Student PaperCultural Competency in Baccalaureate Nursing .docx

1. Student Paper Cultural Competency in Baccalaureate Nursing Education: A Conceptual Analysis Deborah Byrne, RN, MSN, La Salle University, Villanova University Abstract The ability to deliver culturally competent nursing care is an expected competency of undergraduate nursing education programs. The American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) have developed toolkits that provide nurse educators with models and teaching strategies to facilitate student learning in cultural competency. However, the concept of cultural competency varies as does the best method for integrating and evaluating cultural competency in undergraduate nursing curriculum. With the growing number of diverse clients, it is imperative that nursing students deliver culturally competent care. This article explores the current view of the concept of cultural competency from the standpoint of nursing education and the methods used to evaluate cultural competency in undergraduate nursing education programs. Keywords: cultural competency, simulation, undergraduate nursing education, cultural

2. awareness, cultural humility Background and Significance Health care is increasingly complex, diverse, and growing in the United States. The United States Census Bureau (2009) predicts that the U.S. population of non-European Caucasians will be equivalent to Caucasian Americans by 2050. According to Healthy People 2020, there are significant health disparities among minority groups. A fundamental goal of Healthy People 2020 is to eliminate health disparities for all groups (U.S. Department of Health and Human Services [USDHHS]). The need for culturally competent health care is essential to reduce health disparities and ensure positive health outcomes. The National League for Nursing (NLN) and American Association of Colleges of Nursing (AACN) include culturally appropriate care in their accreditation standards and have developed toolkits for nurse educators to assist with incorporating cultural competency in undergraduate nursing curricula (NLN, 2009; AACN, 2008). There is, however, no consensus in the literature regarding effective ways to teach cultural competency to undergraduate baccalaureate nursing students. Most nursing programs in the United States include the concept and skill of cultural competency as a program outcome and attempt to integrate cultural competency into their curricula. Attempts at integration have been reported as inadequate in developing culturally competent nurses (Brennan

3. & Cotter, 2008). As the diversity of the population increases, so too must the cultural competency of nurses in practice. It is imperative that undergraduate nursing students develop cultural competency knowledge, awareness, and skills while experiencing didactic courses, clinical, and simulation experiences. Culture is integral to how people view death, birth, illness, and health (Delgado et al., 2013). For individuals to seek health care, they need to feel safe and secure with their providers. Health care providers need to understand client culture and deliver culturally sensitive and competent care to achieve the best patient outcomes. For health care providers to deliver culturally competent care, they must be aware of their own biases about the culture they are serving to prevent poor patient outcomes (Campinha- Bacote, 2007). In nursing education, interaction with culturally diverse clients, families, and communities is essential for student development of cultural competence (Campinha-Bacote, 2003). Integration of cultural nursing skills, knowledge, and attitudes will produce the best outcomes. Cultural knowledge is the basis of cultural competence, but it is the application of knowledge in clinical, simulation, and immersion experiences that will develop culturally competent nurses (Campinha-Bacote, 2003). The concept analysis model by Walker and Avant (1988) clarifies understanding of the various attributes of the term cultural competence. This method provides a systematic process by which a concept can be

4. clarified further by identifying the attributes, antecedents, and consequences of the concept. In order to deliver quality care to a diverse population, it is imperative that nurse faculty incorporate cultural competency skills in undergraduate nursing programs. Background of Concept Culture is defined as a pattern of traditions, beliefs, values, norms, symbols, and meanings among a group of people (Campinha-Bacote, 2007). Competency refers to performing, ‘‘in a manner that is satisfactory to the demand of the situation, to interact effectively with the environment’’ (Thomas, 1993, p. 429). The definition of the concept cultural competence varies, but a commonly used definition of cultural competency is ‘‘the ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community)’’ (Campinha- Bacote, 2003, p. 5). Cultural competency is embedded in various fields of study, including social and behavioral sciences, law, and nursing. All three disciplines profess the same definition of culture but apply the term cultural competency based on relevance to their respective fields (Singer, 2012; Gould & Martindale, 2013; Leininger & McFarland, 2002). Numerous definitions of culture are based in the social and behavioral sciences; however, there are four basic concepts that the social and

5. behavioral sciences use in their definitions (Singer, 2012). The first concept describes culture as learned through the process of socialization from birth. This concept is incorporated in many psychological interpretations of culture. The second concept is that all members of the same group share the same cultural values and beliefs. This concept is broad and does not include subgroups of larger cultural groups. For example, in the Jewish faith there are multiple subgroups with shared values and beliefs; each has some variation from the larger group (IJS Israel & Judaism Studies, n.d.). The third concept of culture is the adaptability of a cultural group to social and environmental conditions, and the fourth concept states that culture is an ever- changing process (Singer, 2012). The third and fourth concepts appear crucial to delivering culturally competent care. Each generation presents with new circumstances that affect the care they receive. An older Hispanic client may believe in folklore to treat illnesses, but a younger Hispanic client may prefer technology and modern medicine. In the legal field, cultural competency and sensitivity are increasingly important when performing child custody evaluations (Gould & Martindale, 2013). The authors define culture as a ‘‘pattern of traditions, beliefs, values, norms, symbols, and meanings’’ (Gould & Martindale, 2013, p. 3.). More than half the U.S. population are from immigrant families, and many of the families are experiencing separation or divorce. In the field of matrimonial law, it is understood that cultural competence has three broad dimensions.

6. Attorneys and child evaluators need to have an awareness of their own beliefs toward different cultures and an awareness of the expectations of their clients. They also need to utilize culturally appropriate assessment tools when conducting evaluations with culturally diverse people. The International Journal for Human Caring114 attorneys and evaluators are aware of the importance of delivering culturally competent assessments to properly arrange the best custody arrangement for children. Gould and Martindale (2013) noted the lack of literature providing guidance on how to address cultural issues in child custody assessments. There are several components to integrating cultural competency into a child custody evaluation: interviews, psychological testing, direct parent-child observations, record review, expert opinions, cultural relativism, and responsible opinion formulation. Cultural sensitivity and awareness must be integrated into all of these components. The evaluator should retain professional interpreters when necessary when interviewing a parent or child. The evaluator should also be cognizant of the family’s beliefs, customs, and attitudes when evaluating direct parent-children observations, psychological testing, and record review. Experts engaged in the case should also be familiar with the cultural background of the child and parents.

