Effectiveness of cultural competence educational interventions on health professionals and patient outcomes: A systematic review

Relationship between social identity and cultural competence among Mexican nursing professionals

INTRODUCTION

Cultural competence in nursing is crucial for providing effective health care. Social Identity is the degree to which they identify with their professional group. Identifying with the group of nursing professionals allows nurses to connect with norms and values that favor the development of cultural competence. The objective of this study is to analyze the relationship between social identity and the level of cultural competence of nursing professionals.

METHODOLOGY

This was a cross-sectional correlational study (n = 211). Sociodemographic data were measured, and Cameron's social identity scales and a cultural competence measurement scale were used. The data were analyzed using correlations and a structural equation model.

RESULTS

The structural equation model demonstrated good fit (CFI = 0.94, TLI = 0.928 WRMR = 0.952, RMSEA = 0.058). The model indicated positive and significant relationships between social identity, cultural skills, and knowledge. However, it also revealed a negative and significant relationship between social identity and cultural awareness.

CONCLUSIONS

The findings suggest that greater identification with the nursing profession by nursing professionals is associated not only with higher levels of cultural knowledge and skills but also with lower levels of cultural awareness. This finding may be due to the fact that individuals seek to reinforce their professional identities when they feel that acknowledging their own personal biases represents a threat.

CLINICAL RELEVANCE

This study contributes to the understanding of how social identity can be related in a different way to the components of cultural competence. This work recognizes the challenges in developing cultural awareness in nursing and suggests that its findings can inform interventions to improve patient care and relationships.

The effectiveness of cultural competence interventions in nursing: A systematic review and meta-analysis

BACKGROUND

The growing need to provide culturally competent nursing care has increased the importance of implementing and evaluating cultural competence interventions in healthcare settings. Previous research showed that increasing healthcare professionals' cultural competence can reduce racism and inequalities and enhance their ability to navigate cultural diversity. Whilst some evidence shows that educational interventions can improve cultural competence of healthcare professionals, a summary of this evidence is lacking, especially regarding the effectiveness of such interventions on nurses' cultural competence and patient-related outcomes.

OBJECTIVES

In this systematic review, the effectiveness of cultural competence interventions on nurses' levels of cultural competence and patient-related outcomes is assessed.

DESIGN

A systematic review and a meta-analysis were conducted.

METHODS

We searched in MEDLINE, Embase, CINAHL, PsychINFO, ERIC and CENTRAL up to September 2023 for studies using a quasi-experimental or experimental design. We used the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA guideline for methodological and reporting guidance. Two researchers independently assessed the eligibility of the studies and their methodological quality. We assessed the quality of experimental studies using the Revised Cochrane Risk of Bias Assessment Tool for Randomized Trials (RoB 2), and the quality of quasi-experimental studies with the Risk of Bias in Nonrandomized Studies - of Interventions tool (ROBINS-I).

RESULTS

Overall, 17 studies, three randomised controlled trials and 14 pre-test/posttest studies, were included in this review. Of these 17 studies, 12 provided sufficient, appropriate data for inclusion in the meta-analysis. Cultural competence interventions were offered through education and training (including lectures, presentations, case studies, discussions, or various reflection activities) or technology-based applications and support (mobile app, online database, or web-based training). Education and training were shown to slightly increase nurses' levels of cultural competence, with a low certainty of the evidence. Technology-based applications and support may increase nurses' levels of cultural competence, but the evidence is very uncertain. No pooling of studies was possible for the patient-related outcomes.

CONCLUSION

Education and training can improve the level of nurses' cultural competence; therefore, they should be offered as continuing education for nurses. However, our confidence in the underlaying evidence for cultural competence interventions is low due to the imprecision and risk of bias of included studies; thus, the results should be interpreted with caution. Despite the growing interest in and body of research on nurses' cultural competence interventions, our review indicates a significant lack of studies examining the impact of such interventions on patient-related outcomes.

Cultural Factors Predict Positive Caregiving Appraisal Among Racially and Ethnically Diverse Dementia Family Caregivers

Positive caregiving appraisal is strongly linked to health among caregivers of persons with Alzheimer's Disease and Related Dementias (ADRD). This study hypothesized that race and ethnicity, as well as cultural factors, would predict positive caregiving appraisal. One-hundred thirty-six racially and ethnically diverse ADRD caregivers completed a cross-sectional survey. Race and ethnicity did not predict positive appraisal. However, culture-based values around caregiving and perceived provider cultural competence did predict positive appraisal. Findings reinforce the need to assess and incorporate culture-based values in services for ADRD caregivers and the importance of provider cultural competence when working with diverse ADRD family caregivers.

A Hybrid Type III Analysis of a Filmed Story-Telling Intervention's Impact on Provider Stigma

Identity Development Evolution and Sharing (IDEAS) reduces provider stigma, but few have been trained to implement IDEAS, highlighting a need for implementation strategies that facilitate uptake. We evaluated whether external facilitation successfully supported IDEAS implementation and whether IDEAS reduced provider stigma within and across sites irrespective of implementation barriers and facilitators. Key informants from 10 sites completed interviews and surveys of appropriateness, acceptability, and feasibility. Interviews were analyzed using the Consolidated Framework for Implementation Research guidelines. Intervention effectiveness was measured via paired t tests of pre-/post-quantitative data on provider stigma completed by practitioners who attended the training. Ten sites successfully implemented IDEAS via external facilitation; 58 practitioners from nine sites completed pre- and post-surveys. Data showed significant decreases in stigma after the intervention. IDEAS, supported by external facilitation, is a feasible, acceptable, and appropriate means of reducing stigma among occupational therapy practitioners.

Psychometric evaluation of the Chinese version of the BENEFITS-CCCSAT based on CTT and IRT: a cross-sectional design translation and validation study

Background

The importance of culturally competent care in multicultural environments is increasingly recognized; however, effective tools to assess nursing students' cross-cultural competence remain limited. This study aimed to validate the BENEFITS-CCCSAT for Chinese nursing students.

Methods

The original BENEFITS-CCCSAT was translated, back-translated, culturally adapted, and pre-tested using the Brislin model to form a Chinese version. A combined approach of classical test theory (CTT) and item response theory (IRT) was then used for multidimensional validation.

