Cultural Competence Training African Immigrants
Cultural competence can be described as the ability of understanding, communicating, and interacting efficiently with people across cultures (Schouler-Ocak et al., 2015). Cultural competence comprises the process of one’s being aware of their own view of the world based on their cultural practices and traditions as well as developing positive attitudes toward the differences in cultures of others (Allison et al., 2016). Cultural competence is an important aspect of healthcare because cultural practices directly impact health care practices (Venters et al., 2019). African immigrants often find themselves in situations of cultural dilemmas because of the differences in culture between their original areas of residence and their new ones (Price et al., 2015).
The main problem witnessed on the project site is the lack of cultural competence among health care providers regarding African immigrants. This problem negatively affects the health care experience of African immigrants (Purnell & Fenkl, 2019). Because of the gap in cultural competence, there is a huge disparity in the quality of health services received by the African immigrant population as compared to other population groups in the United States (Clough et al., 2013). Evidence points to the fact that the African immigrant population has a lower health score and patient outcomes as compared to other groups with less than 18% of those admitted showing improved results over the course of their recovery (World Health Organization, 2020).(click here for help)
Knowledge gaps existing in practice causing cultural incompetence needs to be addressed because it violated the health care sector’s goal of ensuring fairness and equality in the access to services regardless of ethnic or racial orientation (Allen et al., 2012). As the World Health Organization explains, the health care sector aims at ensuring that everyone can be as healthy as possible, including the African immigrants (World Health Organization, 2020). The lack of cultural competence among health care providers that leads to African immigrants having poor health experiences violates this goal. The solution put forth by this project is the development of a cultural training program for African immigrants. This program is aimed at equipping health care providers with the right knowledge and set of skills to address the health concerns of African immigrants. The development of a cultural competence program is important because it will help in the removal of sociocultural factors that negatively impact the health experiences of African immigrants (Omenka et al., 2020).
Background
The number of African immigrants entering and settling in the United States increases almost every year (Purnell & Fenkl, 2019). This is because African immigrants prefer moving to the United States in search of better living conditions, better employment opportunities, and better health care services (Seck, 2015). However, African immigrants have been brought up in entirely different societies with completely different cultural beliefs and practices (Allen et al., 2012).
The African immigrant group has unique health care needs and most of these needs are related to their cultural practices (Purnell & Fenkl, 2019). Purnell and Fenkl (2019) reported that health care providers are not devoted to finding methods of addressing these unique health care needs of African immigrants. Omenka et al. (2020) explained that the lack of cultural competence among health care providers is a crucial contributing factor to the poor health of African immigrants. Without cultural competence training, health care providers cannot effectively tackle the health care concerns of African immigrants (Kamya, 2017).
Problem Statement
The main problem faced at the project site is the lack of cultural competence training among health care providers, specifically regarding African immigrants. The facility is a primary care clinic in Garland, Texas that attends to various groups of people and the African immigrants group is one of them. However, the African immigrant group is different in terms of their health care needs since most of their medical needs are related to their culture (Asare & Sharma, 2012). The staff has not received formal training on addressing the needs of this population; therefore, they cannot deliver health services that address the cultural, social, and linguistic needs of the African immigrant group. This results in poor health conditions for African immigrants. There are several resources available that are not being used, and this project plans to address these gaps.
The Center for Disease Control and Prevention (CDC) reported that the failure of health care providers to administer effective health care services to African immigrants puts the group at an increased risk of getting sick (CDC, 2021). The CDC reported that this has been clear, especially during the COVID-19 period, as many African immigrants have suffered from and died of COVID-19 (CDC, 2021). The proposed solution is the development of a cultural competence training program for the health care providers. This program is aimed at enabling the health care providers to gain the knowledge and techniques they can employ to provide quality health care services to African immigrants.
PICOT Question
In healthcare workers caring for African Immigrant groups (P), how can an effective cultural competence training program (I) compared to no training program (C) be developed to improve the resource allocation and referrals for African Immigrants (O) in less than 4 weeks (T)?
Literature Review
Search Methods
The search strategy for this project included the use of databases, search terms, and keywords. The databases included MEDLINE (PubMed), Web of Science, Google Scholar, and CINAHL Complete. The keywords used were based on the PICO framework. The participants were “African immigrants”, “African incomers”, and “African in-migrants”. The intervention was “cultural competence”, “competence in cultures”, “cultural awareness”, “intercultural competence”, “culturally responsive”, “cultural literacy”, and “culturally informed”. The outcomes were “improved health care”, “better health care”, “enhanced health”, and “raised health care status”. Boolean operators were also used to combine search terms. The search terms were combined to broaden or narrow the search results. “OR” and “AND” were the Boolean operators used. The citation list was reviewed to identify any additional studies that were eligible for inclusion. This was to ensure that no relevant studies were excluded. There was focus on the breadth and specificity of the search.