7. In nursing, culture has been defined as by Leininger and McFarland (2002) as, ‘‘the learned and shared beliefs, values, and lifeways of a designated or particular group that are generally transmitted intergenerationally and influence one’s thinking and action modes’’ (p. 9). This definition has been central in transcultural nursing and allows for a holistic approach to delivering culturally congruent nursing care. Both definitions and their concepts guide nurses delivering care to diverse groups of clients. There have been numerous studies regarding cultural competency in nursing (Jeffreys & Dogan, 2013; Jeffreys & Dogan, 2012; Kardong-Edgren et al., 2010; Kardong-Edgren & Campinha- Bacote, 2008; Krainovich-Miller et al., 2008; Noble, Nuszen, Rom, & Noble, 2014; Caffrey, Neander, Markle, & Stewart, 2005; Reyes, Hadley, & Davenport, 2013). In nine studies, students measured the cultural awareness level based on self-perception reports. These studies all had cultural competency as a program outcome in a nursing curriculum and tested various teaching methods and interventions to increase cultural competency. The studies also showed a positive outcome when cultural competency was integrated throughout the curriculum. The application of cultural competence in social and behavioral sciences, law, and nursing is closely related and shares similar concepts. In social and behavioral science, law, and nursing, cultural competence is needed to ensure positive and fair outcomes. In social and behavioral

8. sciences, cultural competency is implemented in many fields including psychology. A psychologist needs to be culturally competent to deliver best practices. If psychologists are not aware of client culture, they can cause undue harm. In law, a child custody evaluator needs to deliver culturally competent care in order to ensure the optimal custody arrangement is made for the child. In nursing, a nurse needs to practice culturally congruent care in order to ensure positive health outcomes and reduce health disparities. Significance of the Concept for Nursing There are several cultural competency theories and models in the literature related to nursing. Campinha-Bacote’s Cultural Competence Model (2007) has been widely documented in global nursing research studies. Her model has five interdependent constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Campinha-Bacote (2007) contends that as individuals move toward cultural competence, they must experience all of these constructs. A pilot study by Delgado et al. (2013) evaluated the effectiveness of implementing a 1-hour class on cultural competence at a large Midwestern medical center. In this study, the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals–Revised (IAPCC-R) was administered to participants to assess baseline cultural competence prior to an intervention, and then another assessment was given at 3 and 6 months post training. This

9. instrument was developed by Campinha-Bacote based on her cultural competency conceptual model and integrates five cultural competency constructs. The intervention was a 1-hour class to promote cultural competency and show the impact of cultural competency on quality of care. The intervention included participants examining their own ethnic heritage, issues related to health care, and implications for health care providers. Participants included registered nurses, patient care assistants, and unit secretaries. Results showed a statistically significant difference (p¼ .02) in cultural awareness over time (Delgado et al., 2013). Kardong-Edgren et al. (2010) evaluated cultural competency in graduating baccalaureate nursing students. The investigators evaluated six nursing program outcomes with different methodologies for teaching cultural competence. They used the IAPCC-R to measure cultural competency in graduating nursing students. All the participating nursing programs integrated Campinha-Bacote’s cultural care model into the nursing curriculum except for Program 1, which did not integrate any specific cultural care model in the curriculum. The results showed an increase in all five constructs by implementing this conceptual model in the undergraduate nursing programs (Kardong-Edgren et al., 2010). Jeffreys (2009) also developed a conceptual model, the Cultural Competency and Confidence model (CCC). In a study by Jeffreys and Dogan (2013), an instrument was administered to evaluate culturally specific care provided for a diverse population. The Clinical Cultural

10. Competency Evaluation Tool (CCCET) was based on the CCC model. In the model, Jeffreys defines cultural competence as a ‘‘multi-dimensional learning process that integrates transcultural skills in all three education learning domains (cognitive, practical, and affective), involves transcultural self-efficacy (TSE), and aims to achieve culturally congruent care’’ (Jeffreys & Dogan, 2013, p. 189). The CCCET has three subcategories including provision of cultural-specific care, cultural assessment, and cultural sensitivity. The instrument was administered to second-semester students at the end of their medical-surgical course. The findings in this study suggest that educational interventions in the clinical setting move nursing students from a passive role to an active role (Jeffreys & Dogan, 2013). In all three studies, cultural competency conceptual models framed the research. Some authors agree that cultural competency models are needed to guide teaching cultural competence; however, disagreements center on the best way to integrate the models into the curriculum. The literature supports the proposition that delivering culturally congruent care can decrease health disparities. Attributes of the Concept There are several characteristics of the concept of cultural competence in the literature: (a) cultural awareness, (b) cultural knowledge, (c) cultural skill, (d) cultural encounters, (e) cultural desire, (f) cultural sensitivity, and (g) cultural humility. Cultural awareness is the self-evaluation

11. of our personal biases and prejudices about individuals from a culture different than our own and requires individuals to explore their own cultural heritage (Campinha-Bacote, 2007). Since biases are ingrained in the mind and not easily recognized, cultural competence is difficult to accomplish. Van Ryn and Burke (2000) investigated 193 physician-patient interactions. Findings revealed that physicians rated African- American patients as less intelligent, less educated, less likely to comply with medical advice, and more likely to abuse drugs (van Ryn & Burke, 2000). Cultural knowledge is the process of acquiring a strong educational base about culturally diverse groups. This construct includes the common knowledge of health-related beliefs, disease incidence and prevalence, treatment efficacy, and diagnostic clarity (Campinha-Bacote, 2007). For example, the genetic disease Tay-Sachs is more prevalent in the Jewish-American community (National Tay-Sachs & Allied Diseases, n.d.). Nurses who practice culturally competent care possess the knowledge and skills to identify at- risk Jewish patients for genetic screening. Cultural skill is the ability to perform culturally competent care, including collecting relevant 2016, Vol. 20, No. 2 115 Student Paper cultural data and performing a culturally sensitive

12. health assessment. Several assessment instruments are available on cultural assessment, which health care providers can employ to ensure accurate assessment is obtained from an individual, group, or community. Cultural encounters are interactions with patients from diverse backgrounds (Campinha- Bacote, 2007). The purpose of cultural encounters is to improve verbal and nonverbal communication with different cultures. The exposure to diverse cultures will assist in obtaining effective communication skills and increasing awareness of other cultures. Additionally, cultural desire is the motivation of an individual to participate in the process of becoming culturally competent (Campinha- Bacote, 2007). The motivation of the individual must be genuine for the process to be successful. To achieve this construct, the individual has to possess the characteristics of caring, sacrifice, commitment to social justice, and humility. The concept of caring is fundamental to the construct of cultural desire and is based on a humanistic view of caring (Campinha-Bacote, 2007). Cultural sensitivity is the acceptance and understanding of cultural differences. The implementation of cultural sensitivity produces better health outcomes because the practitioner is sensitive to the beliefs, values, and attitudes of a different culture (Burnard, 2005). For example, a culturally sensitive, female, registered nurse would possess the cultural knowledge to refrain from shaking hands with a male Muslim patient. Cultural humility is the ability of individuals to be

13. humble and think less of themselves. This concept translates into the realization that one’s own culture is not paramount (Schuessler, Wilder, & Byrd, 2012). Schuessler et al. (2012) used reflective journaling to evaluate undergraduate nursing students’ level of cultural humility. Results showed novice nursing students began to understand cultural humility by interacting with patients from different cultures. Students stated they began to be aware of how other cultures interacted with each other and with health care practitioners. Model Case Kate, a community health registered nurse, cares for Mary, an elderly client who lives alone in an inner city housing complex. Mary is an 85- year-old African-American woman with several chronic conditions including diabetes, hypertension, peripheral vascular disease (PVD), obesity, and transient ischemic attacks. Mary has been hospitalized several times in the past year for exacerbation of her chronic conditions. Upon arriving at Mary’s home, Kate notices the unhealthy food on Mary’s kitchen counter, lack of assistive devices, and swelling in Mary’s lower extremities. Kate has been working in this community for several years and is aware of the beliefs, values, behaviors, and past experiences of this African- American community. As a result, Kate understands the importance and value of religion in this community. The church in this community serves not only as a place of worship but also as

