Cultural humility is the first step to becoming global care providers

Exploring the implementation of person-centred care in nursing practice

Person-centred care involves nurses working in partnership with patients to ensure their needs and preferences are at the centre of their healthcare, as well as considering the biographical and social factors that are relevant to the person's health. This aims to support patients in developing the knowledge, confidence and skills to make informed decisions about treatment and to manage their own care where possible. This article discusses the concept of person-centred care and considers some of the facilitators and barriers that may affect its implementation in healthcare practice. It also explores some of the approaches that nurses can use to support person-centred care, such as cultural humility and role modelling.

HPV vaccination and cervical cancer screening promotion among Black individuals: social ecological perspectives from key informants interviews

OBJECTIVES

Rates of HPV infection and HPV-related cancers are elevated in the Black population of the US. Efforts to promote HPV vaccination and cervical cancer screening are important to reducing the cancer burden among Black populations. The purpose of this qualitative descriptive study guided by social ecological model (SEM) was to describe from the perspective of key informants, the challenges and opportunities for HPV vaccination and cervical cancer screening promotion among Black adults.

DESIGN

Twenty-three key informants participated in individual interviews over zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy prior to data analysis. Two qualitatively trained researchers analyzed the data using content analysis.

RESULTS

Participants were aged 50 ± 4.1 years, 12 were females, and 18 identified as Black. Participants included health care providers, teachers, church and community leaders. Themes included HPV and cancer literacy, influence of religion, health care provider recommendations, social and cultural influences, accessibility and availability of services, economic constraints, limited community resources, and HPV vaccine mandates.

CONCLUSIONS

SEM factors contribute to low HPV vaccine uptake and cervical cancer screening and these factors need to be addressed. Interventions addressing SEM factors peculiar to Black populations may promote HPV vaccination and cancer screening in this population.

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Practising cultural humility to promote person and family-centred care

The concept of cultural humility in nursing involves an awareness of diversity and how an individual's culture can affect their health behaviours. Nurses can use this awareness to develop sensitive, tailored and person-centred approaches to patient care, which ultimately contribute to a positive healthcare experience. This article examines the concept of cultural humility with reference to person and family-centred care. It also explores how individuals and organisations can challenge discriminatory attitudes and behaviours in the workplace.

Humility in health care: A model

This paper presents the author's model of humility structures that can be operationalized as behaviours and incorporated into healthcare practice, the Humility in Health Care Model. The Humility in Health Care Model expands and combines the concepts of cultural humility, holistic nursing, servant leadership and the Chinese concept 'QIAN'. The paper identifies ways to create a regular practice of humility behaviours on the personal/interpersonal, leadership, systems and policy levels. The paper discusses the benefits of operationalizing humility, forces that favour humility and barriers to practicing its behaviours. Suggestions for future research on humility in the healthcare professions are offered.

Animal-derived medications: cultural considerations and available alternatives

CONTEXT

Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership.

OBJECTIVES

To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility.

METHODS

A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: "medication selection," "medication," "adherence," "pharmaceutical preparations," "religion and medicine," "religion," "animal," "dietary," "porcine," and "bovine." Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients.

RESULTS

Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review.

CONCLUSIONS

Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example

Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6 months post-treatment and 9 months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient's scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.

Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities

Purpose

The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities.

Summary

To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Efforts may include training in cultural humility and cultural competency, education about the organization’s vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities.

Conclusion

By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers—and helping pave the road towards equity throughout the US health care system.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

Background

Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them.

Methods

A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA.

Results

Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

Conclusions

A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Building Transformative Global Nursing Partnerships

BACKGROUND AND PURPOSE

Global nursing is a relatively new term identifying nurses contributing to global health. While personally and professionally rewarding, global health projects present unique challenges to global nurses that impact partnerships. The aim of this article was to describe the role of global nursing, and focus on relational-cultural theory as the foundation of transformative partnerships.

METHODS

This article is based upon a review of literature related to global health and relational inquiry. Peer-reviewed papers and research articles published within the past 10 years were used to support this discussion. Publications considered to be classics in the field of relationship inquiry were also utilized.

RESULTS

Global nursing is a relatively recent conceptualization in describing the role of nursing. Global nursing practice based upon relational-cultural theory and mediated by cultural humility provides a strong foundation for the development of transformative global nursing partnerships.

