Cultural Competency of Nurses

1.1 Cultural competency

The commitment to equality in health care provision is ingrained within the core values of the health care profession and nurses are expected to fulfill these requirements. The Nursing and Midwifery Council’s (NMC) Code of Professional Conduct clearly states that nurses must treat every patient as individual, respect their dignity and not to discriminate irrespective of age, ethnicity or cultural background (Husband and Torry 2004a). The NMC (2004) emphasises that culturally competent care is moral and legal requirement for nurses. Thus the requirement for the development of cultural competence is to be found within the NMC code of conduct. Josipovic (2000) points out that the delivery of individualised care, in consideration of religious and cultural requirements of Black and Ethnic Minorities (BME) patients can assist nurses to fulfill their obligations.

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However, there is no universal definition of cultural competence; Campinha-Bacote (2002) defines cultural competence as a process, which requires the health care professional to continuously attempt to gain the ability to work competently with the cultural context of the patient. Nevertheless Papadopoulas et. al. (1998) defines cultural competence as the ability to give effective care while taking into account patient’s specific cultural needs, behaviors and beliefs. Narayata definition

Nonetheless, there has been significant discussion of different models of cultural competence in nursing literature (Gunaratnam, 2007). Campinha-Bacote (1998) model of cultural competence: “the process of cultural competence in the delivery of health care service”, identifies five essential constructor of cultural competence:

Cultural awareness

Cultural knowledge

Cultural skill

Culturally encounter

Culturally desire

Conversely the Papadopoulas et. al. (1998) model of developing cultural competence consists of four stages: Cultural awareness, Cultural knowledge, Cultural sensitivity and Cultural competent. Rosenjack Burchum (2002) identified the attributes of cultural competence as same as those of Papadopolos et al (1998) but adds cultural understanding, and cultural skill as essential attributes. Cultural competence is, according to Rosenjack Burchum (2002), the development of knowledge and skill manifested by the synthesis of the above attributes and their respective dimensions in human interaction.

Although there is distinction in the models of cultural competence they all express common concern of three main components: cultural sensitivity, cultural knowledge and cultural skills (Gogwin et al. 2001). According to Garity (2000) cultural competence involves having understanding and sensitivity toward different cultural groups and factors that affect their lives such as immigration, discrimination and the possibility for these factors to improve or inhibit professional practice. Hence, for a nurse to become cultural competent s/he needs to develop an understanding of one’s own cultural needs, views, beliefs, behavior and those of the patient while avoiding stereotyping and generalisation (http://www.culturediversity.org/cultcomp.htm). The aim is to ensure that the health care services and professionals are respectful and responsive to the health beliefs, practices, cultural and linguistic needs of diverse patients, which can help bring about positive health outcome (http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvl).

Cultural competency is a process that needs to be continuously developed in order to enhance one’s ability to give affective health care (Papadopoulos 2006). All registered nurses have the responsibility to competently maintain professional knowledge and practice by ensuring up to date knowledge, skill and ability as well as safe and effective practice (NMC2008). Although the NMC clearly places the individual with the responsibility of developing cultural competence, it should be acknowledged that individuals alone cannot be held responsible for the delivery of culturally safe and competent health care service if insufficient resources are not made available (Husband and Torry, 2004a).

Nonetheless, Dreher and MacNaughton (2002) described cultural competence as the same as nursing competence; the ability to deliver care individualised and therapeutic to each patient despite social context or cultural background, this being the signature of contemporary nursing. However, the basic principle of providing nursing care to culturally diverse populations is not an entirely new idea, as the need for such was recognised in the United States in the late 1800s (Davis, 1996) and was also recognized by Florence Nightingale when advising British nurses working in India (Wilkins, 1993).