14. a community of support. Therefore, Kate has developed a relationship with the church leaders in this community. She also has an open line of communication with various social programs in this community. Upon assessing Mary, Kate is aware of Mary’s mistrust of health care providers based on past encounters. In addition, Mary has a reluctance to ask for help and likes to eat good ‘‘home cooking.’’ Mary is on a fixed income and believes she cannot afford to eat healthier. Mary has missed several doctor’s appointments owing to her lack of transportation. Kate acknowledged and was sensitive to Mary’s mistrust of health care professionals and worked to develop a trust-based relationship with Mary. Kate developed a comprehensive care plan, in collaboration with Mary, to reduce her frequent hospital admissions. Kate was sensitive to the importance of religion to Mary and contacted the minister of her church to see if they had any programs to assist seniors with running errands and transportation to medical appointments. In addition, Kate contacted a local senior group to see if they had social gatherings to help combat Mary’s loneliness. Kate found a food cooperative (co-op) that was not far from Mary’s apartment. Within 6 months of implementing this comprehensive plan of care, Mary did not have any hospital admissions, started to enjoy outings with people from the senior center, and received rides from church volunteers to visit her

15. physicians. Mary started going with a friend to the food co-op to begin eating healthier. Mary expressed feeling respect and understanding from Kate, and they continue to work together. Overall, Mary’s health has improved, and she feels she is a participant in her health. This model case demonstrates positive health outcomes when culturally competent care is delivered. This client represents an underserved minority group that faces health disparities at an alarming rate (USDHHS, 2010). The registered nurse is aware of the culture of the group that she serves and has developed the knowledge, skills, and attitude needed to deliver culturally competent care. The registered nurse also demonstrated a cultural desire and sensitivity to customs and beliefs held by the cultural group. The client responded positively to the nurse’s recommendations because she said she felt the nurse listened and respected her beliefs and feelings. Borderline Case Joseph is a registered nurse with 20 years experience caring for a largely Hispanic population. Through his work experience, Joseph has learned a few key Spanish terms in order to communicate with his patients. He feels confident interacting with patients in the Hispanic community. He is aware that many Hispanic patients use complementary medicine and implement healing traditions different from American culture. Joseph is caring for an elderly Hispanic woman named Maria who presents with

16. shortness of breath. Joseph uses his limited Spanish to communicate with Maria and her family. The family speaks limited English, but through hand gestures and some Spanish, Joseph asks Maria and her family if they take any over-the-counter herbal supplements or practice any healing rituals. About 4 hours into his shift, Joseph notices Maria’s shortness of breath is increasing despite breathing treatments and administration of steroids. The attending physician contacts Maria’s family physician and learns she has chronic obstructive pulmonary disease (COPD) and just finished a course of steroids. The dose of steroids Maria is currently receiving is too low to explain increased shortness of breath. Maria’s medications are adjusted and within 2 hours her shortness of breath decreased. Upon reviewing this case with his nurse manager, Joseph realized that although he showed awareness toward this patient from a different culture, he still did not have the cultural knowledge and skill to call for a professional interpreter. Joseph and the nurse manager developed an in-service program to educate the staff on the benefits of using a professional interpreter. This borderline case demonstrates the need to develop cultural competency skills continually. The nurse in this case had the self-efficacy desire, awareness, and knowledge to perform a culturally sensitive assessment on his patient but did not have the knowledge or skill to utilize a

17. professional interpreter. Not using an interpreter could have led to further harm of the patient. Contrary Case Lisa, a registered nurse, works on a busy telemetry floor at a small community hospital with a predominantly white population. She has had little experience with people from a different culture and does not think it is an important part of her job. Lisa received a report on a 22-year-old, African-American male patient named Anthony, with a diagnosis of exacerbation of sickle cell anemia. Lisa notes in her report that the patient is requesting a stronger dose of hydromorphone for increased pain. Lisa comments to the reporting nurse, ‘‘Of course, I get the drug addict. This is going to be a long shift.’’ Lisa enters Anthony’s International Journal for Human Caring116 Student Paper room and proceeds to perform a brief assessment. Anthony appears in distress and rates his pain as a 10 out of 10 on the pain scale. He begs the nurse for more pain medication. Lisa calls the attending physician and states, ‘‘The patient, Anthony, in room 383, is complaining of pain. He is getting plenty of pain medication and is just drug seeking. I recommend we discontinue his narcotics and give him ibuprofen. He will want to go home quicker if we stop feeding his addiction.’’ The physician discontinues the

18. hydromorphone, and Lisa gives Anthony ibuprofen with a lecture about abusing narcotics. Anthony remains in pain for the rest of Lisa’s shift. Upon discharge, Anthony feels dissatisfied with the care he received, and he develops a distrust of physicians and nurses. This case demonstrates a complete lack of cultural competency of the nurse and physician. The nurse did not demonstrate cultural knowledge, skills, awareness, desire, sensitivity, or humility. The nurse works with a predominantly white population and lacked knowledge of sickle cell anemia. However, if Lisa had the cultural awareness, desire, and humility, she would have educated herself about the disease. She would have been culturally sensitive to the pain caused by sickle cell anemia. She did not have the cultural awareness of her own biases and stereotypes of cultural humility to know that each culture is different, which resulted in harm to the patient. Assumptions for the Concept There are several assumptions about the cultural competency model: � Cultural competence is a life-long process. � Cultural competence is a fundamental component in delivering culturally congruent care. � Cultural awareness is essential for cultural competence to occur.

19. � Rendering culturally competent care will reduce health disparities. These assumptions are based on experiential knowledge and the literature (Campinha-Bacote, 2007; Jeffreys & Dogan, 2012). Antecedents and Consequences Prior to the development of cultural competence, certain behaviors, attitudes, and ideas must occur. The following are cultural competency antecedents based on the literature: � Self-awareness: Practitioners must be aware of their own biases, stereotypes, and attitudes toward other cultures. They must also be aware of their own cultural heritage. � Encounters: Practitioners’ past cultural encounters can affect their interactions with other cultures. � Attitude: Practitioners’ attitudes must be open, flexible, and sensitive to others. � Communication: Practitioners’ level of communication skills must be high in order to effectively interact with other cultures. � Knowledge: Practitioners should have a basic knowledge of the prominent culture in which they are delivering care. � Self-efficacy: Practitioners should have the confidence to deliver culturally competent

20. care. When cultural competence has been demonstrated, the consequences of those behaviors and events result in improved health outcomes. Behaviors represent the actions of healthcare providers. If those actions or behaviors are culturally competent, improved health outcomes may follow for the patient. Events are the actual interactions between healthcare provider and patient. The following are cultural competency consequences based on the literature: � Culturally competent registered nurses deliver culturally congruent care to all patients. � Clients become active participants in their health care. � Clients have decreased fear of the health care system and health care practitioners. � Clients have increased satisfaction with health care services. Figure 1 A Cultural Competency Conceptual Model 2016, Vol. 20, No. 2 117 Student Paper

21. � Decreased health disparities are reported. � Better health outcomes result by increasing health promotion and preventive care. � Nurse educators support culturally competent practices in undergraduate nursing students. � Health status of ethnic, racial, and low- income groups improves. Conceptual Model The conceptual model in Figure 1 illustrates the cyclical direction of attaining cultural competency. The antecedents need to exist in order for the nurse to attain the characteristics needed to reach cultural competency. If cultural competency is reached, the consequences demonstrate a benefit to the individual, community, and nation. Discussion of Concept The concept of cultural competency is integral to giving the best care possible to individuals, families, and communities. It is imperative that nursing students receive cultural competency education in the classroom, and in clinical and simulation settings. The literature establishes the effectiveness of cultural competency education in the classroom and study abroad. However, study abroad and immersion experiences are expensive and only available to a select few. The research conducted on simulation (Jeffries, 2009; Miller,

