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.

Beliefs and Intentions of Anesthesia Physicians Toward Providing Culturally Competent Care to Transgender Patients

Purpose

Anesthesiologists have limited relationships with their patients before delivering care and have little time for patient interactions. Yet, they should possess the knowledge and skills to treat all patients in an equitable, culturally competent manner, including transgender patients. The study's purpose was to determine behavioral factors influencing culturally competent care by anesthesia physicians with transgender patients.

Methods

A two-phase design was utilized in 2020 to examine the attitudes, subjective norms, and perceived behavioral control of anesthesia physicians, both in training and practicing independently. Phase 1 allowed exploration of themes related to facilitators and barriers of the provision of culturally competent care to transgender patients. Phase 2 involved the creation and deployment of a 51-question survey informed by phase 1 to 100 anesthesia physicians at a single academic medical center in the southeastern United States.

Results

Thematic analysis was performed on results from the phase 1 elicitation survey, which informed the creation of the survey for phase 2. One hundred phase 2 surveys were distributed, with a 70% response rate. Analyses were conducted to determine the largest influence of intent to interact with transgender patients in a culturally competent manner, as well as to establish the reliability of the tool.

Conclusion

Attitude followed by subjective norms were positive influencers of intent, while lack of knowledge was a negative influencer. Strengthening attitudes and subjective norms, while implementing programs to increase knowledge, competence, and humility, would be goals for future studies and actions toward improving healthcare of transgender individuals.

Does cultural competence training for health professionals impact culturally and linguistically diverse patient outcomes? A systematic review of the literature

OBJECTIVE

To assess the impact of cultural competence training for health professionals on patient outcomes.

METHOD

A systematic review of cultural competence training interventions for healthcare workers including papers published January 2010 to January 2021, identified through MEDLINE, CINAHL, ERIC and APA PsychINFO. Health conditions were not specified, however, only studies reporting patient outcomes were included. Training frameworks and delivery, measures of health professional cultural competence, and patient outcomes were reviewed.

RESULTS

Of 7879 unique studies identified, five met inclusion criteria including two randomised control trials, two mixed method and one multi-method pre/post study. Professionals reported the training was beneficial, and some improvements in patient perceptions of health providers' cultural competence were found. However, patient health outcomes did not improve significantly in any study.

CONCLUSION

Cultural competence training is promoted to improve outcomes of patients from culturally diverse backgrounds; however, few studies assess outcomes when examining training impact. Inconsistencies in theoretical frameworks and training makes it difficult to assess the efficacy of training on patient outcomes.

RESULTS

Of 7879 unique studies identified, five met inclusion criteria including two randomised control trials, two mixed method and one multi-method pre/post study. Professionals reported the training was beneficial, and some improvements in patient perceptions of health providers' cultural competence were found. However, patient health outcomes did not improve significantly in any study.

CONCLUSION

Cultural competence training is promoted to improve outcomes of patients from culturally diverse backgrounds; however, few studies assess outcomes when examining training impact. Inconsistencies in theoretical frameworks and training makes it difficult to assess the efficacy of training on patient outcomes.

PRACTICE IMPLICATIONS

To ascertain the benefits of health professional cultural competence training on patient outcomes, research needs to address the issues of definition, theoretical frameworks and implementation approaches to training.

Translation to practice of cultural safety education in nursing and midwifery: A realist review

OBJECTIVES

Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives.

DESIGN

A systematic review following realist review publication standards.

DATA SOURCES

Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included.

REVIEW METHODS

A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed.

RESULTS

Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety.

CONCLUSION

Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety.

E-learning cultural competence for public health workers: A feasibility and pilot study

OBJECTIVE

To describe the development, feasibility, and preliminary efficacy of a seven-module e-learning for enhancing cultural competence of public health workers.

DESIGN

The study was based on the framework of the new Medical Research Council; a mixed methods design was used.

SAMPLE

A four-week pilot cluster-randomized controlled trial was conducted with 39 public health workers and 74 migrants in South Korea. Feasibility and preliminary efficacy were assessed according to initiation, retention, adherence, usability, acceptability, individual and organizational cultural competence, and migrant trust and satisfaction. Quantitative data were collected at baseline, 4 weeks, and 12 weeks. Focus group interviews were conducted with eight public health workers at 12 weeks.

RESULTS

Initiation, retention, and adherence rates were high. Participants agreed on acceptability, but exhibited mixed results on usability. Participants were satisfied with "well-structured content," "authentic case stories and videos," "increased interest in migrant care," and "opportunity for self-reflection." However, "flawless and trouble-free system," "screen design for easy navigation," "instructor's expertise," and "more situational cases and videos" were desired. Statistically significant differences were observed for individual cultural competence, migrant trust, and satisfaction.

CONCLUSION

Generally, the intervention seems feasible and has preliminary efficacy, yet usability improvement is necessary for full-scale randomized controlled trials.