In the last century, most western countries saw significant changes in the make up of their populations due to increased trends in global migration that resulted in multiethnic and multi-religious societies. In the UK BME groups make up 7.9 % of the total population (Office for National Statistics, 2001). As the population becomes more diverse so does the complexity of the patients needs that the nurse must address (Black, 2008). Thus far, the need for the nurses to become culturally competent has become import (Black, 2008, Gunaratnam, 2007).The pertinent literature highlights that, in the last few decades, scholars and researchers have debated the issue relating to the delivery of appropriate nursing care to meet the needs of BME groups (refs). There is a growing body of evidence that show there are inadequacies in the nursing care provided to these groups (Vydelingum, 2006, Cortis, 2004) and concerns about ethnic disparities in health in the UK (Aspinall and Jacboson, 2004). Studies on utilisation of hospital services by BME patients, in particular the elderly have consistently demonstrated level of dissatisfaction with the care provided from cultural and/or religious viewpoints (DoH, 2009; Clegg, 2003; Patel, 2001; Cortis, 2000, Vydelingum 2000)

1.2 BME Elders

Nevertheless, the concept of the ageing population is one that has generated much discussion in the UK (Caldwell et al, 2008) as this age group is the main users of both health and social care services (Department of Health, 2001). While all older people have common needs and experiences of hospitals, the needs and experiences of the BME older people are shaped by their race and ethnicity (Ahmad, 1993; Blakemore and Boneham, 1994).

Majority of todays BME elders are yesterdays “young migrants” from the commonwealth countries (Patel, 2001), who came to the UK during the 20th century as a result of government policy to fill labour shortage (Houston and Cowley, 2002). According to Evandrou, (2006) in 2001 4% of the BME population were over 65 and this number is rapidly rising, from approximately 60 000 in 1981 to about 360 000 in 2001-2002 (Butt and O’Neil, 2004, Beaven, 2006) and is expected to increase in the next 15 years (Evandrou, 2000). These elderly groups have particularly been disadvantaged by the cumulative effect of age, race and inaccessibility to services (Norman, 1985). However, newly arrived migrants are likely to share similar concerns and experience in hospital care (Patel, 2001).

The 2001 and earlier censuses show that health disparities exist in the UK and that levels of long term illness are higher in older BME groups than in the general population (From A Szczepura 2005).Older people from BME are report more chronic illnesses such as cardio-vascular disease, diabetes, hypertension and stroke when compared to the majority (Tilke, 1998; Ebrahim, 1999; Evandrou, 2000b). An appreciation of the health care needs of this group is vital in understanding the difficulties they face in accessing health care services (Toofany, 2007).

One occurring theme connected with old age and ethnicity that has been repeatedly identified from the1980s until today is the lack of urgency over government action for the group (Norman, 1985, Patel, 1990, Lindesay, 1997, Patel, 2001). The Policy Research Institution on Aging and Ethnicity (PRIAE) highlights that these groups are not normally considered in old age research (Patel, 2003). Hoong Sin, (2003) points out that BME older people in the UK are disadvantaged by the lack of a reliable sampling frame. Although there are few national studies, most research projects are small and involve localised samples (Hoong Sin 2003). Therefore the infrastructure for doing research with such population groups is inadequately set up (Hoon Sin, 2003). In PRIAE’s view “we have had too much discussion, action is overdue” (Patel, 2001). This information suggests that BME elderly groups have never been a priority on the agenda for research or policy makers in the health care services. Saleh (2009) suggests that the introduction of the Race Relations (Amendment) Act 2000 increased pressure on health care organisations to adapt services to ensure equitable access for local all BME groups.

On the other hand, Department of Health (DoH) ensures that reducing health disadvantage and social exclusion for BME elders is central to UK health and social policy (DoH, 2001b). The DoH made specific commitments, in the “National Standards, Local Action”, to improve quality of service for BME where they are disadvantaged in terms of health (refs). This approach according to Papadopoulos et al. (2006) is a sign that the NHS is undergoing modernization.

Unfortunately, the last two National Patient Survey Programme reports (2008 & 2009) show the experiences of all BME groups (with the exception of those from the Irish community) are significantly less likely to be positive than those of the indigenous population’s. From a nursing aspect this outcome questions the nurse’s competence in delivering culturally appropriate care.