22. 2010; Shin, Park, & Kim, 2015) demonstrates the effectiveness of using simulation to bridge the gap between the classroom and practice. The literature illustrates the effectiveness of students engaging with patients of a different culture in study abroad or immersion experiences. Reeves and Fogg (2006) gathered data on the perceptions of undergraduate nursing students regarding their life experiences with cultural diversity. The authors noted several themes during the analysis of the interviews. One unexpected theme emerged—defining life experience—and is the only one discussed in this study. The authors elaborated on this theme with direct quotes from the participants. The quotes from the students highlighted the lack of cultural exposure in the nursing curriculum and how various exposures outside of nursing helped them become culturally aware. Participants in the study reported unique cultural experiences that shaped how they viewed different cultures. One participant spoke about attending camp as a counselor where the majority of the staff were lesbians. The participant had never been exposed to a homosexual culture and had a difficult time with adjustment. At the end of the summer, however, she acknowledged it was an exceptional educational experience and had changed her views. The experience reinforced the need for cultural awareness and exposure during nursing education programs (Reeves & Fogg, 2006). Reeves and Fogg (2006) illustrated the importance of exposing undergraduate baccalaureate students to other cultures.

23. Exposures help to cultivate cultural awareness in nursing students so that they can continue to develop cultural competency knowledge and skills. Specific cultural skills emphasized in the literature are culturally appropriate assessment tools, diagnosis, planning, interventions, and evaluation methods. Cultural competency affects how patients interact with nurses in the hospital setting. With the implementation of the Patient Protection and Affordable Care Act (2010) and an aging population, health care is moving from the acute care setting to the community. In public and community health, culturally appropriate attitudes, skills, knowledge, awareness, humility, and sensitivity are essential to delivering culturally congruent care. In ethnic minority communities, there are many barriers to attaining quality health care, including language barriers, distrust of the medical profession, immigration status, and lack of preventive care and health promotion. By delivering culturally congruent care in the community setting, health disparities and health outcomes of a community can be improved. Conclusion The delivery of culturally competent care is a benefit to society. The need for culturally competent care is evident in the literature without a clear consensus as to best methods. With a growing, diverse population, health disparities will increase unless health care professionals educate students and clinicians to provide culturally competent care. A review of nursing education literature reveals various methods to integrating cultural competency in the curriculum. In order to

24. meet the needs of the population, consensus is needed to ensure all nursing students are given the same cultural competency knowledge and application in practice. References American Association of College of Nursing. (2008). Tool Kit for resources for cultural competent education for baccalaureate nurses. Retrieved from http://www.aacn.nche. edu/education-resources/toolkit.pdf. Accessed: November, 2014. Brennan, A., & Cotter, V. (2005). Student perceptions of cultural competence content in the curriculum. Journal of Professional Nursing, 24(3), 155–160. Burnard, P. (2005). Cultural sensitivity in community nursing. Journal of Community Nursing, 19(10), 4–8. Caffrey, R. A., Neander, W., Markle, D., & Stewart, B. (2005). Improving the cultural competence of nursing students: Results of integrating cultural content in the curriculum and an international immersion experience. Journal of Nursing Education, 44, 234–240. Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services: A culturally competent model of care (4th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates.

25. Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services: The journey continues (5th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates. Delgado, D. A., Ness, S., Ferguson, K., Engstrom, P. L., Gannon, T. M., & Gillett, C. (2013). Cultural competence training for clinical staff: Measuring the effect of a one- hour class on cultural competence. Journal of Transcultural Nursing, 24, 204–213. Gould, J. W., & Martindale, D. A. (2013). Cultural competency and child custody evaluations: An initial step. Journal of the American Academy of Matrimonial Lawyers, 26, 1–13. IJS Israel & Judaism Studies. Variants within Judaism. Retrieved from: www.ijs.org.au/ variants-within-Judaism/default.aspx Jeffreys, M., & Dogan, E. (2013). Evaluating cultural competence in the clinical practicum. Nursing Education Research, 34, 88–94. doi:10.5480/1536-5026-34.2.88 Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural self-efficacy perceptions. Journal of Transcultural Nursing, 23, 188–194. Jeffries, P. R. (2009). Dreams for the future for clinical simulation. Nursing Education

26. Perspective, 30(2), 71. Kardong-Edgren, S., & Campinha-Bacote, J. (2008). Cultural competency of graduating US Bachelor of Science nursing students. Contemporary Nurse: A Journal for the Australian Nursing Profession, 28(1–2), 37–44. doi:10.5172/conu.673.28.1-2.37 Kardong-Edgren, S., Cason, C. L., Brennan, A. W., Reifsnider, E., Hummel, F., Mancini, M., & Griffin, C. (2010). Cultural competency of graduating BSN nursing students. Nursing Education Perspectives, 31, 278–285. Krainovich-Miller, B., Yost, J. M., Norman, R. G., Auerhahn, C., Dobal, M., Rosedale, M., ... Moffa, C. (2008). Measuring the cultural awareness of nursing students. Journal of Transcultural Nursing, 19, 250–258. Leininger, M., & McFarland, M. R. (2002). Transcultural nursing (3rd ed.). New York, NY: McGraw-Hill. Miller, S. (2010). Implications for incorporating simulation in nursing education. Journal of Practical Nursing, 60(3), 2. National League of Nursing. (2009). A Commitment to Diversity in Nursing and Nursing Education. A Commitment to Diversity International Journal for Human Caring118 Student Paper

27. in Nursing and Nursing Education. Retrieved from http://www.nln.org/aboutnln/reflection_ dialogue/refl_dial_3.htm National Tay-Sachs & Allied Diseases Association of Delaware Valley. Tay-Sachs Disease. Retrieved from: www.tay-sachs.org/taysachs_ disease.php Noble, A., Nuszen, E., Rom, M., & Noble, L. M. (2014). The effect of a cultural competence educational intervention for first-year nursing students in Israel. Journal of Transcultural Nursing, 25(1), 87–94. Reeves, J. S., & Fogg, C. (2006). Perceptions of graduating nursing students regarding life experiences that promote culturally competent care. Journal of Transcultural Nursing, 17, 171–178. Reyes, H., Hadley, L., & Davenport, D. (2013). A comparative analysis of cultural competence in beginning and graduating nursing students. ISRN Nursing, 2013, doi:10.1155/2013/ 929764 Schuessler, J. B., Wilder, B., & Byrd, L. W. (2012). Reflective journaling and development of cultural humility in students. Nursing Education Perspectives, 33, 96–99. Shin, S., Park, J., & Kim, J. (2015). Effectiveness

28. of patient simulation in nursing education: Meta-analysis. Nursing Education Today, 35(1), 176–182. Singer, M. K. (2012). Applying the concept of culture to reduce health disparities through health behavior research. Preventive Medicine, 55, 356–361. Thomas, C. L. (1993). Taber’s cyclopedic medical dictionary. Philadelphia, PA: F.A. Davis. U.S. Department of Health and Human Services (USDHHS). Office of Disease Prevention and Health Promotion. Healthy people 2020. Washington, DC. Retrieved from: https://www. healthypeople.gov/2020/leading-health- indicators/2020-lhi-topics/social-determinants Van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science & Medicine, 50(6), pp. 813–828. Walker, L. O., & Avant, K. C. (1988). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall. Author Note Deborah Byrne, RN, MSN, is Assistant Professor at the School of Nursing and Health Sciences, La Salle University, Philadelphia, Pennsylvania, and a doctoral student in nursing at the College of Nursing, Villanova University,

