25 years, and as many as 25 million internally displaced persons. Migrants represent 2.9 percent or approximately 190 million people of the world population, up from 175 million in the year 2000. Moreover, international migration is decreasing while internal migration is increasing, especially in Asian countries. Only two countries in the world are seeing an increase in their migrant stock— North America and the former USSR (CIA, 2007). The International Organization for Migration completed the first-ever comprehensive study looking at the costs and benefits of international migration. According to the report, ample evidence exists that migration brings both costs and benefits for sending and receiving countries, although these are not shared equally. Trends suggest a greater movement toward circular migration with substantial benefits to both home and host countries. The perception that migrants are more of a burden on, than a benefit to, the host country is not substantiated by research. For example, in the Home Office Study (2002) in the United Kingdom, migrants contributed U.S. $4 billion more in taxes than they received in benefits. In the United States, the National Research Council (1998) estimated that national income had expanded by U.S. $8 billion because of immigration. Thus, because migrants pay taxes, they are not likely to put a greater burden on health and welfare services than the host population. However, undocumented migrants run the highest health risks because they are less likely to seek health care. This not only poses risks for migrants but also fuels sentiments of xenophobia and discrimination against all migrants. 2•CHAPTER 1 What evidence do you see in your community that migrants have added to the economic base of the community? Who would be doing their work if they were not available? UNITED STATES POPULATION AND CENSUS DATA As of 2006, the U.S. population was over 300 million, an increase of 16 million since the 2000 census. The most recent census data estimates that 74.7 percent are white, 14.5 percent are Hispanic/Latino (of any race), 12.1 percent are black or African American, 0.8 percent are American Indian or Alaskan Native, 4.3 percent are Asian, 0.1 percent are Native Hawaiian or other Pacific Islander, 6 percent are some other race, and only 1.9 percent are of two or more races. Please note: These figures total more than 100 percent because the federal government considers race and Hispanic origin to be two separate and distinct categories. The categories as used in Census 2000 are 1. White refers to people having origins in any of the original peoples of Europe, the Near East, and the Middle East, and North Africa. This category includes Irish, German, Italian, Lebanese, Turkish, Arab, and Polish. 2. Black or African American refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any person who self-designates this category regardless of origin. 3. American IndianandAlaskan Nativerefer to people having origins in any of the original peoples of North, South, or Central America and who maintain tribal affiliation or community attachment. 4. Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This category includes the terms Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, and Thai. 5. Native Hawaiian and other Pacific Islander refer to people having origins in any of the original peoples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands, and Chuuk. 6. Some other race was included for people who are unable to identify with the other categories. © 2008 F A Davis 7. In addition, the respondent could identify, as a write-in, with two races (U.S. Bureau of the Census, 2006). The Hispanic/Latino and Asian populations continue to rise in numbers and in percentage of the overall population; although the black/African American, Native Hawaiian and Pacific Islanders, Native American and Alaskan Natives groups continue to increase in overall numbers, their percentage of the population has decreased. Of the Hispanic/Latino population, most are Mexicans, followed by Puerto Ricans, Cubans, Central Americans, South Americans, and lastly, Dominicans. Salvadorans are the largest group from Central America. Three-quarters of Hispanics live in the West or South, with 50 percent of the Hispanics living in just two states, California and Texas. The median age for the entire U.S. population is 35.3 years, and the median age for Hispanics is 25.9 years (U.S. Bureau of the Census, 2006). The young age of Hispanics in the United States makes them ideal candidates for recruitment into the health professions, an area with crisis-level shortages of personnel, especially of minority representation. Before 1940, most immigrants to the United States came from Europe, especially Germany, the United Kingdom, Ireland, the former Union of Soviet Socialist Republics, Latvia, Austria, and Hungary. Since 1940, immigration patterns to the United States have changed: Most are from Mexico, the Philippines, China, India, Brazil, Russia, Pakistan, Japan, Turkey, Egypt, and Thailand. People from each of these countries bring their own culture with them and increase the cultural mosaic of the United States. Many of these groups have strong ethnic identities and maintain their values, beliefs, practices, and languages long after their arrival. Individuals who speak only their indigenous language are more likely to adhere to traditional practices and live in ethnic enclaves and are less likely to assimilate into their new society. The inability of immigrants to speak the language of their new country creates additional challenges for health-care providers working with these populations. Other countries in the world face similar immigration challenges and opportunities for diversity enrichment. However, space does not permit a comprehensive analysis of migration patterns. the Secretary’s Task Force’s report on Black and Minority Health (Perspectives on Disease Prevention and Health Promotion, 1985). Two goals from Healthy People 2010are to increase quality and years of healthy life and eliminate health disparities (Healthy People 2010, 2005). In 2005, the Agency for Healthcare Research and Quality (AHRQ) released the Third National Healthcare Disparities Report (Agency for Healthcare Research and Quality [AHRQ], 2005) that provides a comprehensive overview of health disparities in ethnic, racial, and socioeconomic groups in the United States. This report is a companion document to the National Healthcare Quality Report (NHQR) that is an overview of quality health care in the United States. These two documents highlight four themes: (1) Disparities still exist, (2) some disparities are diminishing, (3) opportunities for improvement still exist, and (4) information about disparities is improving. These documents address the importance of clinicians, administrators, educators, and policymakers in cultural competence. Disparities are observed in almost all aspects of healthcare, including 1. Effectiveness, patient safety, timeliness, and patient centeredness. 2. Facilitators and barriers to care and health-care utilization. 3. Preventive care, treatment of acute conditions, and management of chronic disease. 4. Clinical conditions such as cancer, diabetes, endstage renal disease, heart disease, HIV disease, mental health and substance abuse, and respiratory diseases. 5. Women, children, elderly, rural residency, and individuals with disabilities and other special health-care needs. 6. Minorities and the financially poor receive a lower quality of care (AHRQ, 2005). When ethnocultural specific populations are examined, although some disparities have shown improvement, many have not improved and some have worsened. With whites as the comparison group, the report shows: 1. Blacks were 10 times more likely to be diagnosed with AIDS, 59 percent less likely to be given antibiotics for the common cold, 9 percent more likely to receive poorer quality care, 17 percent more likely to lack health insurance, 7 percent less likely to report difficulties in getting care, and 10 percent more likely to have worse access to care. 2. Non-white Hispanics/Latinos were 3.7 times more likely to be diagnosed with AIDS, 16 percent more likely to receive poorer quality care, 2.9 times for under age 65 to lack health insurance, 18 percent less likely to report difficulties or delays getting care, and 87 percent more likely to have worse access. However, they were 40 percent less likely to die of breast cancer. 