The literature available identifies cultural competency as one of the main factor that can help cease the inequalities in health care system (refs). According to Papadopoulos et al. (1999) although mention of the term cultural competence in DoH and National Health Services (NHS) documents has increased, there is no attention to what this actually means for patients or nurses and how it could be measured. Having and implementing clear, strong policies on race and equality is essential for health and social care organisations but this has to be supported with training and education (PRIAE, 2005). Consequently, Dreher and MacNaughton (2002) doubted whether cultural knowledge translated into culturally specific care would necessarily result in improved clinical outcomes or the reduction of health disparities.

2. The review Aim and Research Strategies

2.1 Aim

Nurses are at the front line of care for BME older people in hospital therefore it is important that the care delivered is in line with what is viewed as appropriate by the patients to their needs. The Department of Health openly acknowledges that much remains to be done in terms of measuring older patients’ experiences of the process of care, respect, dignity, information and education (Shaw and Wilson, 2008).

This review, therefore, intends to bring together the literature concerning nurse’s views of what is essential in delivering culturally appropriate care to BME older patients as well as this group’s expectations and experiences of nursing care. The aim is to explore the cultural competency of nurses in caring for BME elderly patients in Hospital setting.

2.2 Search Strategy (Include: inclusion/exclusion criteria, databases searched, keywords, languages and inclusive dates of the literature searched.)

Search Term

Search was carried out using combination of keywords such as Nurses, Cultural Competence/Awareness/Sensitivity, Geriatric, Elderly/Older, Black and Minority Ethnic and Experiences/Views. Furthermore, concepts relevant to hospital care such as Dignity, Respect and Appropriate Care were searched in combination with the above key terms.

Databases

The electronic databases British Nursing Index, PsycINFO, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Assia and Cochrane Library were searched to identify peer-reviewed literature published in the English language between 1990 and 2010 that are UK based. The databases yielded XXX potential studies relevant to the topic under review.

Further search was conducted in the World Wide Web using the same key words and it produced xxx studies. The websites of the Department of Health, Transcultural Nursing Society, Royal Collage of Nursing and relevant Third Sector Organisations such as Age Concern, and PRIAE were also accessed which yielded XXX literature. Further literature was gained from the reference and the bibliography of the gathered data as well as the library of the University.

The titles and abstracts of the obtained literature were examined and studies focusing on care provided by nurses to BME elderly patients as well as studies examining the views/experiences of hospital care by this particular geriatric group were selected. For the purpose of the literature review an older person is defined as person older than 50 years. NSF considers an older person as a person who is over the age of 50 years. Yet, a limited numbers of studies (how many) about BME elders in hospital setting were identified. For this reason studies focusing on the topic that had a wide range of age sample group i.e. 30-80 were included as it would assist in identifying additional pertinent literature. In total, XX studies were identified to meet the inclusion criteria for the literature review.

The literature selected were mainly primary empirical studies using qualitative approach. A qualitative research aims to understand the feelings, values, and perceptions that under lie and influence behavior (xxxx). Therefore the use of a qualitative methodology is seen to be appropriate as all the studies examine the experiences of the BME patients through their own eyes and those of the nurses (from internet).

2.3 Critical Appraisal of Three Qualitative Studies on the Experiences of Nurses in Caring for BME Patients and BME patients Experiences of Nursing Care

Cortis (2004) ‘Meeting the Needs of Minority Ethnic Patients’

Clegg (2003) ‘Older South Asian patients and Care Perceptions of Culturally Sensitive Care In a Community Hospital Setting’

Hamilton and Essat (2008) ‘Minority Ethnic Users Experiences and Expectations of Nursing’

Using Caldwell’s frameworks for critiquing health research, the three above stated studies will be analyzed systematically and supporting/contradicting evidence from other studies will be offered. WHY USE THIS FRAME WORK? Following the discussion of the review themes will be identified.

Title

Although the title of the study of Cortis is brief and conveys the nature of the study (Polit and Beck, 2010), it could be viewed as misleading as it gave the impression that the sample group was representative of different communities of BME groups. However, the study specifically focuses on the Pakistani ethnic community. Conversely, the titles of the researches by Clegg (2003) and Hamilton and Essat (2008) are short, accurate and clearly specifies what and who is being studied while reflecting the study content (Burns, 2000).