29. Villanova, Pennsylvania. Correspondence concerning this article should be addressed to Deborah Byrne, School of Nursing and Health Sciences, La Salle University, 1900 West Olney Avenue, Philadelphia, PA 19141, USA. E-mail may be sent to [email protected] 2016, Vol. 20, No. 2 119 Student Paper Copyright of International Journal for Human Caring is the property of International Association for Human Caring and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. The client-oriented model of cultural competence in healthcare organizations Giovanni Di Stefano , Eleonora Cataldo and Chiara Laghetti Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo , Palermo, Italy ABSTRACT The paper aims to propose a new model of cultural competence in health organizations based on the paradigm of client orientation. Starting from a literature

30. review, this study takes inspiration from dimensions that characterize the cultural competence of health organizations, and re-articulates them in more detail by applying a client orientation view. The resulting framework is articulated into six dimensions (formal references; procedures and practices; cultural competences of human resources; cultural orientation toward client; partnership with community; and self-assessment) that define the ability of a health organization to achieve its mission, acknowledging, understanding, and valorizing cultural differences of internal clients (staff) and external clients (consumers). This study makes an effort to address the paucity of studies linking approaches to managing cultural diversity in health organizations with cultural competence within the framework of client orientation. ARTICLE HISTORY Received 30 March 2017 Accepted 3 October 2017 KEYWORDS Cultural competence; health organizations; client-oriented model Introduction Globalization has deeply changed the profile of both the workforce and the users of organizations in the societies of the new millennium. One important ques- tion is how to deal with growing cultural diversity in such a way that it may produce positive results – in

31. terms of productivity and service quality, well-being and satisfaction – for organizational systems and for people, both workers and users. The Diversity Management (DM) approach aims to accomplish such a result by adopting a heterogeneous viewpoint in order to lever cultural differences and treat them as an added value rather than an obstacle. In fact, the premise for managing diversity is the recog- nition of differences as positive attributes of an organization, rather than as problems to be solved [1]. In this way, diversity may become a source of competitive advantage, increase the quality of organizational life and ultimately be advantageous for business [2]. The point is not, therefore, the acceptance of differences, but the creation of an inclusive environment and the commitment to valuing them. This can be made possible through a culture of inclusion that creates a work environment nurturing teamwork, participation, and cohesiveness. However, many organizations do not see the advantages that cultural diversity could bring to them and how well-managed cultural diversity may achieve a competitive edge in the market. The topics of cultural differences and disparities that may result from them have been already described in healthcare organizations, since the emerging challenges of providing health services in a growing multi-ethnic world [3,4]; within these organizations, the approach of intercultural DM and the cultural competence are considered a priority. In particular, cultural competence is a powerful instrument for managing cultural diversity in multicultural settings, since it improves quality and eliminates racial/ethnic disparities in organizations. The goal of cultural competence is to

32. create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency. Although cultural competence may be considered an important need for every contemporary organization, since the growing pressures of globalization to develop international influence or operating on an international scale, it is indeed a core requirement for healthcare organizations, since the exigency they have to respond to the specific needs of any person seeking help, and the related concerns that come from working with culturally diverse patient groups, in order to alle- viate, at least in part, health disparities related to racial and ethnic differences. The aim of this work is to propose a client-oriented model of cultural competence, meaning the ability of a health organization to acknowledge, understand, and value cultural differences of internal clients (staff) and external clients (consumers), as well as the ability to commit to achieving its mission, taking account of clients’ cultural identity and the individual needs. In order to respond to this objective, we reviewed the literature on cultural competence to identify a set of elements that define a culturally competent © 2017 Informa UK Limited, trading as Taylor & Francis Group CONTACT Giovanni Di Stefano [email protected] Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo , Viale delle Scienze, Ed. 15, Palermo 90128, Italy

33. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019, VOL. 12, NO. 3, 189–196 https://doi.org/10.1080/20479700.2017.1389476 http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.20 17.1389476&domain=pdf http://orcid.org/0000-0001-7276-549X mailto:[email protected] http://www.tandfonline.com organization within the framework of client orientation. EBSCO, MEDLINE, Scopus, and Web of Science databases were searched for relevant peer- reviewed articles regarding the organizational cultural competence and client orientation in healthcare. Toward a definition of cultural competence for health organizations Since the 1980s, several scholars have paid attention to the construct of cultural competence, focusing on students [5–7], research [8], policy organizations [9], counseling services [10–12], and above all, the human service sector – social work and healthcare [3,4,13–24]. With specific reference to healthcare organizations, the concept of cultural competence was used not only in reference to the individual’s ability to provide care in a culturally appropriate way but also in relation to systems and organizations. Cultural competence has been defined variously in the literature. For example, Green [20] first defined it as the ability to conduct professional work in a way that is consistent with the expectations, which mem-

34. bers of a distinctive culture regard as appropriate among themselves. This definition emphasizes the worker’s ability to adapt professional tasks and work styles to the cultural values and preferences of clients. According to Cross et al., cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situation [25],p.1. Sue defines cultural competence as the ability to engage in actions or create conditions that maximize the optimal development of client and client systems [11],p.817. According to the National Quality Forum, cultural competence is the ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient- and family centered, evidence based and equitable [26],p.2. Last but not least, Betan- court et al. [3] define cultural competence as the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs. Despite these differences, authors seem to agree that cultural competence is an active and developmental process that is ongoing and never reaches an endpoint. Cultural competence develops over time through training, experience, guidance, and self-evaluation [4,14,25]. In connection to such a general statement, Campinha- Bacote views cultural competence in the specific field of healthcare as the ongoing process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community) [4],p.181. Scholars

35. tend to consider cultural competence as increasingly important for healthcare quality [13,14,15,22], and believe that there is a link between cultural competence and reducing or eliminating racial and ethnic disparities in health care [7,16,27]. Although the centrality of cultural competence in health practice appears to be a widely accepted concept [3,13,14], still exists a scarce research on the effects and the outcomes of developing culturally competent healthcare organizations [16,28]. Nevertheless, there is some evidence that the implementation of cultural competence models improves the ability of health systems and their workers to provide services to culturally diverse patient groups, reducing disparities in quality of health care [13,15,16]. Main models of cultural competence Several models of cultural competence have been developed in the last two decades; in them, the dimensions of this construct were delineated with particular attention to individuals and organizations. Cross et al. [25], focusing on systems of care, propose a continuum that ranges from cultural destructive- ness, that is destructive attitudes, policies, and practices toward diverse cultures and individuals within a culture to cultural proficiency or advanced cultural competence, i.e. attitudes, policies, and practices that hold culture in high esteem, with the intermediate stages of cultural incapacity, in which the organization not intentionally seeks to be culturally destructive, but rather is not able to help minority clients, cultural blindness, that is believing that all people are the same and that approaches used by a dominant culture

36. are universally applicable, cultural pre-competence, namely realizing weaknesses in serving minorities and attempting to improve service for a specific part of the population, and cultural competence, i.e. adapt- ing a service model to the needs of minorities, expand- ing cultural knowledge and resources, conducting cultural self-evaluation continuously. In order to assess at which of these stages a given organization is, one may evaluate the entity of five essential elements that contribute to a system’s ability to become more culturally competent: (1) the propensity to valuing diversity, that is the awareness, acceptance, and respect of differences in lifestyle, communication, behaviors, values, and attitudes; (2) the cultural self-assessment, specifically the ability of the system to assess itself and have a sense of its own culture; (3) the dynamics of difference, or the ability of the organization to manage mis- interpretation and misjudgment when a member of one culture interacts with other from a different one; (4) the institutionalization of cultural knowledge, namely how much organization provides cultural knowledge to their workers about family system, values, history, and etiquette of specific populations; 190 G. D. STEFANO ET AL. and, finally, (5) the adaption to diversity, i.e. the sensi- bility of the organization to adapt its approaches in order to create a better fit between the needs of minority groups and services available. Rodgers’ model, instead, focuses on the identifi- cation of attributes of cultural competence rather than the development of a definition of the concept.