Predetermined criteria for inclusion and exclusion had already been established and all the citations were reviewed against it. Various types of study designs were included, and these include systematic reviews, cross-sectional studies, and case reports and series. All included studies specifically addressed how cultural competence in the health care profession would be useful in improving the health outcomes of African immigrants or how deficiency of cultural competence among health care providers contributed to the poor health of African immigrants. The definition of cultural competency along with all its elements was based on the United States National Library of Medicine-National Institutes of Health (National Library of Medicine, 2019). The library defines cultural competency among health care providers as the ability to collaborate effectually with individuals from different cultures to improve their health care experience and outcomes (National Library of Medicine, 2019).
The studies included also specifically compared the cultural competency of health care providers to the health outcomes and experiences of African immigrants. All potential settings, such as hospitals, clinics, community settings, and others that were related to the studies, were included. The studies included specifically had their participants as African immigrants and no other group was substituted for the participants. Studies were exempted because of the following: (a) The study population was not only African immigrants, or there was no separate reporting of the results of African immigrants. (b) The study discussed African Americans instead of African immigrants. (c) The study did not have its core focus as cultural competence among health care providers in relation to African immigrants. (d) The intervention targeted the health care system or the health care providers instead of the patients. However, no studies were excluded based on participant age or sex, or article language.
Review Synthesis
Developing the themes was founded on analysis and examination of previous studies that were related to cultural competence issues among African immigrants. The main themes that emerged include effects of cultural incompetence, how language barriers affect cultural competence, and the impact of cultural competence training on health care workers. These themes are the main points of emphasis when developing a cultural competence program for African immigrants. Focusing on these themes will guarantee the success of the cultural competence program for African immigrants.
Review of Study Methods
Most of the literature items reviewed the qualitative literature review methods to supplement the facts in their studies. The qualitative literature review research was conducted in hospital and clinical settings by assessing redacted medical records. The facts gave insight into how cultural competence affected the quality of patient outcomes among the African immigrant population. The case study aimed at identifying the percentages of hospitals and clinics that acknowledge cultural sensitivity and inclusion through cultural competence training.
Literature Themes
Effects of Cultural Incompetence
The main issue observed in the research is the lack of cultural sensitivity and competence within the health care profession regarding African immigrants. This issue has a negative impact on the healthcare received by African immigrants. Because of the disparity in cultural competence, the health care providers cannot efficiently deliver health services that cater to the cultural, social, and linguistic needs of the African immigrant patients (Purnell & Fenkl, 2019). As a result, the African immigrant group is seen to have an overall health status score that is lower compared to other groups (Seck, 2015). As the World Health Organization defines, the health care sector has a goal of guaranteeing that everyone’s wellbeing is catered for as effective as possible, including African immigrants (World Health Organization, 2020). Health is determined by various social factors outside of the traditional healthcare setting (Purnell & Fenkl, 2019).
Some of these social determinants of health are housing quality, access to healthy foods, and education. Seck (2015) explained that African immigrants have unfavorable social determinants of health which contribute to their lack of quality healthcare. This leads to their poor health experiences because of the lack of understanding by health care workers regarding these social determinants of health. Lack of representation of African immigrants both in leadership and training is also responsible for the lack of cultural competence programs for African immigrants (Clough et al., 2013). Another reason for the lack of cultural incompetence regarding African immigrants is the fact that even most health care workers are White and without cultural training, it is hard for them to understand the needs of African immigrants (Seck, 2015). Even though the medical field is showing increased diversity, most people working in healthcare are not familiar with the culture of African immigrants, so they do not know how to handle this group (Purnell & Fenkl, 2019).
Cultural incompetence has had negative outcomes for African immigrant patients, such as serious health complications and even death. Clough et al. (2013) explained that, due to cultural incompetence, African immigrants are two to three times more likely to suffer from various health-related issues compared to other groups, like White people. The cultural incompetence of health care workers makes African immigrants, who are primarily Black, suffer severely and longer from easily preventable diseases. Seck (2015) reported that some of these negative outcomes are because of subconscious prejudices and implicit bias about the African immigrant group. Addressing cultural incompetence and its effects is the first step to the development of a successful cultural training program for African immigrants (Purnell & Fenkl, 2019).