The Researcher’s Academic and Professional Qualification

The authors of the three researches have particular interest about the topic in question, which gives the assumption that they are familiar or have professional insights. The qualification (PhD, MsC) of the researchers is relevant as it indicates that they are competent and have creditability to carry out researches.

Further evidence to support researchers’ knowledge and interest of the topic was demonstrated as they are all nurses with extensive experience; Cortis is a senior lecturer at the University of Leeds with Qualitative Research interest in ethnicity and BME issues. Clegg is a consultant in older people’s services and intermediate care at Leeds Teaching Hospital NHS Trust. Hamilton was a principal lecturer at De Montfort University with research interests in multi-ethnic care and Essat was research assistant at the same university working on a project exploring the educational preparation of student nurses to work in a culturally diverse way.

Abstract and Rationale

A qualitative study must offer an abstract containing summary of study aim/objectives, research approach, methods adapted and the result of the study including the clinical applications (Cormack, 1996). Bellow the abstract there should be key words related to the study offering the reader an overview of the research question. All studies have offered a comprehensive abstract with key words relevant to their topics.

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Clear rationale for undertaking the study was given by all researchers; Cortis rationale was the fact that there is little exploration of nurses’ experiences of caring for specific BME community while Cleggs rationale was that there is a lack of research defining the concept of cultural sensitive care from patient/care perspective. Lastly, the rationale provided by Hamilton and Asset is that, nationally, there is an evidence to suggest that care provided doesn’t always meet the needs of BME patients.

LR

All three researchers did review pertinent literature (classics & up to date), which was evident in the studies as well as the reference list. According to Doordan (1999) the literature offered should have discussed and critically reviewed related literature to find out what questions remains to be answered. Nevertheless, only Clegg (2003) provided a separate section for LR, which she must be praised for (Morse, 1994). In grounded theory studies, researchers start with data collection first and as the data is analysed and as the theory takes shape researchers then begin to search the literature in order to link it to the emerging theory (Polit and Beck, 2010), which was evident in Clegg’s study.

Aim

The three studies clearly identify and justify their aims. Cortis’s (2004) argues that in a number of studies BME are seen as homogeneous therefore the aim of his study is to investigate a specific community’s uniqueness: the experiences of nurses caring for Pakistani patients in north England. However, this aim is inconsistence with the title of study, which clearly treats BME as a homogeneously. WHAT DOES THIS MEAN?

While the aim of the Clegg (2003), was to identify older south Asian patients’ and carers’ perception of culturally sensitive care. Lastly, the aim of the research by Hamilton and Asset (2008) was to give the minority ethnic groups the opportunity to voice their opinions on nursing care and to inform future nursing education.

Ethical Issues

Both Cortis and Clegg clearly highlight that permission to do the study was sought from the Local Research Ethics Committee (LREC), which is an imperative step before conducting any research. However, Hamilton and Essat (2008) omit to mention whether appropriate approval was gained from LREC’s; who exist to examine proposed research projects in order to guard people’s rights and interests (Cormack, 2000).

All the researchers have to be praised for specifying the process and purpose of the study was explained to the participants before the study in order to obtain informed consent. Cortis (2004) clearly specifies that assurance was given to maintain confidentiality and anonymity of the sample group, which is something Hamilton and Essat (2008) fail to address in their study. Both Cortis and Hamilton & Asset don’t comment on the associated ethical issues of autonomy, non-maleficience and beneficence, (Cormack, 20000).

Nevertheless, Clegg considered the vulnerability of the participants (Gerrish and Lacey 2006, Speziale and Carpenter 2007) and therefore committed to the ethical principles of autonomy, non-maleficience and beneficence (RCN, 2004), but fails to mention how confidentiality and anonymity was maintained. Clegg showed sensitivity towards the participants by informing them the voluntary nature of the research with the option of being able to withdraw at any time. This implies a non-coerciveness approach which was important in this study as this was vulnerable group. Conversely,

The three studies inform that permission was sought from the participant to audio-tape the interviews but omit to identify where data was stored and the disposal procedure used (Polit and Beck, 2008). This supports the premise that data used for a particular project should not be used for another without consent (Gerrish and Lacey, 2006).