Results

The CTT analysis showed that the C-BENEFITS-CCCSAT had a Cronbach's α coefficient of 0.80, dimension reliability values ranging from 0.700 to 0.905, a test-retest reliability value of 0.881, and a scale-level content validity index (S-CVI) value of 0.928. The criterion-related validity value was 0.619. The confirmatory factor analysis (CFA) indicated a good model fit (CMIN/DF = 1.071, RMSEA = 0.08), with factor loadings ≥0.50. The Rasch analysis showed an item reliability value of 1, person reliability values ranging from 0.76 to 0.89, item separation index values ranging from 17.37 to 60.34, and person separation index values ranging from 1.76 to 2.89. The information-weighted fit statistic mean square (infit MNSQ) and outlier-sensitive fit statistic mean square (outfit MNSQ) values for all items ranged from 0.86 to 1.27. Overall, the scale demonstrated good reliability and validity for the Chinese nursing students.

Conclusion

The 25-item C-BENEFITS-CCCSAT demonstrates good reliability and validity and can be applied in educational settings to assess students' ability to provide culturally competent care. Future studies should test the scale in culturally diverse populations to further determine its applicability and generalizability.

Addressing Culturally Based Hidden Bias and RacisM (A-CHARM) Using Simulation Experiences, Nik's Story: A Quasi-Experimental Study

Background/PurposeRacism and hidden bias experienced by underrepresented nursing students contribute to a loss of confidence and anxiety. The A-CHARM nursing project developed virtual simulation experiences for nursing students to practice how to address racism. 'Nik's Story' virtual simulation was created as part of the A-CHARM project. The purpose of this study was to examine the effectiveness of an education intervention, that included Nik's story, on cultural humility and cultural diversity awareness.MethodThis quasi-experimental study included a convenience sample of final year nursing students. After informed consent, participants completed a pre-intervention questionnaire that included the Cultural Humility Scale "context for difference in perspective" subscale, and the Cultural Diversity Awareness questionnaire to assess baseline knowledge. Students participated in an education intervention that included a lecture, Nik's story virtual simulation experience, a debrief and then completed a post-education/simulation questionnaire that included usability/learner engagement questions and the Cultural Humility Scale "context for difference in perspective" subscale, and the Cultural Diversity Awareness questionnaire.ResultsForty-seven students consented and completed the pre/post intervention questionnaire. Participants rated the effectiveness, engagement and usability of the simulation experience highly. There was a significant positive change in cultural humility "context for difference in perspective" subscale (pre-scores = 6.9, SD = 3.3; post-scores = 31.0, SD = 3.8, p < 0.001), and cultural diversity awareness (pre-scores = 95.4, SD = 8.9; post-scores = 103.4, SD = 9.8, p < 0.001).DiscussionThis intervention was effective in improving cultural humility and cultural diversity awareness in nursing students.ConclusionSimulation experiences regarding racism in the clinical setting provide a strategy for students to learn how to professionally navigate unwanted experiences.

Socio-Healthcare for Older People in the Mediterranean Basin: An Integrative Review and Quality Appraisal

OBJECTIVES

The aging Mediterranean Basin population presents complex challenges for healthcare systems, which require innovative care approaches. The study aimed to critically assess 19 socio-healthcare practices in the Mediterranean Basin that target the elderly population by analyzing their theoretical foundations, integration of care services, ethical considerations, gender-specific approaches, and use of technology.

DESIGN

An integrative literature review was conducted using a structured methodology.

SAMPLE

Diverse sources across multiple languages were searched, with the inclusion criteria focusing on the alignment of socio-healthcare practices with the components of the nursing metaparadigm, the incorporation of transversal values, and relevance to the elderly population.

RESULTS

The socio-healthcare practices exhibited common themes, such as person-centered care, interdisciplinary collaboration, and incorporation of technology for coordinated care delivery. Ethical principles of autonomy, dignity, and respect were central, with some socio-healthcare practices addressing gender-specific care needs. Evidence-based findings emphasized holistic care, integration, ethics, and innovation in elderly socio-healthcare.

CONCLUSIONS

New eldercare frameworks should integrate these aspects, which offer a comprehensive approach to addressing the complex needs of elderly patients. Managers should design systems prioritizing patient well-being, whereas policymakers should develop equitable and high-quality care policies that collectively improve the well-being of the elderly population in the Mediterranean Basin.

Cultural Competence of Vietnamese Undergraduate Nursing Students and Influencing Factors

INTRODUCTION

Cultural competence is essential for nurses to enhance the quality of care and reduce care inequity in diverse cultures. Throughout the world, populations are resettling to different regions for various reasons, necessitating the importance of teaching cultural skills to nursing students. This study determined the cultural competence of Vietnamese undergraduate nursing students and the factors influencing cultural competence.

METHOD

The cross-sectional study was performed with 169 undergraduate nursing students in Vietnam. Data on cultural competence, measured by the Nurse Cultural Competence Scale (NCCS), empathy, and self-efficacy was collected. Multiple regression analysis examined the factors influencing cultural competency.

RESULTS

A positive relationship was found between self-efficacy and cultural competence (β = 0.47, p < .001), between empathy and self-efficacy (p < .001), and a negative relationship between ethnicity and empathy (p < .05).

DISCUSSION

Improving undergraduate nursing students' cultural competency is essential in education programs; cultural competency training focuses on strengthening self-efficacy and empathy.

Cultural Competence and Nursing Work Environment: Impact on Culturally Congruent Care in Portuguese Multicultural Healthcare Units

BACKGROUND

Cultural competence is central to ensuring effective culturally congruent care to patients and fostering positive work environments, particularly in multicultural settings.

OBJECTIVE

This study aimed to analyse the relationship between cultural competence, the nursing work environment, and the delivery of culturally congruent care in multicultural units of a healthcare organisation in Portugal.

METHOD

This was a quantitative, descriptive, and cross-sectional study, targeting nurses from multicultural units. Data were collected using both online and paper-based questionnaires, which included the Cultural Competence Questionnaire for Help Professionals, the Nursing Work Index-Revised Scale (NWI-R-PT), and a single question assessing nurses' perceptions of the adequacy of the culturally congruent care they provide.