Cultural Competence Training African Immigrants
Language Barriers and Cultural Competence
Language is an aspect of culture that affects the quality of treatment in African immigrant groups (Seck, 2015). Language barriers play an important role in miscommunication between patients and medical providers, which negatively affects the quality of healthcare services and patient satisfaction regarding the African immigrant group (Allison et al., 2016). Due to language barriers, health care professionals have an incomplete understanding of the situations of patients, poorly assess patients, prescribe treatment incompletely, or cause delayed treatment or misdiagnoses (Wamwayi & Murray, 2019). As a result of language barriers, African immigrants end up having decreased satisfaction with health care services, complications arising from medication, and a reduced level of understanding of their diagnosis even if they have access to healthcare (Venters et al., 2019).
All these elements lead to the reduction in the quality of health care experience of African immigrants. One way of overcoming the language barrier is through using technology to bridge the language gap between health care professionals and African immigrants (Venters et al., 2019). Health care professionals can make use of voice recognition technologies such as Google Assistant and Google Translate. These are technologies that allow for two-way interpretation and can help in transcribing and translating dictation such as a doctor’s instructions (Wamwayi & Murray, 2019). Another effective way of overcoming the language barrier is the use of online applications, such as Duolingo, which offer new ways of learning different languages. Health care professionals can use these applications which keep things simple and make learning streamlined and easier, to understand elements of the African immigrants’ language and enhance their communication (Wamwayi & Murray, 2019).
Another way of overcoming the language barrier is through the use of an interpreter. The medical facilities can have interpreters specifically for African immigrant groups to enhance communication (Venters et al., 2019). The interpreter can be available physically at the medical facility and if this is not possible, technology has made it easier for the use of an interpreter using virtual platforms such as Zoom, Google Meet, or Skype (Allison et al., 2016). All these techniques and technologies will help in breaking the language barrier and enhancing effective communication between African immigrants and healthcare professionals. In the long run, the quality of health care services in African immigrants will improve, hence enhancing their overall health care experience and satisfaction.
The Impact of Cultural Competence Training on Health Care Workers
Training programs and cultural competence among health care workers have social, health, and business benefits for health care organizations and African immigrants (Omenka et al., 2020). Cultural competence training programs would increase mutual respect and understanding between African immigrants and health care providers (Kamya, 2017). It would also ensure the inclusion of all community members and increased participation and involvement of African immigrants in health issues (Kamya, 2017). Being culturally competent would also enable health care workers to have improved patient data collection for African immigrants and reduce the health care disparities in the African immigrant population (Asare & Sharma, 2012).
Cultural competence training programs for health care workers would help in reducing medical errors, the number of treatments, and legal costs, which increase cost savings (Asare & Sharma, 2012). When healthcare workers undergo cultural competence training programs, they will incorporate diverse ideas, perspectives, and strategies when deciding about African immigrants. Barriers that slow the progress of the health care experience of African immigrants would also be decreased and the efficiency of these care services will be improved (Omenka et al., 2020). Cultural competence training would also help health care providers to reduce the literacy gap when handling African immigrants (Omenka et al., 2020).
Most African immigrants come from backgrounds of little or no education which makes it hard for them to gain literacy skills to overcome language barriers or to read and understand instructions and conversations with health care professionals (Omenka et al., 2020). Cultural competence training would provide health care professionals with techniques of dealing with African immigrants with low literacy and explain how to offer them the best care quality. Cultural competence training will also enable health care professionals to coordinate with traditional healers among African immigrants and incorporate culture-specific attitudes and values into health promotion activities for this group (Kamya, 2017).
National Guidelines
Various national guidelines provide standards for culturally and linguistically appropriate services in healthcare. These guidelines aim at making health care services more responsive to the individual needs of patients coming from various cultural backgrounds (U.S. Department of Health and Human Services, 2001). These guidelines include ensuring the provision of health care services in a manner that is compatible with patient cultural health beliefs, practices, and preferred language (U.S. Department of Health and Human Services, 2001). Health organizations are required to establish strategies of recruiting, keeping, and promoting organizational staff and leadership that represent demographic characteristics of the area of service (U.S. Department of Health and Human Services, 2001).
