Quality of Nursing and Diversity

Critically discuss how an understanding and application of the concepts of diversity, cultural competence and equality can help to improve the quality of nursing care in today’s diverse healthcare settings for a diverse service-user population

The Office of National Statistics (2014) displays how the population of Britain is becoming increasingly diverse due to migration, with 560,000 people migrating to Britain between March 2013 and March 2014; a significant increase from 492,000 people in the previous 12 months. Globalisation; which is the increasing integration of economies and societies has a profound effect on migration and health. For example the ease of accessibility of borders for services and trade removes the boundaries for migration and increases the production and marketing of products such as tobacco which have an adverse effect on health (Wamala and Kawachi 2007). The increasing movement of countries into the European Union (EU) also removes the boundaries to migration as the European commission state that individuals who hold European citizenship have rights to free movement and residency within the EU(EU 2014).

The acceleration of globalisation and the growth in migration means the NHS have to care for an increasingly diverse service-user population who have a range of health needs which presents many issues and challenges for nursing care. Blakemore (2013) recognised how research by Macmillan cancer support found that patients from Black minority ethnic (BME) groups experience increased challenges and poor treatment compared to white British cancer patients; such as lack of compassion and poor and ineffective communication.

This is an example of how diverse groups can receive poor quality care and highlights the need for nurses to understand and apply the concepts of diversity, cultural competence and equality to evade this diminished care. This essay will explore, discuss and critique these concepts when looking at how they can improve the quality of nursing care in today’s diverse healthcare settings for a diverse service-user population.

Diversity is defined by Dayer-berenson (2014) as the ‘individual differences of the human race’ which should be ‘accepted, respected, embraced and celebrated by society’. The differences encompass many factors such age, religion, ethnicity and sexual orientation, all which shape an individual to be unique. This definition however fails to acknowledge that differences exist within each unique factor. For example in ethnic groups; where although common characteristics such as language and origin are shared, differences within the ethnic group still do exist such the extent to which the individual practices their religion, and the culture to which the individual identifies to (Henley and Schott 1999).

The National Health Service (NHS)(2011) expand on this definition by recognising that diversity includes ‘visible and non-visible’ differences. Recognition of this is important in clinical practice as non –visible differences such as values and beliefs will not be established unless nurses effectively communicate and assess there patients values, needs and prefences. This will prevent the assumption that all members of one ethnicity act as another as mentioned previously, and therefore avoid stereotyping. Henley and Schott (1999) recognise how stereotyping will result in inadequate nursing care as people distance themselves from those they see as different, causing them to have a lack of consideration and respect for the individual, thus diminishing care.

Furthermore, when assessing the values and beliefs of diverse patients, nurses must avoid holding an ethnocentric attitude. Ethnocentrism is when people identify their own cultural ways as superior to others, creating an attitude that any other beliefs and values are wrong. This leads to inadequate care as other diverse beliefs, values and therefore needs; will be rendered as insignificant and may be ignored (Royal college of Nursing (RCN) 2014). Ethnocentric behaviour however is not always recognised by the individual and is therefore difficult to challenge, as through socialisation into their own cultural values and beliefs a viewpoint of what is ‘normal’ and ‘appropriate’ is created. This viewpoint is then used to often negatively judge diverse cultures that the individual comes across (Henley and Schott 1999).

On the other hand Sharif (2012) views ethnocentrism as having a positive influence on healthcare in the United Kingdom. When looking at BME groups, South Asians are a high risk group for public health diseases such as cardiovascular disease, diabetes and chronic kidney disease. Sharif recognises the need for ethnocentric interventions to educate South Asian communities and to distinguish them as a group to further investigate the differences in epidemiology, pathophysiology and health outcomes.

This view is opposed by The Nursing and Midwifery Council (NMC)(2010) who state in their standards for pre-registration nurses that nurses must strive for culturally diverse nursing care by practicing as holistic, non-judgemental and sensitive nurses, avoiding assumption, recognising individual choice and acknowledging diversity. Therefore nurses must adhere to this code by avoiding stereotypical and ethnocentric attitudes which can be done through assessing and recognising patients as individuals. This will result in high quality care which is essential for a diverse service user population.

Respecting individual patient diversity results in respecting equality which is the elimination of discrimination and disadvantage through respecting the rights of individuals and promoting equal opportunity for all. Nurses working within an organisation must comply to the Equality Act 2010 which protects 12 diverse characteristics such as age, disability and religon from discrimation and disadvantage (Equality and Human Rights Commison 2014). In healthcare this is done through the implementation of policies and guideance, however Talbot and Verrinder (2010) highlight how equality policies can express the need for patients to receive equal care regardless of characteristics and background. This ignores personal choice and therefore disregardards individuality and diversity; producing poor quality care.