RESULTS

A moderate, positive correlation was identified between cultural competence and the Fundamentals for Nursing, while the nursing work environment was influenced by organisational support, professional category, and unit type.

DISCUSSION

The findings suggest that enhancing cultural knowledge and technical skills and reinforcing management support may positively impact culturally congruent care delivery in multicultural settings.

CONCLUSION

This study contributes to nursing knowledge by highlighting the complex interactions between cultural competence and the work environment in Portuguese multicultural healthcare units. Future research should explore the impact of transcultural nursing leadership on multicultural work environments and in the delivery of culturally congruent care.

Registered nurses' perceptions of healthy lifestyle counselling for immigrants in primary healthcare: A focus group study

BACKGROUND

The use of primary healthcare and health promotion services is low among immigrants compared with native citizens. Immigrants are at risk of developing chronic diseases due to genetics, nutrition and a sedentary lifestyle. Registered nurses play an integral role in teaching, counselling for a healthy lifestyle and care coordination in primary healthcare.

AIM

We aimed to explore the perceptions of registered nurses on healthy lifestyle counselling for preventing type 2 diabetes and other chronic diseases among immigrants in the primary healthcare setting.

DESIGN

We performed a qualitative descriptive study using focus group interviews.

METHODS

Data were collected with semi-structured focus group interviews with a total of 23 registered nurses working in primary healthcare. We recruited the participants by using the purposive sampling method in the primary healthcare setting of four municipalities in Finland. Interviews were audio-recorded, transcribed verbatim and analysed with qualitative inductive content analysis.

RESULTS

The participants' perceptions were related to (1) uniform counselling practice for both immigrants and native citizens, (2) challenges in counselling immigrants, (3) understanding cultural factors influencing immigrant counselling, (4) the need to improve immigrant counselling and (5) utilizing insights from practical experience to improve the counselling service.

CONCLUSIONS

Developing a culturally sensitive health promotion service is suggested to support the health of immigrants. Moreover, both migrant communities and healthcare professionals should be involved in co-designing and implementing health promotion projects through a community-based participatory approach.

IMPACT

Our study contributes to healthcare practice and management by underscoring the need for culturally tailored health promotion services for the at-risk group of immigrants in primary healthcare. Cultural competence in nursing education needs to be reinforced. The provided recommendations inform researchers and policymakers about the health disparities and health needs of immigrants.

PUBLIC CONTRIBUTION

Healthcare professionals were consulted in the study design.

Simulation Experiences Focusing on Addressing Culturally Based Hidden Bias and RacisM (A-CHARM)

BACKGROUND

Racism experienced by nursing students contributes to a loss of confidence and anxiety. The Addressing Culturally Based Hidden Bias and RacisM (A-CHARM) nursing project simulation experiences (SEs) provide opportunities to practice addressing racism/inappropriate comments experienced in the clinical setting. The aim is to describe the development of the A-CHARM nursing project SEs.

METHOD

The frameworks used in the development of the SEs include the (1) six-step approach, (2) ERASE framework, (3) SENSE debriefing model, and (4) Microaggressions Triangle model.

RESULTS

Five SEs were created that depicted scenes where a nursing student encounters racism/inappropriate comments. Each SE aligned with one of the frameworks and users utilized the framework to navigate the SE.

CONCLUSION

The A-CHARM nursing SEs may benefit nursing students by enhancing their knowledge and skills related to racism or inappropriate comments in clinical settings. Future research will evaluate the impact of the SEs on nursing students and clinical faculty. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Ecological predictors of cultural competence among nurses in the neonatal intensive care unit: A cross-sectional descriptive study

Active migration and globalization have led to increased opportunities for critical care nurses to care for patients from diverse racial and cultural backgrounds. This study thus aimed to identify the individual, interpersonal, and organizational factors affecting cultural competence levels among neonatal intensive care unit (NICU) nurses based on an ecological model. This was a cross-sectional descriptive study that included 135 NICU nurses in South Korea. A hierarchical multiple linear regression analysis was conducted using the proposed ecological model, and a regression model for each of the four subdomains of cultural competence was constructed and compared. NICU nurses' cultural competencies were influenced not only by the "necessity of multicultural education" and "ethnocultural empathy" at the individual level but by the "hospital's readiness and support for cultural competencies" at the organizational level. To promote the cultural competence of nurses in critical care settings, environmental and organizational support should be improved, along with developing strategies that focus on nurses' individual characteristics. It is also necessary to investigate the "intersectionality" of the effects of individual and environmental factors on cultural competence.

Graduate Nursing Faculty Perceptions of LGBTQ+ Health Curriculum: A Mixed-Methods Study

BACKGROUND

The lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community experiences profound health disparities due to discrimination and lack of health care provider knowledge. Although data exist about undergraduate nursing and medical school education on LGBTQ+ topics, there is a gap in understanding graduate nursing schools' preparation of nurse practitioners.

METHOD

A survey measuring faculty perceptions of LGBTQ+ health curricula was sent to graduate nursing schools to collect both qualitative and quantitative data.

RESULTS

Graduate nursing faculty spent a median of 3 hours teaching LGBTQ+ health topics. LGBTQ+ health content in their courses was limited despite their awareness of LGBTQ+ topics, their readiness to include it, and their belief in the importance of including such topics. Respondents indicated a lack of resources and knowledge about where to start and identified a need for support from their institution.

CONCLUSION

The gaps identified in graduate nursing LGBTQ+ health curriculum demonstrate the need for additional institutional support. [J Nurs Educ. 2024;63(2):65-71.].

Increasing transcultural competence in clinical psychologists through a web-based training: study protocol for a randomized controlled trial

BACKGROUND

In mental health care, the number of patients with diverse cultural backgrounds is growing. Nevertheless, evaluated training programs for transcultural competence are missing. Barriers for engaging in transcultural therapy can be identified in patients as well as in therapists. Besides language barriers, clinical psychologists report insecurities, for example, fear of additional expenses when involving a language mediator, ethical concerns such as power imbalances, or fear of lack of knowledge or incorrect handling when working with patients from other cultures. Divergent values and concepts of disease, prejudices, and stereotyping are also among the issues discussed as barriers to optimal psychotherapy care. The planned study aims to empower clinical psychologists to handle both their own as well as patients' barriers through a web-based training on transcultural competence.