3. Asians were 57 percent more likely to report communication problems with the child’s provider, TRANSCULTURAL DIVERSITY AND HEALTH CARE •3 What changes in ethnic and cultural diversity have you seen in your community over the last 5 years? Over the last 10 years? Have you had the opportunity to interact with newer groups? Racial and Ethnic Disparities in Health Care A number of organizations have developed documents addressing the need for cultural competence as one strategy for eliminating racial and ethnic disparities. In 1985, the Department of Health and Human Services released © 2008 F A Davis 40 percent less likely to report difficulties or delays in getting care, and 20 percent more likely to have worse access to care. 4. American Indians and Alaskan Natives were twice as likely to lack early prenatal care, 67 percent less likely to develop late-stage breast cancer, 8 percent more likely to receive poorer quality care, twice as likely for the under-age-65 group to not have health insurance, 23 percent more likely to lack a primary-care provider, and 4 percent more likely to have worse access to care. 5. Data for Native Hawaiians and other Pacific Islanders were not available for this report but will be in future reports (AHRQ, 2005). The health of the lesbian, gay, bisexual, and transgender populations has not been addressed in the Healthy People 2010 document or in other government publications. However, the Gay and Lesbian Medical Association (www.glma.org) in 2001 developed Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. Salient disparities are noted in this publication. Gays and lesbians are more likely than their heterosexual cohort groups to have higher rates of tobacco, alcohol, and recreational drug use. Sexually transmitted infections, HIV (especially for men), suicide and suicide ideation, depression, being a victim of street violence (especially for men) and home violence (especially for women), sexual abuse among men, hate crimes, and psychological and emotional disorders are higher among these groups. They are also more likely to be discriminated against by health-care providers owing to homophobia. Because of the stigma that alternative identity gender discrimination brings, especially among racially and ethnically diverse populations (Purnell, 2003), these populations were less likely to disclose their sexual orientations. They are also less likely to have health insurance, have a primary-care provider, or take part in prevention programs; in fact, 57 percent of transgender people do not have health insurance (Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, Transgender Health, 2001; Purnell, 2003). To help combat violence and crimes against lesbians, gays, and transgender people, several cities such as Washington, D.C.; Fargo, North Dakota; and Missoula, Montana, in the United States have initiated Gay and Lesbian Crime Units (Police Unit Reaches Out to Gay Community, Inspires Others, 2006). ethnic disparities in other countries. However, documents that include other countries, conditions, and policies are listed as a resource herein. Additional information on the role of cultural competence on eliminating racial and ethnic disparities includes: 1. Transcultural Nursing Society, International (www.tcns.org) 2. U.S. Department of Health and Human Services Office of Minority Health: Physician’s Toolkit and Curriculum (http://www.omhrc.gov/assets/ pdf/checked/toolkit.pdf) 3. Institute of Medicine’s Unequal Treatment study (http://www.iom.edu/?id=4475) 4. The Commonwealth Fund Report on Health Care Quality (http://www.cmwf.org/) 5. Delivering Race Equality: A Framework for Action (http://www.londondevelopmentcentre. org/silo/files/577.pdf) 6. Protecting Vulnerable Populations (www.wccassembly.info/en/news-media/news/english) 7. Canadian Institutes of Health Research: Reducing Health Disparities and Promoting Equity for Vulnerable Populations (www.cihr-irsc. gc.ca/e/19739.html) 8. American Physical Therapy Association’s document and monographs on cultural competence (www.apta.org) 9. Health Inequalities: A Challenge for Europe that includes health policies for the Czech Republic, England, Denmark, Finland, Greece, Germany, Hungary, Ireland, Latvia, the Netherlands, Northern Ireland, Poland Portugal, Scotland, Spain, Sweden, and Wales (www.fco.gov.uk/ Files/kfile/HI_EU_Challenge,0.pdf) 10. American Academy of Family Physicians documents on health disparities and cultural competence (http://www.aafp.org) 11. American Academy of Physician Assistants document The Four Layers of Diversity (http:// www.aapa.org/) 12. Health Resources and Services Administration publication “Indicators of Cultural Competence in Health Care Delivery Organizations” and Cultural Competence Works (www.hrsa.gov) 13. American Student Medical Association Culture and Diversity Curriculum (http://www.amsa.org/ programs/diversitycurriculum.cfm) 14. American Academy of Nursing Standards of Cultural Competence (in press). 15. Diversity Rx (www.diversityRx.org) Self-Awareness and Health Professionals Culture has a powerful unconscious impact on health professionals. Each health-care provider adds a new and 4•CHAPTER 1 What health disparities have you observed in your community? To what do you attribute these disparities? What can you do as a professional to help decrease these disparities? Only broad categories of health disparities are addressed in this chapter. More specific data are included in individual chapters on cultural groups. As can be seen by the overwhelming data, much more work needs to be accomplished to improve the health of the nation. Space does not permit an extensive discourse on racial and © 2008 F A Davis unique dimension to the complexity of providing culturally competent care. The way health-care providers perceive themselves as competent providers is often reflected in the way they communicate with clients. Thus, it is essential for health professionals to think about their cultures, their behaviors, and their communication styles in relation to their perceptions of cultural differences. They should also examine the impact their beliefs have on others, including clients and coworkers, who are culturally diverse. Before addressing the multicultural backgrounds and unique individual perspectives of each client, healthcare professionals must first address their own personal and professional knowledge, values, beliefs, ethics, and life experiences in a manner that optimizes interactions and assessment of culturally diverse individuals. Self-knowledge and understanding promote strong professional perceptions that free health-care professionals from prejudice and allow them to interact with others in a manner that preserves personal integrity and respects uniqueness and differences among individual clients. The process of professional development and diversity competence begins with self-awareness, sometimes referred to as self-exploration. Although the literature provides numerous definitions of selfawareness, discussion of research integrating the concept of self-awareness with multicultural competence is minimal. Many theorists and diversity trainers imply that self-examination or awareness of personal prejudices and biases is an important step in the cognitive process of developing cultural competence (Andrews & Boyle, 2005; Campinha-Bacote, 2006; Giger & Davidhizar, 2008). However, discussions of emotional feelings elicited by this cognitive awareness are somewhat limited, given the potential impact of emotions and conscious feelings on behavioral outcomes. Culture and Essential Terminology CULTURE DEFINED Anthropologists and sociologists have proposed many definitions of culture. For the purposes of this book, culture is defined as the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making. Health and health-care beliefs and values are assumed in this definition. These patterns may be explicit or implicit, are primarily learned and transmitted within the family, are shared by most (but not all) members of the culture, and are emergent phenomena that change in response to global phenomena. Culture, a combined anthropological and social construct, can be seen as having three levels: (1) a tertiary level that is visible to outsiders, such as things that can be seen, worn, or otherwise observed; (2) a secondary level, in which only members know the rules of behavior and can articulate them; and (3) a primary level that represents the deepest level in which rules are known by all, observed by all, implicit, and taken for granted (Koffman, 2006). Culture is largely unconscious and has powerful influences on health and illness. Health-care providers must recognize, respect, and integrate clients’ cultural beliefs and practices into health prescriptions. An important concept to understand is that cultural beliefs, values, and practices are learned from birth: first at home, then in the church and other places where people congregate, and then in educational settings. Therefore, a 3-month-old male child from Korea adopted by an African American family and reared in an African American environment will have an African American worldview. However, that child’s “race” would be Asian, and if that child had a tendency toward genetic/hereditary conditions, they would come from his Korean ancestry, not from African American genetics. TRANSCULTURAL DIVERSITY AND HEALTH CARE •5 In your opinion, why is there conflict about working with culturally diverse clients? What attitudes are necessary to deliver quality care to clients whose culture is different from yours? Self-awareness in cultural competence is a deliberate and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional knowledge standards, your ethics, and the impact of these factors on the various roles you play when interacting with individuals different from yourself. The ability to understand oneself sets the stage for integrating new knowledge related to cultural differences into the professional’s knowledge base and perceptions of health interventions. What have you done in the last 5 to 10 years to increase your self-awareness? Has increasing your selfawareness resulted in an increased appreciation for cultural diversity? How might you increase your knowledge about the diversity in your community? In your school? Who in your family had the most influence in teaching you cultural values and practices? Outside the family, where else did you learn about your cultural values and beliefs? What cultural practices did you learn in your family that you no longer practice? When individuals of dissimilar cultural orientations meet in a work or a therapeutic environment, the