Health care organizations ensure that staff at all levels undergo education and training for culturally and linguistically appropriate delivery of service. Language help services inclusive of bilingual staff and interpreter services at no cost to the patients with limited English proficiency must be offered by health care organizations (U.S. Department of Health and Human Services, 2001). Patients should be informed of the right to receive language help services for their preferred languages. Easy-to-understand materials relating to patients should be made available by health care organizations and the development, implementation, and promotion of a written strategic plan outlining clear goals and policies for providing culturally and linguistically appropriate services must be in place (U.S. Department of Health and Human Services, 2001). Internal audits, patient satisfaction assessments, and outcome-based evaluations should be done on integrating culturally and linguistically related measures about the organization’s conduct. Health records should have slots for collecting the patient’s race, ethnicity, and language, and this should be integrated into the management information system of the organization management (U.S. Department of Health and Human Services, 2002).
An updated demographic cultural profile of the community should be maintained by the organization and collaborative, participatory partnerships with communities should be developed by the health care organizations regarding the designing and implementation of cultural and linguistic related activities (U.S. Department of Health and Human Services, 2002). Conflict and grievances resolution processes should be culturally and linguistically sensitive, also cross-cultural conflicts and complaints should be resolved appropriately by health care organizations (U.S. Department of Health and Human Services, 2002). Health organizations should make available to the public information about progress and successful innovations in implementing the culturally and linguistically appropriate services standards (U.S. Department of Health and Human Services, 2001).
Aims of the Quality Improvement Project
The quality improvement project is aimed at designing a cultural competence training program that will enable health care professionals to understand African immigrants’ expression of health needs. The project is aimed at breaking down barriers that get in the way of African immigrant patients receiving the care they need. It is also aimed at ensuring improved understanding between African immigrant patients and their health care providers. The project is aimed at structuring a cultural competence training program that will accommodate the growing diversity of the United States population demands regarding the African immigrant group and expanding the ability of health care professionals to address the needs of this group. Generally, this quality improvement project is aimed at developing a cultural competence training program that will train health care providers on how to incorporate different ideas, perspectives, and strategies as they make health decisions about African immigrants which would improve the overall health care experience of this group.
Cultural Competence Training African Immigrants
Objectives
The objectives of this project are:
- To create a cultural competence training program that will help in promoting cross-cultural awareness and competence skills needed for health care professionals to be culturally competent regarding African immigrants.
- To create an African Immigrant Cultural Competence Toolkit that will be used by care providers to assess and enhance cultural competence in the organization.
- To create a Resources Toolkit that will be given to African immigrant patients visiting the primary care clinic.
Conceptual Model: Madeleine Leininger’s Cultural Care Theory
The theoretical underpinning or conceptual framework for this project will be provided by Madeleine Leininger’s cultural care theory. Leininger’s theory focuses on the definition of what pertains to transcultural nursing and how nurses comprehend the beliefs and practices of diverse cultural groups (Leininger, 1988). This theory is the most appropriate for this DNP project since it aims at explaining how nurses can provide culturally congruent care through taking actions that are mainly designed to suit the individual’s, group’s, or institution’s cultural values, lifeways, and beliefs (Leininger, 1988). The goal of the cultural care theory is to enable improved health outcomes for individuals of different cultural backgrounds (Leininger, 1988).
Historical Development of the Theory
In the late 1950s, Madeleine Leininger envisioned how the world was increasingly becoming integrated, and human beings were interacting on a global scale (Leininger, 1988). Leininger decided that she would go beyond anthropology and emphasize groups of people from diverse parts of the world in expressing her thoughts from a nursing perspective (Leininger, 1988). Leininger had always believed that care is the most essential component of nursing, even before establishing the field of transcultural nursing (Leininger, 1988). Her study of the Gadsup people in Papua New Guinea in the early 1960s was the first transcultural nursing research, and she proceeded to establish the initial formal doctoral programs and courses in transcultural nursing in 1965 at the University of Colorado School of Nursing (Wehbe-Alamah, 2015). The first book to be published regarding Leininger’s cultural care theory was Nursing and Anthropology: Two Worlds to Blend, which was published in 1970 (Wehbe-Alamah, 2015). A third and an updated edition of Transcultural Nursing: Concepts, Theories, and Research Practices was authored by Leininger and McFarland in 2002 (Wehbe-Alamah, 2015).
Through her discussions of the theory, Leininger continued to elaborate on the significant features of culture care diversity within the context of transcultural nursing. Leininger established the Transcultural Nursing Society in 1974, aimed at serving nurses worldwide through teaching them how to reinforce the quality of culturally competent care aimed at improving the health and well-being of people worldwide (Wehbe-Alamah, 2015). Over the years, Leininger’s theory has been used in training nurses how to provide culturally specific care, which is aimed at improving the health and well-being of people as well as helping them to face unfavorable human conditions, illnesses, or death, in culturally meaningful ways (Wehbe-Alamah, 2015).