METHODS

The training includes 6 modules, which are unlocked weekly. A total of N = 174 clinical psychologists are randomly assigned to two groups: the training group (TG) works through the complete training over 6 weeks, which includes a variety of practical exercises and self-reflections. In addition, participants receive weekly written feedback from a trained psychologist. The waitlist control group (WL) completes the training after the end of the waiting period (2 months after the end of the TG's training). The primary outcome is transcultural competence. Secondary outcomes consist of experiences in treating people from other cultures (number of patients, satisfaction and experience of competence in treatment, etc.). Data will be collected before and after the training as well as 2 and 6 months after the end of the training.

DISCUSSION

This randomized controlled trial tests the efficacy of and satisfaction with a web-based training on transcultural competence for German-speaking clinical psychologists. If validated successfully, the training can represent a time- and place-flexible training opportunity that could be integrated into the continuing education of clinical psychologists in the long term.

TRIAL REGISTRATION

DRKS00031105. Registered on 21 February 2023.

Anti-Racism Efforts in Healthcare: A Selective Review From a Social Cognitive Perspective

Health effects of structural racism occur on cultural and institutional levels and potentiate racism on an interpersonal level. Consequently, efforts to mitigate the health effects of racism may require intervention on all levels. The effectiveness of these approaches may depend partly on the degree to which they address the underlying patterns of social cognition, shaping social norms and influencing thoughts, feelings, and expectations about oneself, one's relationships with others, and interactions with the healthcare system. This paper aims to evaluate the current approaches to addressing structural racism (via racism and health statements and training programs in diversity, equity, and inclusion or cultural competence). These interventions work to shift social cognition, and consequently, shape social behavior in the healthcare context. Our goal is to identify ways to maximize the potential of these approaches to address social cognition to guide efforts to achieve a more inclusive and equitable healthcare system.

Developing the better and effective nursing education for improving transcultural nursing skills cultural competence and cultural sensitivity assessment tool (BENEFITS-CCCSAT)

BACKGROUND

A clear need for the development of new comprehensive, reliable, sensitive and valid measurement tools to adequately asses the cultural competence and cultural sensitivity of nursing students exists. This study aimed to develop a new measurement tool to assess the nursing students' cultural competence and sensitivity.

METHODS

This cross-sectional, instrument development study's first phase included postgraduate nursing students (n = 60) for the piloting study, and the second one included undergraduate nursing students (n = 459) for the main survey. This study used two data collection forms: The Student Descriptive Information Form and the Better and Effective Nursing Education for Improving Transcultural Nursing Skills Cultural Competence and Cultural Sensitivity Assessment Tool (BENEFITS-CCCSAT) draft. The content validity index was calculated using the Davis method. Cronbach's α coefficient and the item total correlation were calculated during the reliability analysis. The Kaiser-Meyer-Olkin (KMO) coefficient test, Bartlett significance test, and explanatory factor analysis (EFA) were used to evaluate the validity of the assessment tool.

RESULTS

Scale validity and reliability analyses showed that the BENEFITS-CCCSAT included 26 items and five sub-dimensions: respect for cultural diversity; culturally sensitive communication; achieving cultural competence; challenges and barriers in providing culturally competent care; and perceived meaning of cultural care.

CONCLUSION

The BENEFITS-CCCSAT appears to be a valid and reliable instrument for measuring the cultural sensitivity and cultural competence of nursing students. This can be of great use, especially before attending clinical areas, and can offer both students and faculty reliable information to promote reflective and critical thinking, especially in areas where improvement is needed.

The influence of cultural competence on healthcare outcomes

Background: the demand to improve nurses' Cultural Competence (CC) was recently introduced to light by the growing cultural variety in healthcare in European nations. It is possible to enhance culturally competent treatment by evaluating CC and identifying pertinent influencing variables. The purpose of this research was to use the Cultural Competence Assessment (CCA) scale to measure the CC of nurses and nursing students working in acute care settings and to identify influencing variables. Methods: the design was cross-sectional. Data was collected in March 2021 from nurses and nursing students enrolled in their last year of education and employed in acute care facilities. The research participants' general features and degrees of general CC were shown using descriptive analysis. The influencing aspects of CC were examined using a multiple linear regression analysis. Results: the cultural proficiency of the nurses ranged from moderate to excellent. Age, educational attainment, cultural diversity training (CDT), and self-perceptions of CC all had a significant impact on the level. Conclusions: all healthcare professionals, including nurses who interact with patients frequently, need to be prepared to offer CC healthcare for patients from a variety of cultural backgrounds. Delivering CC care involves the implementation of effective interventions, such as educational training, which may help to eliminate healthcare inequities and enhance patient outcomes

Physical Therapists' Perceptions of Preparedness to Engage in Culturally Competent Practice Upon Graduation: A Qualitative Research Study

INTRODUCTION

Entry-level Doctor of Physical Therapy (DPT) graduates are not demographically diverse compared with the population of the United States. The curriculum must provide depth, breadth, and opportunity to develop culturally competent providers. The purpose of this qualitative study was to examine perceptions of novice/advanced beginner and experienced physical therapists (PTs) as to how well prepared they felt by their PT education to act as culturally competent providers and compare methods of cultural competence education received. Findings can inform whether cultural competence curriculum standards in PT education are viewed as effective or if changes to curriculum may be needed.

REVIEW OF LITERATURE

Research has highlighted measured or perceived changes in perceptions, attitudes, and behaviors of cultural competence with clinical exposure and experience for PT students. Studies that examine or compare practicing PT perceptions of the effectiveness of entry-level cultural competence education are limited, as is evidence supporting specific cultural competence curriculum methodology.

SUBJECTS

Thirteen licensed PTs participated in the study.

METHODS

In this phenomenological qualitative study, subjects participated in semi-structured interviews. Data were coded and analyzed using a constant comparative approach.

RESULTS

Three themes emerged: 1) clinical practice and life experiences had greater influence on perceptions of preparedness, 2) suggestions to improve cultural competence curriculum, and 3) experiential learning was valued and contributed to culturally competent practice.