likelihood for developing a mutually satisfying relationship is improved if both parties attempt to learn about each other’s culture. Moreover, race and culture are not synonymous and should not be confused. For example, most people who self-identify as African American have varying degrees of dark skin, but some may have white skin. However, as a cultural term, African American means that the person takes pride in having ancestry from both Africa and the United States; thus, a person with white skin could self-identify as African American. © 2008 F A Davis IMPORTANT TERMS RELATED TO CULTURE Attitude is a state of mind or feeling about some matter of a culture. Attitudes are learned; for example, some people think that one culture is better than another. One culture is not better than another; the two are just different, although many patterns are shared among cultures. A belief is something that is accepted as true, especially as a tenet or a body of tenets accepted by people in an ethnocultural group. A belief among some cultures is that if a pregnant woman craves a particular food substance, strawberries, for example, and does not satisfy the craving, the baby will be born with a birthmark in the shape of the craving. Attitudes and beliefs do not have to be proven; they are unconsciously accepted as truths. Ideology consists of the thoughts and beliefs that reflect the social needs and aspirations of an individual or an ethnocultural group. For example, some people believe that health care is a right of all people, whereas others see health care as a privilege. The literature reports many definitions for the terms cultural awareness, cultural sensitivity, and cultural competence. Sometimes, these definitions are used interchangeably. However, cultural awareness has more to do with an appreciation of the external signs of diversity, such as arts, music, dress, and physical characteristics. Cultural sensitivity has more to do with personal attitudes and not saying things that might be offensive to someone from a cultural or ethnic background different from the health-care provider’s. Cultural competence in health care is having the knowledge, abilities, and skills to deliver care congruent with the client’s cultural beliefs and practices. Increasing one’s consciousness of cultural diversity improves the possibilities for health-care practitioners to provide culturally competent care. as the humanities. An understanding of one’s own culture and personal values and the ability to detach oneself from “excess baggage” associated with personal views are essential to cultural competence. Even then, traces of ethnocentrism may unconsciously pervade one’s attitudes and behavior. Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally competent care. Ethnocentrism, a concept that most people practice to some degree, perpetuates an attitude in which beliefs that differ greatly from one’s own are strange, bizarre, or unenlightened and, therefore, wrong. Values are principles and standards that are important and have meaning and worth to an individual, family, group, or community. For example, the dominant U.S. culture places high value on youth, technology, and money. The extent to which one’s cultural values are internalized influences the tendency toward ethnocentrism. The more one’s values are internalized, the more difficult it is to avoid the tendency toward ethnocentrism. 6•CHAPTER 1 What activity have you done to increase your cultural awareness and competence? How do you demonstrate that you are culturally sensitive? One progresses from unconscious incompetence (not being aware that one is lacking knowledge about another culture), to conscious incompetence (being aware that one is lacking knowledge about another culture), to conscious competence (learning about the client’s culture, verifying generalizations about the client’s culture, and providing cultural specific interventions), and finally, to unconscious competence (automatically providing culturally congruent care to clients of diverse cultures). Unconscious competence is difficult to accomplish and potentially dangerous because individual differences exist within specific cultural groups. To be even minimally effective, culturally competent care must have the assurance of continuation after the original impetus is withdrawn; it must be integrated into, and valued by, the culture that is to benefit from the interventions. Developing mutually satisfying relationships with diverse cultural groups involves good interpersonal skills and the application of knowledge and techniques learned from the physical, biological, and social sciences as well Given that everyone is ethnocentric to some degree, what do you do to become less ethnocentric? If you were to rate yourself on a scale of 1 to 10, with 1 being less ethnocentric and 10 being very ethnocentric, what score would you give yourself? What score would your friends give you? What score would you give your closest friends? The Human Genome Project provides evidence that all human beings share a genetic code that is over 99 percent identical. However, the controversial term race must still be addressed when learning about culture. Raceis genetic in origin and includes physical characteristics that are similar among members of the group, such as skin color, blood type, and hair and eye color. Although there is less than a 1 percent difference, this difference is significant when conducting physical assessments and prescribing medication, as outlined in culturally specific chapters that follow. People from a given racial group may, but do not necessarily, share a common culture. Race as a social concept is just as important, and sometimes more important, than race as a biological concept. Race has social meaning, assigns status, limits or increases opportunities, and influences interactions between patients and clinicians. Racism has been described as prejudice combined with power (Abrums, 2004). The International Convention on the Elimination of All Forms of Racial Discrimination defines racism (1965) as “Any distinction, exclusion, restriction, or preference based on race, colour, descent, or national or ethnic origin which has the purpose or effect of nullifying or impairing the recognition, enjoyment, or exercise, on equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural, or any other field of public life.” Racism may be overt or covert. Recent antidiscrimination laws make racism illegal, but the laws do not eliminate racist attitudes; thus, people are just less likely to express racist attitudes openly. Moreover, one © 2008 F A Davis must remember that even though one might have a racist attitude, it is not always recognized because it is ingrained during socialization and leads to ethnocentrism. culture. Some of these differences may include socioeconomic status, ethnic background, residence, religion, education, or other factors that functionally unify the group and act collectively on each member with a conscious awareness of these differences. Subcultures differ from the dominant ethnic group and share beliefs according to the primary and secondary characteristics of culture. Primary and Secondary Characteristics of Culture Great diversity exists within a cultural group. Major influences that shape peoples’ worldview and the degree to which they identify with their cultural group of origin are called the primary and secondary characteristics of culture. The primary characteristics are things that a person cannot easily change, but if they do, a stigma may occur for themselves, their families, or the society in which they live. The primary characteristics of culture include nationality, race, color, gender, age, and religious affiliation. For example, consider two people with these primary characteristics: one is a 75-year-old devout Islamic female from Saudi Arabia; the other is a 19-year-old African American fundamentalist Baptist male from Louisiana. Obviously, the two do not look alike, and they probably have very different worldviews and beliefs, many of which come from their religious tenets and country of origin. TRANSCULTURAL DIVERSITY AND HEALTH CARE •7 How do you define race? What other terms do you use besides race to describe people? In what category did you classify yourself on the last census? What categories would you add to the current census classifications? Worldviewis the way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them. Worldview includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics. Any generalization—reducing numerous characteristics of an individual or group of people to a general form that renders them indistinguishable—made about the behaviors of any individual or large group of people is almost certain to be an oversimplification. When a generalization relates less to the actual observed behavior than to the motives thought to underlie the behavior (i.e., the why of the behavior), it is likely to be oversimplified. Thus, generalizations can lead to stereotyping, an oversimplified conception, opinion, or belief about some aspect of an individual or group. Generalization and stereotyping are similar, but functionally, they are very different. Stereotyping is an endpoint; generalization is a starting point. For example, knowing whether the person comes from an individualistic versus a collectivistic culture is important. Remember, individualism and collectivism exist to some degree in all cultures, but one pattern tends to dominate. People identifying with a collectivist culture, such as most Asians, are more