IMPLICATIONS FOR PRACTICE

This article provides a theoretical foundation for global nurses practicing in local and global contexts with diverse populations. Nursing partnerships in both local and global contexts can be challenging to initiate and manage, but global nurses are responsible for creating partnerships which are ethically sound, based on theory, and transformative in nature. Cultural humility plays a central role in the ongoing process of disconnecting and re-connecting for transformational partnerships with individuals, communities, and other health-care providers.

Medical electives: exploring the determinants of placement and access variables between 2010 and 2016 at the University of Auckland

BACKGROUND

Medical electives undertaken during sixth year at medical school provide an opportunity for students to work in an overseas or New Zealand health facility to gain exposure to a health system outside their training facility. Previous work suggests that the elective experience can be profound, exposing global health inequities, or influencing future career decisions. This study assessed patterns within elective choice by students' socio demographic and programme entry characteristics.

METHODS

A retrospective analysis of student elective records from 2010 to 2016 was undertaken using a Kaupapa Māori research framework, an approach which prioritises positive benefits for Māori (and Pacific) participants and communities. A descriptive analysis of routinely collected de-identified aggregate secondary data included demographic variables (gender, age group, ethnicity, secondary school decile, year and route of entry), and elective site. Route of entry (into medical school) is via general, MAPAS (Māori and Pacific Admissions Scheme) and RRS (Regional and Rural Scheme). Multivariable logistic regression analysis determined the odd ratios for predictors of going overseas for elective and electives taking place in a "High" (HIC) compared to "Low- and middle-income countries" (LMIC).

RESULTS

Of the 1101 students who undertook an elective (2010-2016) the majority undertook their elective overseas; the majority spent their elective within a high-income country. Age (younger), route of entry (general) and high school decile (high) were associated with going overseas for an elective. Within the MAPAS cohort, Pacific students were more likely (than Māori) were to go overseas for their elective; Māori students were more likely to spend their elective in a HIC.

CONCLUSION

The medical elective holds an important, pivotal opportunity for medical students to expand their clinical, professional and cultural competency. Our results suggest that targeted support may be necessary to ensure equitable access, particularly for MAPAS students the benefit of an overseas elective.

Enriching the Student Experience Through a Collaborative Cultural Learning Model

This article provides a knowledge and understanding of an international, collaborative, cultural learning model for students from the United States and Scotland. Internationalizing the student experience has been instrumental for student learning for the past eight years. Both countries have developed programs that have enriched and enhanced the overall student learning experience, mainly through the sharing of evidence-based care in both hospital and community settings. Student learning is at the heart of this international model, and through practice learning, leadership, and reflective practice, student immersion in global health care and practice is immense. Moving forward, we are seeking new opportunities to explore learning partnerships to provide this collaborative cultural learning experience.

Making a Difference in Migrant Summer School: Testing a Healthy Weight Intervention

OBJECTIVE

Evaluate the effectiveness of a healthy weight intervention designed for children of migrant farmworkers embedded in a 7-week summer Midwest Migrant Education Program (MEP) for changes in: weight; Body Mass Index (BMI); BMI-percentiles (BMI-p); muscle strength and muscle flexibility; nutrition knowledge; attitudes; and behaviors.

DESIGN AND SAMPLE

This is a two-group pre-post quasi-experimental study. Latino children of migrant farmworkers attending summer MEP in grades one through eight were enrolled (n = 171: comparison n = 33, intervention n = 138).

MEASURES

Weight, BMI, BMI-p, muscle strength and flexibility, knowledge, and healthy behaviors.

INTERVENTION

Classroom content included: food variety; increasing fruits and vegetables; healthy breakfasts; more family meals; increasing family time; decreasing TV and electronic game time; increasing physical activity; limiting sugar-sweetened drinks; portion sizes; and food labels.

RESULTS

Statistically significant were increase in comparison group mean weight, decrease in intervention group BMI-p, and improvements in muscle flexibility and healthy behavior attitudes. The intervention students showed trends toward healthy BMI. The number of MEP days attended was significantly correlated in four outcomes.

CONCLUSION

Study findings have the potential to decrease incidence of unhealthy weight in Latino migrant children, reduce rates of premature adult diseases in these children, and a potential to decrease future health care costs.