DISCUSSION AND CONCLUSION

Entry-level DPT programs may consider exposing students to diverse patient populations through diverse clinical rotation opportunities, community outreach, and interactive learning early in the curriculum. Incorporating student experiences with different social, cultural, or ethnic groups may promote a greater perceived value of cultural competence curriculum and improve PTs' perceptions of preparedness to practice culturally competent care. Programs may also examine the direct and indirect influence clinical instructors have on developing DPT students' cultural competence during clinical rotations.

"Health without Borders": Early Findings and Lessons Learned from a Health Promotion Program for Ethnic Minorities Living in Italy

In multicultural contexts, health promotion can be challenging due to people's differences in beliefs, values, and practices regarding health and healthcare. Using the prototypical case scenario offered by the "Health without Borders" program, this study was generally aimed at summarizing the lessons learned and suggesting implications that are hopefully relevant to future culturally competent health promotion programs. This exploratory study used in-depth interviews, focus groups, and document analyses as primary methodological tools to gather data. A qualitative approach was chosen because it has the potential to explore, in depth, the main characteristics (values, operational domains, and action strategies) behind this prototypical case. The study findings suggest that the multicultural health promotion program under study is characterized by four main intertwined core values (i.e., empowerment; peer education; social embeddedness; tailor-made). In turn, these values are expressed in the ten main operational domains (i.e., proactive approach to health promotion; fostering interculturality in health promotion; fostering multidisciplinarity in health promotion; measuring the impact of initiatives; identifying, training, and activating key community members in the role of peer educators; promoting community engagement; fostering a "domino effect"; building institutional links with the organization of the territory; continuous training of the professionals involved in the initiatives; flexibility and a constant focus on projects' continuous redesign) that orient specific strategies of action. This program is based on a tailor-made principle for intervention design and delivery. This feature allows intervention providers to flexibly incorporate the target population's values in delivering health promotion activities. Therefore, the value of this prototypical case lies in the design of "adjustable" initiatives that fit the "program-as-designed" with the cultural characteristics of target populations involved in the intervention.

The role of service providers' linguistic backgrounds on assessment of multilingual children

INTRODUCTION

Cultural and linguistic competencies play a critical role in speech-language pathology services when working with people from diverse linguistic backgrounds with communication disorders (CD; Hopf et al., 2021). The personal experiences of speech-language pathologists (SLPs) influence their cultural and linguistic competence skills. Training programs that consider these personal factors might address the unique needs of the SLPs based on their experiences. The current research explores the connection between the linguistic backgrounds of the SLPs and the challenges and needs they reported while assessing multilingual children with CD.

METHOD

This study uses a survey method for documenting and comparing 105 SLPs with varying linguistic backgrounds - monolingual, bilingual, and multilingual - on their reported challenges and needs associated with evaluating communication abilities in children from multilingual families with CD.

RESULTS

Although all the SLPs worked with children from multilingual families, their linguistic backgrounds introduced differences in their clinical assessment opinions. Across all SLPs in the study, common challenges were the limited availability of interpreters, dedicated assessment materials, multilingual clinical supervisors, and pre-professional training opportunities.

CONCLUSION

This study provides valuable information on the effects of linguistic backgrounds on the clinical opinions of SLPs and alludes to the importance of personal experiences on clinical practices. Future research that examines other personal factors and their effects on the SLPs' clinical opinions and practices will help the development of evidence-based cultural and linguistic competence training programs.

Testing the Assumptions in the Process of Cultural Competence in the Delivery of Healthcare Services Using Empirical Data, Focusing on Cultural Awareness

INTRODUCTION

Encounters with children of foreign origin call for school nurses' cultural competence during the health visits. This study aimed to investigate the statistical associations between the cultural constructs described by the Process of Cultural Competence in the Delivery of Healthcare Services (PCCDHS) model and whether school nurses' cultural encounters, cultural knowledge, and cultural skill could statistically predict their cultural awareness.

METHODOLOGY

Spearman correlation and hierarchical regression analyses were conducted using cross-sectional secondary data from 816 Swedish school nurses. The cultural constructs in the theoretical description of the PCCDHS model guided the selection and sorting of the items on cultural competence.

RESULTS

The constructs of cultural knowledge, cultural skill, cultural encounters, and cultural awareness were positively correlated with each other. However, becoming culturally aware was not statistically predicted by included cultural constructs (R² = 13.4, p = .06).

DISCUSSION

Despite the interrelations between the investigated cultural constructs of the PCCDHS model, understanding cultural awareness development requires further empirical testing.

International Portuguese Nurse Leaders' Insights for Multicultural Nursing

Cultural diversity among patients and healthcare workers in the Portuguese healthcare organizations will increasingly challenge nurse managers to develop favorable nursing work environments and to improve culturally congruent care.

AIM

This study aimed to identify nurse managers' interventions that improve favorable nursing work environments in multicultural nursing teams and culturally congruent care for patients, based on Portuguese nurse leaders' experience in international settings.

METHODS

A qualitative and exploratory study was conducted as the first stage of a sequential exploratory mixed study design. A convenience sample of Portuguese nurses with leadership experience of multicultural teams was recruited to participate in one focus group. Qualitative data were recorded and transcribed for content analysis. Text segments were organized into themes and categories with the support of the qualitative software IRaMuTeQ.

RESULTS

Nurse managers' interventions, such as adapting the leadership style, thanking nurses for their work, adjusting the unit to attend to patients' worship practices, and supporting foreign nurses in learning the local language, were categorized into three main themes and five categories-transcultural nursing leadership assumptions, capitalizing nurses, improving culturally congruent care, team problems and strategies, and improving effective communication.

CONCLUSIONS

These findings corroborate international studies, advocate for capable nurse managers to lead in a globalized world, and are suitable to develop a transcultural nursing leadership questionnaire.