likely to place a higher value on the family than on the individual, harmony, and solidarity. However, people who identify with an individualistic culture, such as the dominant American and Scandinavian cultures, are more likely to place a higher value on the individual, independence, autonomy, and achievement. The health-care provider must specifically ask questions to determine these values and avoid stereotypical views of clients. Everyone engages in stereotypical behavior to some degree. We could not function otherwise. If someone asked you to think of a nurse, what image do you have? Is the nurse male or female? How old is the nurse? How is the nurse dressed? Is the nurse wearing a hat? How do you distinguish a stereotype from a generalization? Even in relatively homogeneous cultures, subcultures and ethnic groups exist that may not hold all the values of their dominant culture. Subcultures, ethnic groups, or ethnocultural populations are groups of people who have experiences different from those of the dominant What are your primary characteristics of culture? How has each one influenced you and your worldview? How has your worldview changed as your primary characteristics have changed? How is each of these a subculture? The secondary characteristics include educational status, socioeconomic status, occupation, military experience, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented status), and length of time away from the country of origin. For example, the secondary cultural characteristics of being a single transsexual urban business executive will most likely evolve into a different worldview from that of a married heterosexual rural secretary who has two teenagers. In another case, a migrant farm worker from the highlands of Guatemala, who has an undocumented status, has a different perspective than an immigrant from Mexico who has lived in New York City for 10 years. People who live in ethnic enclaves and get their work, shopping, and business needs met without learning the language and customs of their host country may be more traditional than people in their home country. Such was the case for a Japanese man who lived in a Japanese ethnic enclave in San Francisco. When he returned to Japan after 20 years to visit relatives, he was criticized for being too traditional. Japanese society had changed, while he had not. © 2008 F A Davis Immigration status influences a person’s worldview. For example, people who voluntarily migrate generally acculturate more willingly; that is, they have given up most traits from the culture of origin as a result of contact with another culture. A number of acculturation scales exist; some are generic for any population, whereas others are specific to a particular culture such as Chinese, Korean, or Filipino. Yet, others are specific to an age group such as teenagers and older people. More traditional people adhere, and sometimes tenaciously, to most of the traits of their culture of origin. Similarly, assimilation is gradually adopting and incorporating the majority of the characteristics of the prevailing culture. Many people who migrate become bicultural; they are able to function equally well in their dominant and their host cultures. Marginalized people seem to have few traits from their dominant or host culture. People who voluntarily immigrate assimilate and acculturate more easily than people who immigrate unwillingly or as sojourners. Sojourners, who immigrate with the intention of remaining in their new homeland only a short time, or refugees, who think they may return to their home country, may not identify a need to acculturate or assimilate. In addition, undocumented individuals (illegal aliens) may have a different worldview from those who have arrived legally with work visas or as “legal immigrants.” The debate regarding the precise definition and differences among the terms transcultural, crosscultural, and intercultural continues. Many authors and texts define the terms differently. This book uses the terms interchangeably to mean “crossing,” “spanning,” or “interacting” with a culture other than one’s own. When people interact with individuals whose cultures are different from their own, they are engaged in cultural diversity. Awareness of the differences and similarities among ethnocultural groups results in a broadened multicultural worldview. Ethics Across Cultures As globalization grows and population diversity with nations increases, health-care providers are increasingly confronted with ethical issues related to cultural diversity. At the extremes stand those who favor multiculturalism and postmodernism versus those who favor humanism. Internationally, multiculturalism asserts that no common moral principles are shared by all cultures; postmodernism asserts a similar claim against all universal standards, both moral and nonmoral. Postmodernism holds the stance that everything is social construction, which leads to the contention that context is allimportant (Baker, 1998). The concern is that universal standards provide a disguise whereas dominant cultures destroy or eradicate traditional cultures. Humanism asserts that all human beings are equal in worth, that they have common resources and problems, and that they are alike in fundamental ways (Macklin, 1999). Humanism does not put aside the many circumstances that make individuals’ lives different around the world. Many similarities exist as to what people need to live well. Humanism says that there are human rights that should not be violated. Macklin (1998) asserts that universal applicability of moral principles is required, not universal acceptability. Beaucamp (1998) concurs that fundamental principles of morality and human rights allow for cross-cultural judgments of immoral conduct. Of course, there is a middle ground. Throughout the world, practices are claimed to be cultural, traditional, and beneficial, even when they are exploitive and harmful. For example, the practice of female circumcision, a traditional cultural practice, is seen by some as exploiting women. In many cases, the practice is harmful and can even lead to death. Whereas empirical anthropological research has shown that different cultures and historical eras contain different moral beliefs and practices, it is far from certain that what is right or wrong can be determined only by the beliefs and practices within a particular culture or subculture. Slavery and apartheid are examples of civil rights violations. Accordingly, codes of ethics are open to interpretation and are not value-free. Furthermore, ethics belong to the society, not to professional groups. Ethics and ethical decision making are culturally bound. The Western ethical principles of patient autonomy, self-determination, justice, do no harm, truth telling, and promise keeping are not interpreted or shared by some nonWestern societies. In the dominant American culture, truth telling, promise keeping, and not cheating on examinations are highly valued. However, not all cultures place such high regard on these values. For example, in Russia, the truth is optional, people are expected to break their promise, andmost students cheat on examinations. Cheating on a business deal is not necessarily dishonorable (Birch, 2006). In health organizations in the United States, advance directives give patients the opportunity to decide about their care, and staff members are required to ask patients about this upon admission to a healthcare facility. Western ethics, with its stress on individualism, asks this question directly of the patient. However, in collectivist societies, such as among ethnic Chinese and Japanese, the preferred person to ask may be a family member. In most collectivist societies, a person does not stand alone, but rather is defined in relation to another unit, such as the family or work group. In addition, translating these forms into another language can be troublesome because a direct translation can be confusing. For example, “informed consent” may be translated to mean that the person relinquishes his or her right to decision making. 8•CHAPTER 1 What are your secondary characteristics of culture? How has each one influenced you and your worldview? How has your worldview changed as your secondary characteristics have changed? How is each of these a subculture? How do you perceive truth telling? Do you always tell the truth? Do you always tell the whole truth? If a female colleague asks you how you like her new hairstyle, are you completely truthful or are © 2008 F A Davis Some cultural situations occur that raise legal issues. For instance, in Western societies, a competent person (or an alternative such as the spouse, if the person is married) is supposed to sign her or his own consent for medical procedures. However, in some cultures, the eldest son is expected to sign consent forms, not the spouse. In this case, both the organization and the family can be satisfied if both the spouse and the son sign the informed consent. Instead of Western ethics prevailing, some authorities advocate for universal ethics. Each culture has its own definition of what is right or wrong and what is good or bad. Accordingly, some health-care providers encourage international codes of ethics, such as those developed by the International Council of Nurses. These codes are intended to reflect the patient’s culture and whether the value is placed on individualism or collectivism. Most Western codes of ethics have interpretative statements based on the Western value of individualism. International codes of ethics