37. Rodgers [29] identifies seven attributes of cultural competence: cultural awareness, i.e. developing consciousness of culture and the ways in which culture shapes values and beliefs; cultural knowledge, that is a continued acquisition of information about different cultures and an essential underpinning of cultural understanding; cultural understanding, specifically the ongoing development of insights related to the influence of culture on the beliefs, values, and behaviors of diverse groups of people by which one can begin to address problems such as marginalization and sub- jection that may be the result of beliefs and values of one culture differing from those of the dominant culture; cultural sensitivity that develops as one comes to appreciate, respect, and value cultural diversity and, in so doing, one also comes to realize how one’s own personal and professional cultural identity influences practice; cultural interaction, namely the personal contact, communication, and exchanges that occur between individuals of different cultures; cultural skill, or the ability to communicate effectively with those from other cultures, including the incorporation of the client’s beliefs, values, and practices into the provision and planning of care and also varying procedures and techniques to accommodate cultural beliefs; cultural proficiency, that is the commitment to change through some activities as the sharing of information. A different model is proposed by Purnell [23]. It is based on the assumption that cultural competence is not a linear process in which a healthcare provider – or any organization – progresses from unconscious incompetence, a condition in which it is unaware that is lacking knowledge about another culture, to conscious incompetence, to one in which is aware, and

38. from this to a state in which it has a conscious competence, learning about the client’s culture and providing culturally specific interventions, to the optimal condition in which it automatically provides congruent care to clients of diverse cultures, namely it holds an unconscious competence. Finally, Campinha-Bacote’s model views cultural competence as the ongoing process whereby the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, and community) [4]. Campinha-Bacote’s model is composed of five major constructs that have an interdependent relationship with each other: cultural awareness, that is the self- examination and exploration of one’s cultural and professional background; cultural knowledge, i.e. the pursuit and achievement of a sound educational foun- dation about diverse cultural and ethnic groups; cultural skill, namely the ability to collect relevant cultural data regarding the client’s presenting problem, to conduct cultural assessments and culturally based physical assessments; cultural encounters, or the process that encourages the cross-cultural interactions between healthcare provider and clients from culturally diverse background; and, finally, the cultural desire, that is the motivation of the healthcare provider to want to become culturally aware, knowledgeable and skillful, and familiar with cultural encounters. Although all the models presented so far have had some success and have been implemented in a wide variety of programs in medical schools, the concept of culture competence must go beyond the traditional notion of ‘competency’, involving the fostering of a

39. critical consciousness of the self, others, and the world and a commitment to addressing issues of societal relevance in health care [30]; also, they seem to consider cultural competence only as a means to provide a culturally specific service for users of different ethnicities. The model here proposed, which we call the Client- Oriented Model of Cultural Competence, is instead designed mainly as a tool for the management and development of human resources from different cultural backgrounds. In our proposal, a culturally competent organization aims to promote positive intercultural encounters among colleagues, then between providers and consumers. The organization must be culturally competent with regard to internal customers to dispense a culturally competent service to external customers. The client-oriented model of cultural competence The Client-Oriented Model of Cultural Competence can be considered as a model that, inspired by the DM approach, aims to link the task of managing cultural diversity in health organizations with cultural competence, within the framework of client orientation. In this model, the cultural competence is defined as the ability of a healthcare organization to achieve its mission (service delivery), acknowledging, understanding, and valorizing cultural differences of internal clients (staff) and external clients (consumers). Within the proposed model, we posit that the client orientation view may be considered a specific key element for healthcare organizations. In fact, the

40. focus on provider–client relationship may give added value to healthcare services: for example, when healthcare providers either do not speak the client’s language or are insensitive to cultural differences, the quality of health care can be compromised [13]. Under this point INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 191 of view, a client-oriented healthcare organization is a system that responds effectively to language, and in a more general sense, to psycho-social needs of their clients. Also, the respect, the sensitivity, and the understanding for clients’ culture and values appear to be related to the ability of healthcare providers to offer provisions of health services [3,4,13]. It is articulated into the following six dimensions: (1) Formal references related to cultural competence; (2) Procedures and practices; (3) Cultural competences of human resources; (4) Cultural orientation toward clients; (5) Partnership with community; (6) Self-assessment. These dimensions are described below in detail. Formal references The first dimension of the Client-Oriented Model of Cultural Competence regards written formal organizational statements about mission, values and principles, goals and policies, beneficiaries, and vision. In

41. a culturally competent organization, formal references explicitly stress the importance of cultural competence, consider the cultural diversity of staff members as a resource to be valuable, and include members of different cultures as beneficiaries of the service. A culturally competent governance establishes policies and goals that help ensuring the delivery of the service in a culturally responsible way, by involving various groups in the decision-making process [27]. The organizational statements must be communicated to staff and consumers, and the language in the formal references must acknowledge the cultural diversity of personnel and population served. In other terms, an organization is culturally competent when, even before delivering its services to implement the provision of services, it defines its own primary task in a culturally sensitive way, taking care to distribute its own purposes, principles, and values within the system and in the whole territory and encouraging the sharing of the same goals and principles among staff and users. Procedures and practices The second dimension regards the practices of management and development of human resources. In relation to service delivery procedures, in agreement with Hernandez et al. [27], we believe that cultural competence in service ensures ad hoc services that reflect the needs of consumers. A healthcare organization should have a database containing information about each user’s clinical history, culture of origin, and reported impact ensuing the first encounter with the organization, to ensure a culturally competent service. This database, continuously updated, will be a guide for health providers, who will be able to provide

42. the most appropriate service, in timely fashion and in the most appropriate way, to the specific patient. In relation to management and development of human resources practices, efforts should be made to recruit, select, and hire multicultural administrative staff and medical personnel, who should be representative of the cultures existing in the community and able to speak the languages of the populations served [31,32]. Racial/ethnic diversity in the healthcare leadership and workforce has been clearly connected with the delivery of quality care to diverse patient populations [3]. So conceived, procedures and practices serve the more general objective to render a healthcare organization a culturally competent system; this, in turn, should allow to create a multicultural environment, which is a setting ready to receive people, both consumers and staff, of different cultures. In other words, a culturally competent organization, which has designed and created through its procedures and practices a physical and symbolic multicultural environment, ensures users’ open access to services through the elim- ination of socio-cultural barriers see [3,27]. First, the absence of language barriers, i.e. multilingual bro- chures, documents/information materials allows effective communication between providers and consumers. The organization will monitor consumers’ needs on-site through such devices as anonymous questionnaires on the services offered. As a customer-oriented system, the organization will offer the opportunity to provide feedback also to the staff, who will be able thus to report problematic issues encountered in the workplace and provide suggestions to improve the service. Thus, the organization