Improving Access and Health Outcomes in Palliative Care through Cultural Competence: An exploration of opportunities and challenges in India

People who belong to ethnic, racial and cultural minorities often have less access to healthcare and have poorer health outcomes when compared to the majority population. In the COVID pandemic, too, health disparities have been observed. Similar disparities have been noted in patients with advanced disease and suffering from pain, with minority patients having less access to or making less use of palliative care. In the US, a range of solutions has been proposed to address the issue of inequality in access to healthcare, with cultural competence figuring prominently among them. This study explores whether and how cultural competence may be applied to palliative care in India to improve access and health outcomes. In the literature, it is argued that, in diverse societies, cultural competence is an essential part of the solution towards equitable healthcare systems. Solutions to problems of healthcare disparities must go beyond an increase in financial resources as more financial resources will not necessarily make the healthcare system more equitable. A culturally competent system recognises and integrates at all levels the culture as a significant component of care, which is particularly relevant at the end of life. If efficiently implemented, cultural competence will lead to higher patient satisfaction, better follow-up and patient compliance and an improved reputation of palliative care among minorities. This may help to reduce inequalities in access and health outcomes in palliative care.

Protocol for evaluating external facilitation as a strategy to nationally implement a novel stigma reduction training tool for healthcare providers

Background

Identity Development Evolution and Sharing (IDEAS) is a theatre-based intervention for reducing healthcare provider stigma. IDEAS films are created by collecting narratives from people who have experienced discrimination and healthcare inequity, partnering with professional playwrights to create theatrical scripts that maintain the words of the narratives while arranging them into compelling storylines involving several interviews, and hiring professional actors to perform and record scenes. IDEAS implementation requires a moderator to establish a respectful learning environment, play the filmed performance, set ground rules for discussion, and moderate a discussion between healthcare providers who viewed the film and invited panelists who are members of the minoritized population being discussed. IDEAS’ impact on provider stigma is measured via pre/post Acceptance and Action Questionnaire – Stigma (AAQ-S) data collected from participating providers. The objectives of this manuscript are to provide narrative review of how provider stigma may lead to healthcare inequity and health disparities, describe the conceptual frameworks underpinning the IDEAS intervention, and outline methods for IDEAS implementation and implementation evaluation.

Methods

This manuscript describes a hybrid type 3 design study protocol that uses the Consolidated Framework for Implementation Research (CFIR) to evaluate external facilitation, used as an implementation strategy to expand the reach of IDEAS. CFIR is also used to assess the impact of characteristics of the intervention and implementation climate on implementation success. Implementation success is defined by intervention feasibility and acceptability as well as self-efficacy of internal facilitators. This manuscript details the protocol for collection and evaluation of implementation data alongside that of effectiveness data. The manuscript provides new information about the use of configurational analysis, which uses Boolean algebra to analyze pathways to implementation success considering each variable, within and across diverse clinical sites across the USA.

Discussion

The significance of this protocol is that it outlines important information for future hybrid type 3 designs wishing to incorporate configurational analyses and/or studies using behavioral or atypical, complex, innovative interventions. The current lack of evidence supporting occupational justice-focused interventions and the strong evidence of stigma influencing health inequities underscore the necessity for the IDEAS intervention.

Ethical Considerations for Hospital-Based Infant Feeding Support

I applied a systematic ethical decision-making approach to evaluate how health care professionals in hospital settings should provide infant feeding support after childbirth. Human milk is recommended as the optimal source of nutrition for infants because of the health benefits it provides for infants and their lactating parents. However, health consequences of insufficient oral intake in infants and psychological distress in the lactating parent may occur when infant feeding does not go according to plan. Infant feeding support should be provided in a way that is objective, sensitive, individualized, equitable, and supportive of autonomy and avoids harm. I provide recommendations for ethical infant feeding support that can be applied by individual health care professionals and on postpartum units in hospitals.

Cultural competence in healthcare professionals, specialised in diabetes, working in primary healthcare-A descriptive study

Self-care is the most important cornerstone of diabetes treatment. As self-care is affected by cultural beliefs, it is important for healthcare professionals to be able to adapt their educational approach and to be culturally competent. The aim of this study was to describe the cultural competence in Swedish healthcare professionals, specialised in diabetes care and to examine related factors for cultural competence. The healthcare professionals' perceived level of cultural competence was measured across three domains-Openness and awareness, Workplace support and Interaction skills-in 279 Swedish healthcare professionals from all 21 regions of Sweden, using the Cultural Competence Assessment Instrument (Swedish version-CCAI-S). Descriptive statistics were used to describe cultural competence in healthcare professionals, and linear regression was conducted to examine factors related to cultural competence. Of the healthcare professionals studied, 58% perceived that they had a high level of Openness and awareness, 35% perceived that they had a high level of Interaction skills and 6% perceived that they had a high level of Workplace support. Two factors were found to be related to cultural competence, namely, high percentage of migrant clients at the healthcare clinic and whether the healthcare professionals previously had developed cultural competence through practical experience, education and/or by themselves. In conclusion, most healthcare professionals perceived that they had cultural openness and awareness but need more support from their workplace to improve their interaction skills. Cultural competence-related education could support the healthcare professionals to develop interaction skills.

Open-mindedness trait affects the development of intercultural communication competence in short-term overseas study programs: a mixed-method exploration

BACKGROUND

Overseas study trips can enhance healthcare students' intercultural communication competence. An opportunity to immerse in the new culture enables them to develop their ability to offer services to people from different countries. However, the role that open-mindedness (i.e., a personality trait) can play in this process has not been explored.

METHODS

The present study adopted a mixed-method design to identify how open-mindedness trait affected this overseas learning process. Thirty-two undergraduate healthcare students in Australia took part in the study. Questionnaires, which measured socio-demographic information, intercultural communication competence and open-mindedness trait were administered to the participants before and after their overseas trip. Half of the participants (n = 16) were interviewed after the overseas trip.

RESULTS

The correlational analysis showed that the open-mindedness trait was correlated with cultural skills, a component of intercultural communication competence, but not significant with the other three components. Three themes emerging from the qualitative data indicated that the open-mindedness trait affected students' cultural exposure. This trait enabled participants to be actively involved in the immersion in the local culture. They were willing to learn from peer fellows, and keen to embrace novel challenges.

CONCLUSION

It is concluded that open-mindedness trait is vital for increasing cultural immersion, and hence promote intercultural communication skills.

Relationship between nurses' cultural competence and observance of ethical codes

BACKGROUND

Cultural competence is considered as one of the main skills of nurses enabling them to provide nursing care for those with different cultures. One of the cases related to nurses' cultural competence is observance of ethical codes, but it has not been investigated sufficiently in studies.

AIM

This study has been conducted to determine the relationship between nurses' cultural competence and observance of ethical codes in practice.