do not contain interpretative statements, but rather let each society interpret them according to its culture. As our multicultural society increases its diversity, health-care providers need to rely upon ethics committees that include members from the cultures they serve. As the globalization of health-care services increases, providers must also address very crucial issues such as cultural imperialism, cultural relativism, and cultural imposition. Cultural imperialism is the practice of extending the policies and practices of one group (usually the dominant one) to disenfranchised and minority groups. An example is the U.S. government’s forced migration of Native American tribes to reservations with individual allotments of lands instead of group ownership as well as forced attendance of their children at white people’s boarding schools. Proponents of cultural imperialism appeal to universal human rights values and standards. Cultural relativism is the belief that the behaviors and practices of people should be judged only from the context of their cultural system. Proponents of cultural relativism argue that issues such as abortion, euthanasia, female circumcision, and physical punishment in child rearing should be accepted as cultural values without judgment from the outside world. Opponents argue that cultural relativism may undermine condemnation of human rights violations, and family violence cannot be justified or excused on a cultural basis. Cultural imposition is the intrusive application of the majority group’s cultural view upon individuals and families (Universal Declaration of Human Rights, 2001). Prescription of special diets without regard to clients’ cultures and limiting visitors to immediate family, a practice of many acute-care facilities, border on cultural imposition. Health-care professionals must be cautious about forcefully imposing their values regarding genetic testing and counseling. No group is spared from genetic disease. Ashkenazi Jews have been tested for Tay-Sachs disease for many years. Advances in technology and genetics have found that many diseases such as Huntington’s chorea have a genetic basis. Some forms of breast and colon cancers, adult-onset diabetes, Alzheimer’s disease, and hypertension are some of the newest additions. Currently, only the well-to-do can afford broad testing. Advances in technology will provide the means for access to screening that will challenge genetic testing and counseling. The relationship of genetics to disability, disabled individuals, and the potentially disabled will create moral dilemmas of new complexity and magnitude. Many questions surround genetic testing. Should health-care providers encourage genetic testing? What is, or should be, done with the results? How do we approach testing for genes that lead to disease or disability? How do we maximize health and well-being without creating a eugenic devaluation of those who are disabled? Should employers and third-party payers be allowed to discriminate based on genetic potential for illness? What is the purpose of prenatal screening and genetic testing? What are the assumptions for state-mandated testing programs? Should parents and individuals be allowed to “opt out” of testing? What if the individual does not want to know the results? What if the results could have a deleterious outcome to the infant or the mother? What if the results got into the hands of insurance companies that then denied payment or refused to provide coverage? Should public policy support genetic testing, which may improve health and health care for the masses of society? Should multiple births from fertility drugs be restricted because of the burden of cost, education, and health of the family? Should public policy encourage limiting family size in the contexts of the mother’s health, religious and personal preferences, and the availability of sufficient natural resources (such as water and food) for future survival? What effect do these issues have on a nation with an aging population, a decrease in family size, and decreases in the numbers and percentages of younger people? What effect will these issues have on the ability of countries to provide health care for their citizens? Health-care providers must understand these three concepts and the ethical issues involved because they will increasingly encounter situations in which they must balance the client’s cultural practices and behaviors with health promotion and wellness as well as illness, disease, and injury prevention activities for the good of the client, the family, and society. Other international issues that may be less TRANSCULTURAL DIVERSITY AND HEALTH CARE •9 you likely to be a little less than completely truthful and tell her what you think she wants to hear? If a patient asks you how he is doing and if he is going to get better, do you tell him that everything is okay, even if you know he is not? What practices have you seen that might be considered a cultural imposition? What practices have you seen that might be considered cultural imperialism? What practices have you seen that might be considered cultural relativism? What have you done to address them when you have seen them occurring? © 2008 F A Davis controversial include sustainable environments, pacification, and poverty (Purnell, 2001). Individual Cultural Competence Much has been debated, especially since the early 1990s, about objectively measuring individual competence. Most tools for measuring cultural competence are selfreported and subjective in nature. A number of tools have been developed to assess individual and organizational cultural competence. Some have been validated and are specific to a discipline or area of practice, whereas others are more general in nature. To select one that more specifically meets your needs, go to the Internet search engine www.scholar.google.com and type “cultural competence measurement” or “cultural competence assessment tools” in the search field. The Office of Minority Health also hasa document on Cultural Competence Standards (www.omhrc.gov). In general, cultural competence is a journey involving the willingness and ability of an individual to deliver culturally congruent and acceptable health and nursing care to the clients to whom one provides care. To these authors, individual cultural competence can be arbitrarily divided among cultural general approaches, the clinical encounter, and language. 11. Accepting responsibility for one’s own education in cultural competence by attending conferences, reading literature, and observing cultural practices. 12. Promoting respect for individuals by discouraging racial and ethnic slurs among coworkers. 13. Intervening with staff behavior that is insensitive, lacks cultural understanding, or reflects prejudice. 14. Having a cultural general framework for assessment as well as having cultural specific knowledge about the clients to whom care is provided. THE CLINICAL ENCOUNTER 1. Adapting care to be congruent with the client’s culture. 2. Responding respectively to all clients and their families (includes addressing clients and family members as they prefer, formally or informally). 3. Collecting cultural data on assessments. 4. Forming generalizations as a method for formulating questions rather than stereotyping. 5. Recognizing culturally based health-care beliefs and practices. 6. Knowing the most common diseases and illnesses affecting the unique population to whom care is provided. 7. Individualizing care plans to be consistent with the client’s cultural beliefs. 8. Having knowledge of the communication styles of clients to whom you provide care. 9. Accepting varied gender roles and childrearing practices from clients to whom you provide care. 10. Having a working knowledge of the religious and spirituality practices of clients to whom you provide care. 11. Having an understanding of the family dynamics of clients to whom you provide care. 12. Using faces and language pain scales in the ethnicity and preferred languages of the clients. 13. Recognizing and accepting traditional, complementary, and alternative practices of clients to whom you provide care. 14. Incorporating client’s cultural food choices and dietary practices into care plans. 15. Incorporating client’s health literacy into care plans and health education initiatives. LANGUAGE 1. Developing skills and using interpreters (includes sign language) with clients and families who have limited English proficiency. 2. Providing clients with educational documents that are translated into their preferred language. 10•CHAPTER 1 Whose values and beliefs should come first— yours, the organization’s, or the client’s? CULTURAL GENERAL APPROACHES 1. Developing an awareness of one’s own existence, sensations, thoughts, and environment without letting it have an undue influence on those from other backgrounds. 2. Continuing to learn cultures of clients to whom one provides care. 3. Demonstrating knowledge and understanding of the client’s culture, health-related needs, and meanings of health and illness. 4. Accepting and respecting cultural differences in a manner that facilitates the client’s and the family’s ability to make decisions to meet their needs and beliefs. 5. Recognizing that the health-care provider’s beliefs and values may not be the same as the client’s. 6. Resisting judgmental attitudes such as “different is not as good.” 7. Being open to new cultural encounters. 8. Recognizing that the primary and secondary characteristics of culture determine the degree to which clients adhere to the beliefs, values, and practices of their dominant culture. 