The Major Tenets
In developing the major components of the theory, several factors were taken into account by Leininger. These factors were the elements that guided the development of the major tenets of the cultural care theory (Leininger, 1988). Leininger explained that wellness and illness are molded by various factors, inclusive of perception and coping skills (Leininger, 1988). Cultural competence is an essential component of nursing, and culture affects diverse segments of human life including illness, health, and the search for relief from distress or diseases (Leininger, 1988). Cultural and religious knowledge is a significant aspect of healthcare, and the health concepts that cultural groups hold may impact how they seek modern medical care (Leininger, 1988).
Before discussing the major tenets of the theory, it is important to understand the meaning of certain terms related to the theory as defined by Leininger. Care is assisting others in an effort of improving their human conditions of concern or facing death (Wehbe-Alamah, 2015). Caring is the act of providing care (Wehbe-Alamah, 2015). Culture is the learned, shared, and transmitted norms, beliefs, ways of life, and values of a specific group that guide their decision or lifestyle (Wehbe-Alamah, 2015). Cultural care refers to various elements of culture which are responsible for influencing and enabling people to enhance their human conditions or to face illnesses or death (Wehbe-Alamah, 2015). Cultural care diversity describes the differences in meanings, values, or accepted modes of care between or within diverse groups of people, while cultural care universality describes the common and similar meanings of care in the cultures (Wehbe-Alamah, 2015).
Theory Application to the DNP Project
Generally, the major tenets of the cultural care theory were used in guiding the research and documenting how health care providers can develop an understanding, appreciation, and respect for the diversity and individuality of African immigrant patients’ values, beliefs, culture, and spirituality, in the context of illnesses, causes of illnesses, treatment, and outcomes (Wehbe-Alamah, 2015). They will be used in the project to research and document how nurses can develop care that fits the values, beliefs, and lifestyles of African immigrants, which is based on the patients themselves rather than on predetermined criteria (Wehbe-Alamah, 2015). The major tenets of the theory were also used to identify how nurses can bridge the cultural gap to achieve meaningful and supportive care for African immigrant patients and their families (Wehbe-Alamah, 2015). Based on the concepts of the theory, the project found out how nurses can self-examine their backgrounds and recognize biases prejudices, and assumptions about the African immigrant group.
Cultural care preservation or maintenance was used to identify how the health care providers can develop assistive and facilitative professional actions and decisions that can aid the African immigrants to preserve or retain relevant care values that will help them in maintaining their well-being, recovering from illnesses, or facing handicaps or death (Wehbe-Alamah, 2015).
Cultural care accommodation or negotiation was used in the project to guide the identification and documentation of the assistive, supportive, enabling, or facilitative professional decisions or actions that may help the health care providers in training African immigrants to adapt culturally, for improved and satisfactory health outcomes (Leininger, 1988).
Cultural care repositioning or restructuring was used in the identification and documentation of techniques that the health care providers can use to help African immigrants in reordering, changing, or greatly modifying their lifestyles for newer, better, and different health care patterns while respecting the African immigrants’ cultural values and beliefs (Leininger, 1988).
Implementation Model: The Plan-Do-Study-Act Model
Much health care research and many reports recommend the Plan-Do-Study-Act model as an implementation model for quality improvement projects (Donnelly & Kirk, 2015). The model is made up of four repeating phrases that are cyclical in nature. These are Plan, Do, Study, and Act (Donnelly & Kirk, 2015). Plan is about the effort and background work of proposing change (Donnelly & Kirk, 2015). Do is about implementing the proposed change (Donnelly & Kirk, 2015). Study is about conducting analysis and evaluation of the outcomes of the proposed change (Donnelly & Kirk, 2015). Act is about revisiting and redesigning the previously planned change to take into account the lessons which have been obtained at the Do and Study phases (Donnelly & Kirk, 2015).
The PDSA model was selected because it will be effective in giving rise to changes in a short period and will likely facilitate continuous quality improvement (Donnelly & Kirk, 2015). This model will be used to test the proposed change during the implementation process (Donnelly & Kirk, 2015). It was used to the test the change through planning, trying, observing results, and taking action on the lessons learnt (Donnelly & Kirk, 2015). The model was used during the course of the project to assess how the project implementation could be done in a manner that would lead to the desired improvement (Donnelly & Kirk, 2015). The model was also used to evaluate how much improvement could be expected from the change and how best the proposed change could work in the real environment of interest (Donnelly & Kirk, 2015).
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