RESEARCH DESIGN

This descriptive-correlational study was conducted in 2020. Sampling was done at several stages. The data were collected using questionnaires of demographic information, cultural competence, and observance of ethical codes as self-report. The questionnaires were provided to the subjects by the corresponding researcher and the data were analyzed using Pearson correlation test.

PARTICIPANTS AND RESEARCH CONTEXT

This study was done with participation of 267 nurses working in four training hospitals located in northwestern Iran and 16 head nurses of selected wards.

ETHICAL CONSIDERATIONS

The study was approved by Human Ethics Committee of Hamadan University of Medical Sciences. Participation was voluntary. Consent was obtained and confidentiality kept.

FINDINGS

The results of Pearson correlation coefficient test showed a positive and statistically significant relationship between cultural competence and observance of ethical codes (r = 0.524, p = 0.001). In addition, cultural competence and observance of ethical codes by most nurses were at a moderate level.

CONCLUSIONS

The results of the present study showed a significant relationship between nurses' cultural competence and observance of ethical codes. Therefore, it can be concluded that by strengthening the level of nurses, the level of observing ethical codes by them can be increased. Cultural competency and observance of ethical codes are important components of nursing care, and their development can improve nursing care delivery to clients through academic training, hidden curriculum and in-service education.

The Effect of Institutional Support on the Cultural Intelligence of Nursing Students

Background:

Cultural intelligence is important for studying, working, and living in multicultural societies. Previous studies have indicated that training and learning support are important for improving students’ cultural intelligence. The purpose of this study was to investigate the effect of institutional support on cultural intelligence.

Methods:

933 nursing students in three countries, among Malaysia, the Philippines, and Thailand, answered a rating scale questionnaire. A structural equation model was used to examine the effect of institutional support on cultural intelligence.

Results:

Institutional support had a statistically significant effect on cultural intelligence, with an effect size of 0.57.

Conclusion:

For promoting cultural intelligence divided into three aspects, the first concerns the implementation of multicultural experiences in curricula; the second involves extra-curricular activities for being applied in multicultural situations; and the last regards encouraging teachers to realize the importance of culture and integrating cultural content in their teaching and in the students’ learning.

Actions to Transform US Preventive Services Task Force Methods to Mitigate Systemic Racism in Clinical Preventive Services

IMPORTANCE

US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism.

OBJECTIVE

To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected by systemic racism.

DESIGN AND EVIDENCE

In February 2021, the USPSTF began operational steps in its work to create preventive care recommendations to address the harmful effects of racism. A commissioned methods report was conducted to inform this process. Key findings of the report informed proposed updates to the USPSTF methods to address populations adversely affected by systemic racism and proposed pilots on implementation of the proposed changes.

FINDINGS

The USPSTF proposes to consider the opportunity to reduce health inequities when selecting new preventive care topics and prioritizing current topics; seek evidence about the effects of systemic racism and health inequities in all research plans and public comments requested, and integrate available evidence into evidence reviews; and summarize the likely effects of systemic racism and health inequities on clinical preventive services in USPSTF recommendations. The USPSTF will elicit feedback from its partners and experts and proposed changes will be piloted on selected USPSTF topics.

CONCLUSIONS AND RELEVANCE

The USPSTF has developed strategies intended to mitigate the influence of systemic racism in its recommendations. The USPSTF seeks to reduce health inequities and other effects of systemic racism through iterative changes in methods of developing evidence-based recommendations, with partner and public input in the activities to implement the advancements.

Addressing Racism in Preventive Services: Methods Report to Support the US Preventive Services Task Force

IMPORTANCE

In January 2021, the US Preventive Services Task Force (USPSTF) issued a values statement that acknowledged systemic racism and included a commitment to address racism and health equity in recommendations for clinical preventive services.

OBJECTIVES

To articulate the definitional and conceptual issues around racism and health inequity and to describe how racism and health inequities are currently addressed in preventive health.

METHODS

An audit was conducted assessing (1) published literature on frameworks or policy and position statements addressing racism, (2) a subset of cancer and cardiovascular topics in USPSTF reports, (3) recent systematic reviews on interventions to reduce health inequities in preventive health or to prevent racism in health care, and (4) health care-relevant professional societies, guideline-making organizations, agencies, and funding bodies to gather information about how they are addressing racism and health equity.

FINDINGS

Race as a social category does not have biological underpinnings but has biological consequences through racism. Racism is complex and pervasive, operates at multiple interrelated levels, and exerts negative effects on other social determinants and health and well-being through multiple pathways. In its reports, the USPSTF has addressed racial and ethnic disparities, but not racism explicitly. The systematic reviews to support the USPSTF include interventions that may mitigate health disparities through cultural tailoring of behavioral interventions, but reviews have not explicitly addressed other commonly studied interventions to increase the uptake of preventive services or foster the implementation of preventive services. Many organizations have issued recent statements and commitments around racism in health care, but few have provided substantive guidance on operational steps to address the effects of racism. Where guidance is unavailable regarding the proposed actions, it is principally because work to achieve them is in very early stages. The most directly relevant and immediately useful guidance identified is that from the GRADE working group.

CONCLUSIONS AND RELEVANCE

This methods report provides a summary of issues around racism and health inequity, including the status of how these are being addressed in preventive health.

Care and Rearing of Institutionalized Girls in Arequipa, Peru: An Ethnographic Approach

INTRODUCTION

Institutional care for children is a global phenomenon. Despite its advantages, common threats have been described. In Peru, more than 70% of institutionalized children/adolescents have living parents who cannot take care of them. The study aims to understand the care/rearing of institutionalized girls in Arequipa, Peru.

METHODOLOGY

Ethnographic design, with a sample integrated by 27 institutionalized girls. Data collected based on participant observation and semi-structured interviews. The analysis followed the Method of Constant Comparisons.

RESULTS

Five main themes were found: (a) The little house (foster home) is better than my house; (b) They take care of me-even when I am sick-; (c) But . . .; (d) What I have lived is what I am; (e) Happiness fits in this little house.

DISCUSSION

An ethnography of care/rearing practices could be helpful for a better understanding of the dimensions of the life of institutionalized girls living in developing countries.