9. Having contact and experience with the communities from which clients come. 10. Being willing to work with clients of diverse cultures and subcultures. © 2008 F A Davis 3. Providing discharge instructions at a level the client and the family understand and in the language the client and the family prefer. 4. Providing medication and treatment instruction in the language the client prefers. 5. Using pain scales in the preferred language of the client. 12. The organization is willing to support a mentoring program to entice recruitment into the health professions. 13. Data collected include race, ethnicity, culture, and language preferences of the staff and client base. 14. Patient rights documents are in the major languages served by the community. 15. Cultural and Linguistic Appropriate Services (CLAS) Standards are adhered to. 16. Fiscal resources are available for interpretation. 17. The strategic plan reflects the needs of the community. 18. Input on research priorities is sought from consumers. 19. Researchers are reflective of the staff, clients, and community. 20. Human Resources recruitment and hiring activities reflect the diversity of the community. 21. The job analysis procedure includes scoring for ethnocultural and language ability. 22. Position descriptions and evaluation practices reflect cultural competence. 23. Conflict and grievance procedures reflect the language of the staff. 24. The organization demonstrates active recruitment of bilingual staff. 25. The staff is compensated for bilingual ability and certification. 26. The ethics committee has members reflective of the staff and clients. 27. Hours of operation of clinics are adjusted to meet the needs of the community. 28. Pictures and posters are reflective of the client base. 29. Food choices are reflective of the client and staff. 30. The holiday calendar represents the client population base. 31. Intake forms reflect cultural assessment. 32. Pain scales are in diverse languages of the population served. 33. Culturally appropriate toys are available (Hispanic Santa, black dolls). 34. If staff is used or interpretation is available, a plan is in effect to address their job duties while interpreting for patients and staff (also a Joint Commission on Accreditation of Healthcare Organizations [JCAHO] requirement). EDUCATION AND ORIENTATION 1. Diversity must be addressed as part of newemployees’ orientation, in-service, and continuingeducation programs. 2. Nursing care delivery systems, the U.S. system of insurance reimbursement, and issues related to culture and autonomy are discussed. TRANSCULTURAL DIVERSITY AND HEALTH CARE •11 Look at the list of activities that promote individual cultural competence. Which of these activities have you used to increase your cultural competence? Which ones can you easily add to increase your cultural competence? Which ones are the most difficult for you to incorporate? Organizational Cultural Competence Individual cultural competence is not sufficient for culturally competent care. The organization in which the care is delivered must also demonstrate a commitment to cultural competence. Several things must be in place if an organization is to demonstrate cultural competence. A list of attributes of culturally competent organizations, organized arbitrarily by governance and administration, education and orientation, and language follows: GOVERNANCE AND ADMINISTRATION 1. The organization must have a mission statement and policies that address diversity. 2. The Board of Governance must include members of the ethnicity of the community it serves. 3. A committee for cultural competence exists and includes staff, managers, administrators, chaplains, and members representative of the community. 4. The organization engages in community diversity fairs. 5. The organization seeks resources from federal, state, and private agencies to continually upgrade and integrate cultural competence into care. 6. The organization partners with diverse community agencies. 7. The organization networks with diverse community leaders. 8. Administrators, managers, and staff are encouraged to be active in public policy for the client base to whom they deliver care. 9. Policy statements include efforts to eliminate the bias and prejudice of clients and staff. 10. Programs reflect the needs of the diversity of the community. 11. The organization’s programs are advertised in community newspapers and on the radio and television in the languages of the community. © 2008 F A Davis 3. Mentoring programs exist for diverse student and staff populations. 4. Diversity of the health professions is included in orientation. 5. All employees must be offered cultural general topics and cultural specific needs of populations for whom they provide care. 6. Cultural celebrations are reflective of the staff and clients. 7. Resources are available to staff on the unit and in the library. 8. The staff is trained in language interpretation. 9. Health classes are offered to clients the community serves. 10. Certification in culture for staff is offered at various levels. 11. Pharmacists, nurses, and physicians are educated in ethnopharmacology. 12. A lunch and learn series that supports the ongoing development of cultural competence can be started. LANGUAGE 1. Mechanisms must be in place for translation of written materials in the preferred language of the client. 2. Policies must address interpretation services. 3. Resources are available for translation of educational materials and discharge instructions in the languages of the client population. 4. The organization engages in activities that address health literacy of the population it serves. 5. Written documents undergo a cultural sensitivity review. 6. Consent and procedure forms are translated into the languages of the population served. 7. English-as-a-second language classes exist for staff. 8. Language classes are offered to clients and family (English and language of the population served). 9. Waiting areas have literature in the language of the population served. 10. Directions to referral facilities are in the languages of the client base. 11. Videos are in the language of the client and have pictures of the client base. 12. Diverse language includes sign language. 13. Need for interpreters is determined ahead of time. 14. Telephone system is in the languages of the community. 15. Television programs are in the languages of the community. 16. Satisfaction surveys are in the languages of the community. 17. Staff surveys are in the languages of the employees. 18. Audiovisual materials for staff and clients are in their preferred languages. 19. Wellness and health promotion classes are offered in the languages of the client base. 12•CHAPTER 1 Look at the list of activities that promote organizational cultural competence. Which of these activities have you used to increase the organization’s cultural competence? Which ones can you easily add to increase the organization’s cultural competence? Which ones are the most difficult to accomplish? Evidence-Based Practice: Developing Individual and Organizational Culture Section written by Susan Salmond The mandate for evidence-based practice (EBP) to reduce the “know-do” gap (Antes, Sauerland, & Seiter, 2006) between known science and implementation in practice is being driven by the demand for improved safety and quality outcomes for clients. Although a laudable goal, it will require a culture shift. The prevailing culture in health care is an “opinion-based culture” grounded in intuition, clinical experience/expertise, and pathophysiological rationale (DiCenso, Guyatt, & Ciliska, 2005). A culture of EBP calls for the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals or groups of patients. However, evidence alone does not constitute EBP but requires the integration of this evidence with clinical expertise, patient values and preferences, and the clinical context of care (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). The achievement of best patient outcomes is not assumed but is continuously evaluated though measurement of outcomes and patient safety (Coopey, Nix, & Clancy, 2006). This evidence is fed back into the system for consideration, and improvement changes at the individual, group, and system levels. Figure 1–1 portrays the components of EBP process, and Table 1–1 examines the components of EBP and the change/resources needed to facilitate its implementation. BEST EVIDENCE The best evidence is usually found in clinically relevant research that has been conducted using sound methodology (Sackett, 2000). With more than 1500 new articles per day and 55 new clinical trials per day, individual clinicians cannot hope to locate and read even a small portion of the relevant research published each year to assure best practices (Cilaska, Pinelli, DiCenso, & Cullum, 2001). The © 2008 F A Davis EBP process presents a more focused way of searching for information. Rather than routinely reviewing the contents of journals for interesting articles, the EBP process targets issues related to specific patient problems and provides clinicians with a set of skills for developing clinical questions related to these problems, searching current databases to keep current with the literature, and appraising the validity of the research on the topic of interest. In this process, the abstract exercise of reading and critically appraising the literature is converted into a pragmatic process of using the literature to benefit individual patients while