Methodological

Both Cortis and Hamilton & Essat (2008) fail to specify that the method used was phenomenological-exploratory, which is useful when studying individual’s lived experiences (Crookes and Davies, 1998). The main methodological strength of using phenomenological in these studies is that it is an inductive and holistic approach that looks at what occurs within (Crookes and Davies, 1998). Both of the studies focus was on the unique experiences of providing care by nurses to BME patients and perception of BME older patient views/expectations of nursing care. The biggest methodological limitation for using phenomenological in these studies is that it is labour intensive and time consuming for the researchers in terms of data collection and analysis (Crookes and Davies, 1998). Clegg, on the other hand, identifies the methodology utilized as grounded theory, which is useful when studying individuals XXXX (GG). Methodological strength associated with the use of this approach in this study is xxxxx.

Methodological weakness associated with the use of this approach in this study is

The three studies clearly identify the major concepts of the design used and their concepts, which are what?

Sampling Technique and method

According to Polit and Beck, (2010) in qualitative research there is no rule for sample size as long as data saturation achieved. The sample number (n=30) used by Cortis was considered to be suitable for qualitative research (Cormack 1999) why? However, the sample number by Clegg was four patients and three relatives. Clegg states in her study that she is not sure if data saturation has been achieved. Morse (2000 in polit and beck book) suggests that number of participants required to reach saturation is a firmed by number of factors, such as the wider the research question the more participants necessary. This gives the impression that the sample size could have been too small for the scope of the research question hence why saturation was not reached (Morse 2000) possibly due to time or budget constraints (ref). Sampling number for Hamilton and Essat: six focus groups, member of which range from 8 to 15 (? large sample number for qualitative).

All three researches state how many participants were recruited and from where; areas with high population of BME. Cortis participants were recruited from a large acute hospital in north England and Clegg recruited this sample from a two community Hospital inner city and Hamilton and Essat recruited their sample of 6 diverse BME communities groups. The researchers must be praised for providing a clear indication of inclusive/exclusive criteria, in the process of recruiting participants.

In contrast the three studies fail to identify the sampling methods and techniques used but inferred from the research studies is that non-probability method of purposive sampling was employed (Cormack, 1996). The method of purposive/judgmental sampling relies on the belief that researcher have enough knowledge about the population to be able to pick sample members (Polit and Bechk, 2010).

The main strength associated with the use of purposive sampling in these studies is that the researchers purposively choose the participants knowing they would give relevant information about the topic in question (Polit and Beck, 2008). However, one main limitation is that this technique relies upon the researcher’s knowledge of cultural competence of nurses (Polit and Beck, 2008).

Method of Data Collection

All researchers collected data by audio taping interview and transcription. Cortis, Clegg and Hamilton & Assset adapted different type’s qualitative self-reporting technique, which is flexible in gathering self-reported information as it allows the participants to express their views in a naturalistic way (Polit and Beck, 2008).

Data collection is described by Cortis as semi-structured interviews and supplementary questions to follow-up for clarification. Cortis informs that most interviews were done in the clinical area; implying that participant had choice of venue, which he must be commend for. However, he omits to state where the rest of the interviews were done. WHY IS VITAL TO GIVE PARTICIPANTS CHOICE OF VENUE?

Nevertheless, Cleggs’ choice of data collection was unstructured interview that were done in the first language of the interviewee. Cross validation of the taped interviews was under taken by a second linguist. Both Cortis and Clegg fail to point out who/how many people performed the interview. Interview performed by one person provides uniformity and consistency (Denscombe, 2003).

On the contrary, method of data collection used by Hamilton and Essat was focus group, which was sub-divided into 6 groups where each group had facilitator. The advantage with use of this method in this study is it can generate a lot of dialogue but the disadvantage is that not everyone is comfortable experiences their experiences/view in front of others (Polit and Beck, 2010).

Overall, an advantage associated with the use of all interview technique utilized is that the interviewer can observe the participants non-verbal responses, which can provide valuable information (Burns 2000). Some of the main methodological limitation with the use of this method in these studies is that it was done in face to face, which could jeopardize the participant’s anonymity since they were identifiable for the interviewer (Cormack, 1996).