Improvement in the Cognitive Aspects of Cultural Competence after Short-Term Overseas Study Programs

Universities are providing short-term overseas study programs for healthcare students to increase their cultural competence (i.e., capacity to work effectively in cross-cultural situations). However, there is limited empirical research evaluating the effects of these programs using well-controlled research designs. In the present research study, undergraduate healthcare students in an Australian university were selected as participants. Group 1 (n = 32) participated in a short-term overseas study program in Asia (i.e., China, Vietnam, Singapore, and Taiwan), whereas Group 2 (n = 46) stayed in Australia to continue their university education as usual. All participants completed a self-developed demographic questionnaire, Cultural Intelligence Scale, and Multicultural Personality Questionnaire. Cultural competence was surveyed pre- and post-short-term overseas programs. After controlling for prior overseas experiences and the open-mindedness trait, an ANCOVA indicated that Group 1 had a significantly higher scores than Group 2 in cultural knowledge (p < 0.05), but not in cultural awareness, attitude, or skills. It is suggested that short-term overseas study programs may increase healthcare students' cultural knowledge, a component of competence, and that more needs to be accomplished to improve other areas of cultural competence.

Supporting Occupational Justice for Transgender and Gender-Nonconforming People Through Narrative-Informed Theater: A Mixed-Methods Feasibility Study

IMPORTANCE

Societal stigma gravely impedes occupational justice for transgender and gender-nonconforming (TGNC) people, producing vast health disparities for this population.

OBJECTIVE

To test the feasibility of an intervention to reduce stigma and improve the well-being of TGNC people.

DESIGN

A parallel, mixed-methods design was used to test feasibility in the areas of acceptability, demand, and limited efficacy.

SETTING

Community.

PARTICIPANTS

Forty-two audience members and 5 TGNC interviewees.

INTERVENTION

Virtual, narrative-informed play reading and moderated discussion about gender diversity and affirmative care. Outcomes and Measures: The valid and reliable Acceptance and Action Questionnaire-Stigma was used to assess stigma beliefs. An open-ended, qualitative question assessed TGNC interviewees' experiences.

RESULTS

Recruitment and participant responses to the intervention indicated feasibility in the areas of acceptability, demand, and limited efficacy. However, future efforts at obtaining a diverse TGNC sample are needed.

CONCLUSIONS AND RELEVANCE

The intervention decreased stigma beliefs in audience members and offered a positive experience for TGNC participants. Feasibility outcomes warrant future efficacy testing. What This Article Adds: This article adds an innovative intervention for promoting occupational justice to support the health and well-being of TGNC people. The community-based intervention facilitates change in societal attitudes and stigmatizing beliefs.

Complementary and Alternative Medicine Use by Patients From the Gulf Region Seen in the International Practice of a Tertiary Care Medical Center

BACKGROUND

Patients from various countries may have unique patterns of using complementary and alternative medicine (CAM) and unique reasons for using it.

OBJECTIVE

Our objective was to assess the use of CAM among patients from the Gulf region attending the Executive and International Health Program of the Department of General Internal Medicine at Mayo Clinic in Rochester, Minnesota.

METHODS

This cross-sectional survey was administered to all patients who were from the Gulf region and were undergoing outpatient evaluation in the Executive and International Health Program. After their initial medical evaluation by a physician, the patients were invited to anonymously complete the modified International Complementary and Alternative Medicine Questionnaire.

RESULTS

The survey was completed by 69 patients (41 women, 27 men; mean age, 45.4 years). The most frequently seen providers for CAM treatments were physicians (71.0% of patients), spiritual healers (29.0%), and chiropractors (20.3%). CAM treatments most frequently received from a physician were massage therapy (51.0%), hijama (38.8%), spiritual healing (24.5%), and acupuncture or herbs (16.3%). The most frequently used dietary supplements were ginger (42.0%), bee products (30.4%), and garlic (27.5%). The most common self-help therapies were prayers for health (68.1%), meditation (15.9%), and relaxation techniques (11.6%). CAM therapy, including visits to CAM providers, was used by 92.8% of patients. CAM was mainly used to improve well-being and long-term health conditions rather than for acute illnesses.

CONCLUSION

The use of CAM was high among our patients from the Gulf region, and the CAM therapies used by this population differed from the ones used by US patients. Physicians providing care to patients from the Gulf region should be aware of how the use of CAM may affect the care needs of these patients.

Formative process evaluation of a guideline-driven process for improving the cultural responsiveness of alcohol and drug treatment services

BACKGROUND

To improve Australian Aboriginal and Torres Strait Islander people's access to, and experience of, healthcare services, including Alcohol and other Drug (AoD) treatment services, principles and frameworks have been developed to optimise cultural responsiveness. Implementing those principles in practice, however, can be difficult to achieve. This study has five aims: i) to describe a five-step process developed to operationalise improvements in culturally responsive practice in AoD services; ii) to evaluate the fidelity of implementation for this five-step process; iii) to identify barriers and enablers to implementation; iv) to assess the feasibility and acceptability of this approach; and v) to describe iterative adaptation of implementation processes based on participant feedback.

METHODS

Participating services were 15 non-Aboriginal AoD services in New South Wales, Australia. Implementation records were used to assess the implementation fidelity of the project. Structured interviews with chief executive officers or senior management were conducted, and interview data were thematically analysed to identify project acceptability, and the key enablers of, and barriers to, project implementation. Quantitative descriptive analyses were performed on the post-implementation workshop survey data, and responses to the free text questions were thematically analysed.

RESULTS

A high level of implementation fidelity was achieved. Key enablers to improving culturally responsive practice were the timing of the introduction of the five-step process, the active interest of staff across a range of seniority and the availability of resources and staff time to identify and implement activities. Key barriers included addressing the unique needs of a range of treatment sub-groups, difficulty adapting activities to different service delivery models, limited time to implement change in this evaluation (three months) and the varied skill level across staff. The project was rated as being highly acceptable and relevant to service CEOs/managers and direct service staff, with planned changes perceived to be achievable and important. Based on CEO/management feedback after the project was implemented at the initial services, several improvements to processes were made.

CONCLUSION

The operationalisation of the five-step process developed to improve cultural responsiveness was feasible and acceptable and may be readily applicable to improving the cultural responsiveness of a wide variety of health and human services.