simultaneously expanding the clinician’s knowledge base (Bordley, 1997). Within EBP, not all evidence is the same. The EBP clinician must know the nature and strength of the evidence found and, therefore, the accompanying degree of certainty/uncertainty with which to make decisions about whether the evidence should be applied to practice (Bhandari, 2003). Because much of research has been focused on the evaluation of “intervention effectiveness,” in the evidence pyramid, the gold standard has been the randomized controlled trial followed by cohort studies, case-controlled studies, case series, and qualitative studies (Fig. 1–2). Yet, much of nursing practice and the majority TRANSCULTURAL DIVERSITY AND HEALTH CARE •13 Outcomes Measurement Outcomes Measurement Best Patient Outcomes “Best” Research Evidence Clinical Expertise Patient Values Clinical Context Outcomes Measurement Outcomes Measurement FIGURE 1–1 Components of evidence-based practice. TABLE 1.1 The Evidence-Based Practice Process Components Resources/Change Needed Identify best evidence Clinical inquiry: What knowledge is needed? Informed skepticism: Why are we doing it this way? Is there a better way to do it? What is the evidence for what we do? Would doing this be as effective as doing that? (Salmond, 2007) Convert information needs from practice into focused, searchable questions (patientinterventioncomparison-outcome [PICO] framework). Search databases for highest level of evidence in a timely manner • Shift from “know how” and doing to “know why” • Reflect on what information is needed to provide “best” care • Generate questions about practice and care • Role model clinical inquiry at report, rounds, conferences • Use interdisciplinary case reviews to evaluate actual care • Include clinical librarians as members of teams participating in clinical rounds and conferences • Differentiate between background and foreground questions • Consider recurring clinical issues, need for information, negative incidents/events as sources for questions or information needs • Identify clinical issues sensitive to nursing interventions • Narrow broad clinical issues/questions into searchable, focused questions • Use the mnemonic PICO to frame questions • Use evidence-searching skills to target relevant focused evidence • Access evidence databases ideally at the point of care. • Understand evidence pyramids • Databases available include pre-appraised literature sources for point-of-care answers regarding intervention • Search strategies: key terms, multiple databases, point-of-care data • Use assistance of clinical librarian (Continued on following page) © 2008 F A Davis 14•CHAPTER 1 TABLE 1.1 The Evidence-Based Practice Process (Continued) Components Resources/Change Needed Use critical appraisal process to determine strength and validity of evidence and relevance to one’s practice Clinical experience Use clinical expertise to determine how to use and expertise evidence in care of patient and how to manage patient in absence of evidence or presence of conflicting evidence Patient values and Demonstrate ability to perform a culture preferences assessment and identify client preferences and values that inform the clinical decision. Translation evidence Use all four components in clinical decision- • Provide plan of care based on evidence, clinical from total process making process and implementation of judgment, patient preferences, and organizational into clinical decisions clinical decision context and strategies for best patient outcomes Monitor patient Use outcome tools to track client outcomes • Develop audit systems to track client outcomes outcomes • Make clinical outcomes accessible electronically for analysis • Analyze outcomes and effectiveness of “evidencebased” clinical intervention • Clinical Practice Guidelines available at www.clearinghouse.gov • Preappraised sources such as Critically Appraised Topics (CATs) • Demonstrate knowledge of research design • Demonstrate knowledge of statistics • Use critical appraisal tools to guide process of research critique • Utilize journal clubs • Summarize findings from evaluation, resolving conflicting evidence • Consider evidence in relation to own patient population • Consider cost-benefit ratio • Consider multidimensionality of patient and clinical situation in relation to evidence that is often reductionistic • Understand culturegeneral and culture-specific knowledge to guide interactions with client • Use interview skills to avoid culture imposition and seek client’s true preferences • Communicate evidence and treatment options considering patient values and preferences • Involve client and family in both information giving and decision making of transcultural nursing knowledge are informed by research approaches that describe and explain an experience or phenomenon. Consequently, the hierarchy of evidence focusing on description of experience is quite different. Here, the lowest tier includes quantitative studies, and the highest tier includes qualitative studies and metasyntheses of qualitative work (Fig. 1–3). Whether working from a quantitative or qualitative perspective, searching should begin from the top of the pyramid, where evidence is presented as systematic reviews or evidencebased guidelines. Systematic reviews are a rigorous research methodology that summarizes the research on a prescribed clinical question. This level of evidence is generally most relevant to the clinical setting but may not be available. If evidence is not found at this level, one should continue searching at each subsequent level, being aware that there may be no good evidence to support clinical judgment (Rychetnik, Frommer, Hawe, & Shiell, 2002). Guidelines Systematic Reviews Randomized Controlled Trials Cohort Studies Case-Controlled Studies, Case Series Qualitative Studies, Program Evaluation, Opinion Surveys FIGURE 1–2 Pyramid of evidence. © 2008 F A Davis Through consideration of this evidence or lack of evidence, clinicians and their affiliated health-care organizations have increased their awareness of evidence gaps and provided insight into the need for more research into unanswered questions. Ongoing nursing-driven and nursing-conducted research must become part of the evidence-based environment and not an occasional educational program or “window dressing” for the organization (Pravikoff, 2006). CLINICAL EXPERTISE AND JUDGMENT The value of expert clinical judgment can never be minimized in the clinical setting. Although drawing from best evidence is the goal, often there is insufficient evidence for the findings to be put into practice. Clinicians use their expertise to thoroughly assess the patient and differentiate nuances that influence treatment perspectives. With this expertise, the usefulness of the evidence in helping to care for a particular patient or patient population must be considered, and decisions about how to use that treatment must be made. PATIENT VALUES Combining the evidence with clinical expertise is necessary but not sufficient for driving quality care (Ivers, 2004; Rychetnik et al., 2002; Swales, 1998). Between the science (best evidence) and the final clinical decision, a judgment has to be made based on the values of the patient or group who will be exposed to the intervention (Swales, 1998). Cross-cultural comparisons provide abundant evidence for relativism of value systems. How the individual defines health and perceives the importance of health states such as mobility, freedom from pain, prolonged life expectancy, and preservation of faculties may all be valued differently, and these values influence both clinician recommendations and patient decisions (Swales, 1998). Failure to consider these patient preferences and values leads to “unintentional biasing” toward a professionals’ view of the world (Kitson, 2002). If EBP is to be value-added, it is critical to assure that the users of the knowledge, the clients, become “active shapers” of knowledge and action (Clough, 2005). Clinicians must be prepared to make “real-time” adjustments to their approach to care based on client feedback. To date, much of the focus on EBP has been on scientism and determination of best evidence. Unfortunately, little science examines intervention efficacy or desirability by cultural group. The study of culture and the individual nature of values is by its very nature holistic and adverse to a reductionistic approach that can be expressed as a population average. Clinicians armed with culturegeneral knowledge are more open to multiple ways of being. Understanding of culture-specific knowledge can guide clinicians in their assessment approach, leading to a patient-focused discussion of preferred approaches to treatment and care. This critical component of EBP needs to be more fully developed. How is it operationalized in practice? What are the best strategies for integrating patient values? Is there a preferred intervention by cultural group? This information is needed to facilitate best patient outcomes. The goal is not to achieve a single prescriptive system of care but to respect the individual nonuniform values that determine specific patient needs (Swales, 1998). CLINICAL CONTEXT The clinical context encompasses the setting in which practice takes place or the environment in which the proposed change is to be implemented (McCormack, Kitson, Harvey, RycroftMalone, Titchen, & Seers, 2002). Drennan (1992) argues that culture, or “the way things are done around here” at the individual, team, and organizational levels, creates the context for practice and