Cultural Humility

Diversity is being increasingly recognized as an area of emphasis in health care. The term cultural humility is used frequently but society’s understanding of the term is unclear. The aim of this article was to provide a concept analysis and a current definition for the term cultural humility. Cultural humility was used in a variety of contexts from individuals having ethnic and racial differences, to differences in sexual preference, social status, interprofessional roles, to health care provider/patient relationships. The attributes were openness, self-awareness, egoless, supportive interactions, and self-reflection and critique. The antecedents were diversity and power imbalance. The consequences were mutual empowerment, partnerships, respect, optimal care, and lifelong learning. Cultural humility was described as a lifelong process. With a firm understanding of the term, individuals and communities will be better equipped to understand and accomplish an inclusive environment with mutual benefit and optimal care.

Expanding Worldview: Australian Nursing Students' Experience of Cultural Immersion in India

Abstract Increasing cultural diversity and a sense of global community has necessitated the introduction of cultural competence in the education of health care providers. Some institutions have utilized cultural immersion programs to address this need of cultural competence. Studies have not yet described what this experience is for Australian nursing students. The purpose of this study is to describe the immersion experience of a group of senior Australian nursing students who participated in a five week cultural immersion program in India.

Cultural humility and working with marginalized populations in developing countries

Population health needs in developing countries are great and countries are scaling up health professional education to meet these needs. Marginalized populations, in particular, are vulnerable to poor health and health care. This paper presents a culturally appropriate diversity training program delivered to Global Health Fellows who are educators and leaders in health professions in Malawi and Zambia. The purpose of this interprofessional education experience was to promote culturally competent and humble care for marginalized populations.

Integrating cultural humility into health care professional education and training

As US populations become increasing diverse, healthcare professionals are facing a heightened challenge to provide cross-cultural care. To date, medical education around the world has developed specific curricula on cultural competence training in acknowledgement of the importance of culturally sensitive and grounded services. This article proposes to move forward by integrating the concept of cultural humility into current trainings, in which we believe, is vital in complementing the current model, and better prepare future professionals to address health challenges with culturally appropriate care. Based on the works of Chinese philosophers, cultural values and the contemporary Chinese immigrants' experience, we hereby present the QIAN (Humbleness) curriculum: the importance of self-Questioning and critique, bi-directional cultural Immersion, mutually Active-listening, and the flexibility of Negotiation. The principles of the QIAN curriculum reside not only between the patient and the healthcare professional dyad, but also elicit the necessary support of family, health care system as well as the community at large. The QIAN curriculum could improve practice and enhance the exploration, comprehension and appreciation of the cultural orientations between healthcare professionals and patients which ultimately could improve patient satisfaction, patient-healthcare professional relationship, medical adherence and the reduction of health disparities. QIAN model is highly adaptable to other cultural and ethnic groups in multicultural societies around the globe. Incorporating its framework into the current medical education may enhance cross-cultural clinical encounters.

Navigating the challenges of global reproductive health research

Reproductive health research in low-resource settings poses unique and complex challenges that must be addressed to ensure that global research is conducted with strict adherence to ethical principles, offers direct benefit to the research subjects, and has the potential for adoption of positive findings to the target population. This article addresses challenges to conducting reproductive health research in low-resource settings in the following areas: (1) establishment and maintenance of global collaboration, (2) community partnerships, (3) ethical issues, including informed consent and the role of incentives, (4) staff training and development, (5) data collection and management, and (6) infrastructure and logistics. Particular attention to these challenges is important to ensure that research is culturally appropriate and methodologically sound and enhances the adoption of health-promoting behaviors. Rigorous evaluation of interventions in low-resource settings may be a cost-effective and time-efficient way to identify interventions for large-scale program replication to improve women's health.

Patterns and correlates of nutrition among migrant farm-worker children

Past research has demonstrated a higher incidence of overweight children in migrant farm-worker (MFW) families than in the general U.S. population. This study provided descriptive data on MFWs' acculturation, household food security, and general self-efficacy, and children's food patterns and body mass index. Convenience samples of 60 parent-child dyads were obtained from six MFW camps in two Midwest states. Acculturation and food security were low, higher general self-efficacy was associated with low acculturation, and the majority of children did not meet their U.S. Food Guide Pyramid recommendations. It was noteworthy that 48% of the sample, including siblings (excluded from data analysis), was overweight or obese. The knowledge learned concerning the food patterns and correlates of nutrition in this descriptive phase of the DINE study will direct counseling to MFW mothers on the purchase and preparation of affordable, nutritious, and culturally acceptable foods to achieve healthy weight in their children.