43. creates, maintains, and improves a work environment that is conducive to the well-being and development of all employees [17,33]. Such devices will increase the sense of belonging in the workplace (affective commitment) and employees will identify with the organization and its values. The physical–spatial structure with its premises and furnishings is nothing more than the expression of the organization’s system of values based on acceptance, respect, and appreciation of cultural differences. The culture of an organization, in fact, is primarily inferred from the observation of its visible and tangible aspects, along with the public actions of its members. Cultural competences of human resources The third dimension focuses on attitudes and skills of personnel required to provide culturally acceptable care, developed through training, which are: awareness of own beliefs and bias; knowledge, acknowledgment of, and respect for, beliefs and values of other cultures; 192 G. D. STEFANO ET AL. relational skills in intercultural encounters with co- workers and consumers; appropriate language and effective communication; multicultural team-working skills. A large part of the literature suggests some of these beliefs/attitudes and skills are components of cultural competence [11,12,18,21,24,25]. In particular, Sue et al. [12] list some of the culturally competent counselor’s attitudes and skills, namely: valuing and respecting differences in beliefs, values, language, and helping practices; awareness and knowledge of own

44. and clients’ cultural heritage and experiences, attitudes, values, biases, and stereotypes; ability to engage in a variety of verbal and nonverbal helping responses. In our opinion, it is of primary importance that employees of multicultural organizations be aware of the cultural basis of their behaviors, in such a way that they may realize that their beliefs do bear consequences on their actions in the workplace, possibly leading them to commit errors of assessment. It is also important that they know, accept, and respect the different cultures of co-workers and users. In fact, if staff members are not willing to accept co-workers culturally different from themselves, they will always have difficulties welcoming external customers, which are carriers of culturally specific needs, and this attitude of closure shall affect the delivery of an efficient service. Relational, communication, and team-working skills are necessary to work in a multicultural context. In general, with the acquisition of relational skills, employees become capable of managing intercultural encounters with colleagues and users, listening to others different from themselves, understanding their needs, and managing their own behaviors on the basis of their cultural characteristics. Culturally competent organizations aim to reduce the difficulty of interaction (i.e. misunderstanding, conflicts, and differences of views) between individuals of different cultures. To achieve this, it is also necessary to obtain specific multicultural team-working skills, which allow members to cooperate, share information, share their views, communicate effectively, and reach an agreement on the various clinical issues. Communi- cation skills seem to be essential to interact and work in multi-ethnic groups. In order for the team’s goal to be achieved and the environment to be positive, the com-

45. munication must be clear and transparent, fluid and open, welcoming of others without judging, censor- ship, or misunderstandings. Upon meeting a culturally different customer, it is important the staff adapt their communication style and pay attention also to nonverbal communication. As claimed by Campinha-Bacote [4], nonverbal communication techniques must take into consideration the client’s use of eye contact, facial expressions, body language, touch, and space. Nonverbal language and paraverbal language are the first channels of interaction and affect the transmission of the message more greatly than the spoken word. Communication with the user is effective if there is correspondence between the verbal and the nonverbal channels. Therefore, our model puts special emphasis on communication skills and improves relationships among colleagues and between providers and users. The organizations need to render all employees more sensitive to cultural issues through diversity education and cultural competence training, teaching them culturally adapted models of care or types of interventions [31], and developing their attitudes and skills necessary to deliver service in a culturally responsible manner. Staff members will be involved in group dis- cussions, i.e. case method and self-case method and exercises, such as simulations, role-playing which refer to their multicultural working environments, as well as outdoor training sessions centered on the relational and communication skills and multicultural team-working skills development. The importance of diversity and cultural compe-

46. tence training and education is highlighted by a large part of the literature [3,5,7,11,15,17,18,25,30,32,34– 36], because cultural competence is mediated through the behavior of all human resources that act on both upper and lower levels of an organization. In this way, cultural competence does not stay a mere abstract concept, but rather it becomes a reflection of the skills, abilities, and actions of every resource. In general, the organization must focus on the development of such interpersonal skills in order to be customer-oriented from a cultural standpoint. If the organization grants its employees a chance to acquire and exercise these competences in their workplace relationships, they will also become able to deal with users belonging to any ethnic group in a culturally sensitive and responsible way. Cultural orientation toward clients The fourth dimension is the one that best qualifies the Client-oriented Model of Cultural Competence. It is the analysis of user and staff needs and it regards also the knowledge of their cultural characteristics. Accord- ing to our definition, culturally competent organizations are culturally client-oriented, insofar as they proactively look to meet the cultural needs of both internal and external users. Hernandez et al. [27] and Siegel et al. [32] have already stressed the importance of knowing the needs and cultural characteristics of the local population that constitutes most of the organization’s user pool. In our model, we take into consideration external customers; we are aware that cultural competence is an integral component of patient-centered care, but we

47. plan to extend the analysis of needs and the knowledge of the cultural characteristics also to internal customers, because we consider an organization’s care for its staff an essential element within the construct of cultural INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 193 competence. We also believe that the cultural characteristics of staff affect not only the interaction with multicultural clients – and, therefore, the quality of service, but also the interpersonal relationships among colleagues. The quality of the latter must be guaranteed by the organization, through the promotion of effective communication styles and a positive emotional environment. These aspects of working life promote employee satisfaction, which will impact customer satisfaction in the assessment of Total Quality Management. Accord- ing to this approach, in fact, the treatment of internal customer is transferred to the external customer. In other words, only if the organization is culturally competent with regard to staff, will it also be toward users. The ultimate goal is to provide quality service to multicultural users, but in order for an organization to be defined culturally competent, that organization must ensure a positive work environment for its own multicultural staff. Partnership with community Culturally competent healthcare organizations collab- orate with community partners, such as other public, private, or no-profit organizations that help minority groups. From such collaboration, useful feedback

48. may emerge regarding the analysis of the needs and cultural characteristics of ethnic groups served, upon which the organization sets its own targets for intervention. The community partners are, therefore, considered bridges, which bring together the providers and the consumers even before the latter start using the former’s services [13,19]. Preliminary meetings, during social events, orga- nized periodically (i.e. friendly soccer matches in which healthcare professionals and users of different ethnicity play on the same team), permit the establish- ment of a relationship of trust, which will make the members of minority groups likely to turn to the organization for need of care. In other words, through this continuous dialogue with the territory, the organization makes culturally competent marketing, fostering relationships with potential multicultural users and making the service known to them, in a mutually advantageous process. With respect to minority communities’ users, such a process increases their ability to manage their own health needs more autonomously and use services more responsibly and with the awareness that, once within the organization, they will find a welcoming environment. Broadly speaking, healthcare organizations should develop collaborative partnerships with communities and use a variety of mechanisms, both formal and informal, to facilitate community and patient or consumer involvement in designing and implementing culturally and linguistically appropriate services-related activities [13]. Self-assessment