change. Organizational culture is a paradigm—a way of thinking about the organization, comprising a linkage of basic assumptions, values, and artifacts (Schein, 1992). Implementation of EBP is not so much about getting trained in the right protocol, although that will be necessary, as it is about changing the culture of the organization or practice to one that is measurement- and outcomes-orientated across all disciplines, not in isolated silos (Morrison, 2004). Implementation of evidence (translationof evidence into practice) is explained as a dynamic, simultaneous relationship between evidence (best research evidence, clinical experience, and patient preferences) and context (organizational capacity, infrastructure, and culture). The abundance of new evidence that has not been successfully translated into practice is a critical reminder of the importance of context and the strength of the existing culture. Descriptive and qualitative data must be gathered to make an assessment of the likelihood of transferability; organization-specific strategies need to be used to facilitate this process. Best evidence specific to knowledge transfer and practice change needs to be incorporated in the change plan. Measuring clinician, unit, or organizational outcomes and benchmarking these outcomes provide the feedback necessary to effect change. Difficult questions will need to be grappled with. What should be done with clinicians who cannot or will not adapt to EBP? How will lack of interdisciplinary collaboration be TRANSCULTURAL DIVERSITY AND HEALTH CARE •15 Systematic Review of Descriptive and Qualitative Studies Evidence From a Single Descriptive or Qualitative Study Expert Opinion, Expert Committees Evidence based on Quantitative Approaches FIGURE 1–3 Pyramid of evidence: Description of experience. © 2008 F A Davis approached? How will it be handled if long-standing treatment approaches show no evidence of fostering improvement? What is the individual’s responsibility, as compared with the organization’s responsibility, in assuring readiness for EBP? How the organization handles these critical questions influences the outcomes of the change process. FACILITATING THE SHIFT TOWARD EVIDENCE-BASED PRACTICE Achieving this culture shift requires a commitment and a long-term investment in providing the leadership support, skill development, and infrastructure necessary to advance and sustain this shift. Leadership Commitment The transition must begin with a commitment from upper administration at both the nursing and the hospital administration levels to assure that all clinicians develop information literacy or the “ability to recognize that information is needed, find it, evaluate it, and use it in practice” (American Library Association, 2006). This commitment must include an investment of resources as well as a commitment to build EBP into organizational processes, to consistently communicate a vision for EBP, and to role-model and demonstrate ongoing commitment to EBP. A particularly difficult leadership challenge will be to move away from hierarchical, paternalistic processes and facilitate interdisciplinary involvement and commitment in EBP and to deal with the critical questions that emerge when EBP goals are not being met (Cilaska et al., 2001; Stetler, 2003). Clinical management structures must be developed to support effective interdisciplinary clinical decision-making activities (Mallach & PorterO’Grady, 2006). Mink, Esterhuysen, Mink, and Owen’s model (1993) of transformational change is an appropriate implementation model for leaders to remove barriers to EBP and begin the journey to developing an interdisciplinary culture of EBP. The model calls for formation of interdisciplinary teams consisting of a central, transformational team that performs an environmental assessment, sets goals, and guides the practice change as well as unit-based interdisciplinary action teams who develop clinical practice protocols and practices and implement the change at the point of care. Resources include dedicated time for the teams to work and educational support so that the teams can serve as support systems within the organization for implementation of EBP and clinical research. Developing the Needed Skill Set Developing the needed skill set begins with a commitment on the part of every individual practitioner to making EBP the framework for clinical decision-making (Mallach & Porter-O’Grady, 2006). In addition to individual responsibilities for developing needed knowledge and skills, an EBP organization has ongoing, leveled, onsite educational programs about information literacy, the EBP process, and research. Initial programs should attempt to create a sense of urgency by helping clinicians see how science has changed practice, recognize the lag in transferring this knowledge, and understand how outcomes vary based on the differential use of new science. Clinicians need to be helped with the new vocabulary of EBP. This should be done in a format that can be quickly retrieved and understood. Educational content must target information literacy skills—how to access, interpret, synthesize, and apply most current evidence at the point of care. Table 1–1 summarizes educational targets that must be reached. Multiple approaches to learning, such as face-to-face programs, on-line references and modules, and small group learning, should all be used to reach the multiple audiences and multiple levels of learning. Systematic reviews of traditional forms of continuing education, such as browsing journals, attending conferences, and listening to didactic lectures, have little impact on changing practice (Thomson O’Brien, Freemantle, & Oxman, 2001). Active learning strategies are needed to develop the capacity to engage in EBP. Journal clubs, poster presentations, EBP internships, clinical coaching/mentoring by expert clinical leaders or clinical nurse specialists, evidence-based scholar groups, and evidence-based rounds are all examples of active learning approaches that facilitate development of a culture of inquiry or inquisitiveness, openness, and encouragement of learning new skills (Pravikoff, 2006; Turkel, Reidinger, Ferket, & Reno, 2005). The expectation for EBP should be articulated at orientation as a universal expectation with differing skill sets evident at differing rungs of the clinical ladder. At the lowest rung, everyone should manifest clinical inquiry or informed skepticism and the ability to ask questions about care and know when information is needed. Incorporating more advanced skills can be integrated into the differing levels of a clinical ladder. These advanced skills include translating clinical questions into patientinterventioncomparison-outcome (PICO) format, searching presynthesized literature, critiquing research for reliability and validity, comparing research findings with actual clinical populations and settings, planning for evidence translation, implementing new EBP interventions, measuring the results of evidence implementation, and planning primary research studies needed to fill in evidence gaps. Integrating EBP into career ladder expectations, different levels of clinicians can be advancing the EBP process for the organization. Access to Information In order for nurses to be able to use evidence in their busy clinical routines, there must be a systematic organizational infrastructure to support EBP as a way of delivering care (Mallach & Porter-O’Grady, 2006). This includes access to a digital information framework that provides ready access to real-time information at the point of care delivery that is neither time nor place dependent. The technological/informational infrastructure needed to support EBP includes user-friendly, credible summaries of up-to-date evidence; the informatics structure to integrate EBP data (internal and external) into quality processes (electronic medical records and other clinical databases); access to clinical librarians or others who are expert in 16•CHAPTER 1 © 2008 F A Davis information literacy and who can coach staff; electronic library sources to guide the EBP process; and computer experts and technological support (Antes et al., 2006; Mallach & Porter-O’Grady, 2006). This technology must be at the point of care—either on a unit/service area or via hand-held technology to facilitate EBP as a clinical decision process. The interface among the information infrastructure, performance measurement, and quality patient care outcomes is critical. This requires integration between clinical practice and data management and is ideally tracked through clinical information management systems and/or clinical audits. This component of EBP, in which best practices are implemented and outcomes are tracked, completes the feedback loop needed to modify and adapt evidence in the practice setting. The internal findings can be used for ongoing competency development and performance approval as well as integrated with external evidence and analyzed for needed best practice changes. SUMMARY The move to a culture of EBP requires a shift from a culture of doing to a culture of clinical reflection, in which care is evaluated based on the need for evidence and patient preferences. This culture change process must be actively managed so that all members of the health-care team are aware of the expectations regarding EBP, receive appropriate educational and mentor support for information literacy, and are held accountable through audit and performance appraisal for using EBP as a clinical decision model.
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