Method of Data Analysis

All the researches used thematic content analysis, which is creditable method of data collection (xxxx). Only Hamilton and Asset clearly stated the method used and who analysed the data: two members of the team. What does this mean for the research?

Cortis transcribed the interviews himself to became personally immersed in the information. What does this mean for the research? Clegg points out that Micro-analysis of the data were used to identify categories but fail to say who analysed data. Having different people conducting the interview and the analysis of the texts can have an impact on the richness of the analysis performed (Strauss and Corbin, 1998).

Nonetheless, steps were taken by all researchers to uphold the rigour of the interpretation by checking the transcript with the participants to ensure correctness, which gave the data conformability and credibility (Forchuk and Roberts, 1993). They also must be praised for indicating that the data was analysed systematically in several steps. However, they all fail to state the type of qualitative software used to categorise the information i.e. Ethnograph and if it was positive or negative to the analysis (Barnard, 1991).

(Clegg: Triangulation was introduced into the process of data analysis, which was carried out by a colleague from India).

The methodological strength linked to the utilisation of this thematic content analysis in these studies is that it is commonly used in qualitative research and is suitable the three study aims. Limitation would be this analysis includes gathering statements on the bases of similarity and frequency with the aim of making them to themes (Barnard, 1991). It could be argued that by doing so the researchers are using a quantities method of analysis for qualitative data as each data is not being treated uniquely (Barnard, 1991).

Study Results

The three studies identified themes based on the participant’s experience which implies themes were not based on presumption authors (Cormack, 1996). Each studies result relate to its aim, which they must be praised for. The finding of each study uses the participant’s precise statement from the interview, which demonstrates analytical points and allows the reader to hear the voices of the participants. This demonstrates conformability and credibility (Burns, 2000) and lets the reader to get in-depth understanding of topics in discussion (Morse1196).

Hamilton and Essat’s results highlight the view held by BME groups regarding nursing community’s lack of knowledge of cultural and religious beliefs. Cortis’s findings agree with this as majority of the nurse participants did not deem that the provision of care was affected by culture and spirituality/religion was viewed narrowly by identifying the need for patients to perform prayers with no lack of recognition of other religious requirements. Participants in Clegg’s study described the fundamental importance of religion and its effect on health and hospitalization. Other references re culture and religion to be added.

All three studies highlighted communicational problem between patients and nurses, which as an issue hinders the development of relationship. However, problems in this area have been covered in many other studies such as (add referennces)……. And proposals and provisions to address them have been made by the DoH in order to reduce health inequalities (reference).

Study Discussion

All researchers offer a comprehensive discussion of their topics while comparing and contrasting their results relating to themes with other similar literature, which puts their finding in context making it more objective (Meltzoff, 1998). However, only Clegg specifies the study limitation which was the sample size- a larger sample size would have enhanced the probability of reaching saturation and increase the importance of the finding.

Conclusion

The three studies offer comprehensive conclusions which summarises the main results while suggesting area of further research or implementation.

Cortis suggests that ‘holism’ needs further conceptualization as his study highlighted nurses understanding of culture as part of holistic care was superficial, which presents a challenge for educators, nursing management, researchers and nursing practice in general. Clegg suggested further research needs to be carried out in order to define the nature of culturally sensitive services. She also points out that nurses understanding of culture and cultural sensitivity needs clarification. Hamilton and Asset suggests that nursing education must ensure that nurse’s initial training and post training education prepares them to become culturally understanding and sensitive.

It could be argued that these three studies make useful recommendation for practice for nurses working with BME patients, which are based on education and research on cultural sensitivity. The three studies suggests that nurses are not culturally competent as required by professional bodies and the Government (English National Board for Nursing and Midwifery and Health Visiting 1997, DoH, 1997, United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1999, Quality Assurence Agency 2001).

Cortis (2004) conducted a phenomenological study investigating the experiences of 30 registered nurses who had nursed Pakistani patients in a large acute hospital in north England within the last three months. Semi-structure interviews and supplementary questions to follow up were the main method of da