49. Cross et al. [25] argue that the organization’s self- assessment is essential to the development of its cultural competence. On the basis of the literature [6,9,25], we highlight the importance of self-assessment on the part of a healthcare organization (qualitative and quantitative instruments), with particular attention to service quality, consumer satisfaction, and personnel well-being. These three aspects are closely related and the evaluation of each of them is inter- twined with the evaluation of the other two. The self- assessment is useful for the organization to continuously adapt its strategies. It is constituted as a continuous monitoring action, oriented to reviewing service delivery procedures, management practices, and human resources development, with the ultimate goal of developing the most appropriate strategies for a culturally competent system. It is also useful to assess the quality of the service provided, in terms of process and product quality, from an intercultural standpoint. It is useful to evaluate users’ satisfaction, through the collection of their perceptions and opinions, by means of an on-site desk collecting questions and complaints as well as questionnaires submitted by users during their stay, with a constant focus on addressing the needs of different cultural groups. The on-site desk also allows internal clients to evaluate their own organization, expressing their opinions and suggestions to improve service. In this regard, meetings will be called periodically in order to analyze the data collected from various multicultural sources, discuss, and give guide- lines to staff on how to provide those services in a culturally competent manner. Even the community partners play an important role in the evaluation process and in the examination

50. of the results of service delivery procedures. By acting as representatives of particular ethnic groups present in the territory in which the services are provided, community partners report those groups’ needs to the organization. For example, an association repre- senting the territory’s Tamil community could bring up a specific need for this clinic ethnic group, the organization would take note and, on this basis, become able to develop culturally competent practices. In this self-assessment process, it is important for the organization to evaluate the welfare of its own multicultural staff. Even in this case, it is desir- able to develop qualitative/quantitative questionnaires and focus groups. Finally, the product evaluation aims to assess whether the organization’s clinical and economic results have been achieved. There is no doubt that the self-assessment process will have positive repercussions on all eth- nically diverse systems: leadership, on staff and users. Thanks to this self-assessment, it will be possible to deliver a high-quality service in a culturally competent 194 G. D. STEFANO ET AL. manner, managing to keep costs reduced and enhance the contribution of each human resource involved. Conclusion The six dimensions of the Client-Oriented Model of Cultural Competence interact with each other, according to a principle of circularity (see Figure 1). Even though, thanks to such circularity, each dimension

51. naturally ensues the previous one, the sequence cannot be considered too strictly in the study of an organization that is meant to assess whether it is culturally appropriate. The theoretical model described here places previous conceptualizations of cultural competence under the paradigm of client orientation. By doing so, the success of efforts to develop a culturally competent healthcare organization may be meaningfully influenced by the ability of the organization and their practitioners to recognize, value, and respond to the needs of the specific clients being served, not only those who belong to racial and ethnic minority groups; in this sense, the model considers a set of dimensions that have a pervasive influence in determining clients’ healthcare experience. From this point of view, although the Client-Oriented Model of Cultural Com- petence identifies measurable dimensions associated with culturally competent organization, further research is needed to determine the best approaches and methods to measuring these factors. For example, the model may constitute the basis to develop a specific checklist to assist organizations to develop policies and structures that support a cultural competence specifically framed within the client orientation. Owing to the multifaceted nature of the model, various indicators across multiple domains are required in order to obtain valuable and accurate information, but their identifi- cation goes beyond the purpose of this work. An obvious broad implication of the adoption of the model here represented is, of course, that increased cultural competence can reduce disparities in provision of healthcare services. Conversely, at a more

52. focused level, it is important to distinguish between the cultural competence of individual practitioners of healthcare and cultural competence at the organizational level. At the individual level, some components of client-oriented cultural competence may be identified, for example, in the sensitivity and understanding of one’s own cultural identity, in having knowledge of other cultures’ beliefs, values and practices, and having the skills to interact effectively with clients’ diverse (sub)cultures. At the organizational level, client-oriented cultural competence refers to a set of congruent policies, and structures that come together in a system: for example, creating structures for clients’ commitment, in order to involve them in the design and implementation of services they receive, or developing partnerships that acknowledge strengths and build upon a networks of support within diverse communities, taking into careful consideration the values and principles that underpin community engagement. We believe that an organization is provided with cultural competence from the very moment in which it is created, insofar as its creation revolves around specific cultural values. These values will be acted upon through the organization’s own practices and procedures, the development of specific skills within its staff and the consequent creation of a multicultural environment. In this model, the organization is also open to dialoguing with its territory and is willing to constantly self-evaluate its own actions. All dimensions must be addressed in the cultural competence development process. To assess whether an organization is culturally competent, we posit that it is not necessary, however, to follow the order of

53. dimensions suggested here. Therefore, in our circular model, it is possible to start from any dimension to pro- ceed to the evaluation of any other one. For instance, if an organization is deemed culturally competent for the dimensions ‘Procedures and Practices’ and ‘Partnerships with community’, but it is not competent in regard to any other dimension, it is still possible to use those two successful dimensions to devise strategies to achieve competence in the others. When the tools are given to develop competence in all dimensions, the organization will have an orderly system and may operate indepen- dently in order to remain culturally competent. Disclosure statement No potential conflict of interest was reported by the authors. Notes on contributors Giovanni Di Stefano, PhD, is Assistant Professor of Work and Organizational Psychology at the University of Palermo, Italy. His research interests include the impact of organizational Figure 1. The client-oriented model of cultural competence diagram. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 195 culture on human resource management practices, with particular emphasis on managing deviance and diversities, the organizational well-being, and the attachment to the workplace.

54. Eleonora Cataldo, psychologist,is an independent consultant and researcher based in Palermo, Italy. Specialist in personnel selection, her research interests include the effectiveness of diversity management strategies. Chiara Laghetti, psychologist,is an independent consultant and researcher based in Palermo, Italy. Her work and research interests include the multicultural diversity management practices. ORCID Giovanni Di Stefano http://orcid.org/0000-0001-7276-549X References [1] Thompson N. Anti-discriminatory practice. 6th ed. New York (NY): Palgrave Macmillan; 2016. [2] Cassell C. A fatal attraction? Personnel Rev. 1996;25 (5):51–66. [3] Betancourt JR, Green AR, Carrillo JE, et al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118(4):293–302. [4] Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13(3):181–184. [5] D’Andrea M, Daniels J, Heck R. Evaluating the impact of multicultural counseling training. J Couns Dev. 1991;70(1):143–150. [6] Manoleas P. An outcome approach to assessing the

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58. measures of cultural competency inmental health organizations. Adm Policy Ment Health. 2000;28(2):91–106. [33] Scrima F, Rioux L, Di Stefano G. I hate my workplace but I am very attached to it: workplace attachment style. Personnel Rev. 2017;46(5):936–949. [34] Berlin E, Fowkes W. A teaching framework for cross- cultural healthcare: application in family practice. West J Med. 1983;139(6):934–938. [35] Ferguson WJ, Keller DM, Haley H-L, et al. Developing culturally competent community faculty: a model program. Acad Med. 2003;78(12):1221–1228. [36] Gozu A, Beach MC, Price EG, Gary TL, Robinson K, Palacio A, et al. Self-administered instruments to measure cultural competence of health professionals: a systematic review. Teach Learn Med. 2007;19(2): 180–190. 196 G. D. STEFANO ET AL. http://orcid.org/0000-0001-7276-549X Copyright of International Journal of Healthcare Management is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. AbstractIntroductionToward a definition of cultural competence for health organizationsMain models of cultural competenceThe client-oriented model of cultural competenceFormal

59. referencesProcedures and practicesCultural competences of human resourcesCultural orientation toward clientsPartnership with communitySelf-assessmentConclusionDisclosure statementNotes on contributorsORCIDReferences

Student PaperCultural Competency in Baccalaureate Nursing .docx

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