When looking at equality further nurses can promote equality through ensuring everyone has equal and full access to health care. It is recognised that BME patients have a poor uptake of healthcare services compared to white British patients for several reasons such as; language barriers, negative experiences and inadequate information (Henley and Schott 1999,Washington and Bowles et al 2008). Dayer-berenson (2014) however identifies that barriers to healthcare are not just due to racial factors but also socio-economic factors. Nimakok and Gunapala et al (2013) expand on this further by recognising that individuals from BME communities are more likely to be of poor socio-economic status than their white counterparts ; due to factors such as low income and poor housing quality. Nurses must therefore be in the position to promote equality through endorsing equal access to healthcare and complying to equality policies. This must be done whilist respecting individual patients and their diversity which produces culturally competenet nurses and thus high quality care for the diverse service user population.

Cultural competence is defined by Papadopolus and Tilki et al. (2003) as the act of respecting the cultural differences of patients in order to provide effective and appropriate care. This is a brief definition which fails to include all aspects of being a culturally competent practicioner, which arguably involves more than respecting cultural differences which will later be explored (McClimens and Brewster et al. 2014).

Leininger (1997) states that cultural competence is the goal of providing culturaly congruent, compent and compassionate care through holisticly looking at culture, health and illness patterns and respecting the similarities and differences in cultural values and beliefs.This definition fails to recognise that cultural competence Is never a completed goal but an ongoing process (Dean 2010), however it recognises the importance of looking at the similarties within cultures. This increases the nurses ability to understand and meet the patients full range of needs thus producing culturally competent care (Henley and Schott 1999).

Cultural competent nursing care is essential for enusuring high quality care in the increasingly diverse service user population, with The NHS stating that it provides a comprenhesive service for all regardless of background and characteristcs and In consideration of each individuals human rights. Respect for equality and diversity are two important aspects of The NHS`s vison and values as highlighted in this statement; and through culturally competent care these values can be achieved (McClimens and Brewster et al. 2014, NHS 2014).

Educating health care professionals on culturally competent care is therefore important with Hovat and Horey et al. (2014) looking at the effects of educational cultural competence interventions for healthcare proffesionals on healthcare outcomes. The review found that health behaviour such as concordance to treatment was improved however they also acknowledged that there quality of evidence was poor and that cultural competence is still a developing stratergy, therefore further research is needed to establish its effectiveness on healthcare outcomes.

Dayer-Berenson (2014) however, states how culturally competent care does produce positive healthcare outcomes and therefore high quality care as through culturally competent practice, cultural sensitivity can be developed. This will bridge the gap between the healthcare professional and the patient which allows the patient to feel understood, respected and supported.

There are various models which offer an understanding of cultural competence and a process for developing cultural competence to allow for high quality care. Campinha-Bacote developed the `The Process of Cultural Competence in the Delivery of Healthcare Services model’ in 1998 which looks at how the healthcare professional must work within the cultural context of the patient and ‘become’ culturally competent rather than ‘be’ culturally competent. Campinha-Bacote sees becoming culturally competent as an ongoing process which involves the constructs of cultural awareness, knowledge, skill, encounters and desire Campinha-Bacote (2002). When looking at cultural awareness; which is the process of the nurse exploring there own cultural and professional background and any bias towards other cultures, Dayer-Berenson (2014) agrees nurses need to be aware of there own culture so that they can step outside of it when necessary and care for patients only in terms of their needs. This will reduce misunderstandings and misjudgements and therefore failures in care, allowing for high quality care for the diverse service user population.

On the other hand this model has some weaknesses. When looking at the construct of cultural skill which Campinha-Bacote (2002) defines as the collection of relevant cultural data through cultural assessment in regards to the patients presenting problem, Leishman (2004) identifies some issues. Her study on perspectives of cultural competence in healthcare found that nurses do not agree that the personal beliefs and values of patients should be impinged upon as Camphinha-Bacote suggests in her model. Leishmans study found that this may impact the patients overall impression on the care they receive and that individual patient needs irrespective of culture should be the focus of care.

This view argues that patient centered care is favourable over cultural competence when caring for a diverse patient population . Patient centered care describes care which is centred around the individual and their needs with inclusion of families and carers in decisions about treatment and care (Manley and Hills et al. 2011). It is a philiosphy which is embedded at the forefront of all patient care, with a recent inquiry comminsed by the Royal College of General Practicioners (2014) emphasising the importance of patient centred care in the 21^st century to meet the challenging and changing needs of patients; such as the increase in the diverse patient population.

Kleinmans explanatory model of illness offers an alternative approach for looking at cultural competence as it supports the delivery of person centred care. The model contains steps that the healthcare professional can use to communicate with their patients. The steps look at several issues such as; establishment of the patients ethnic identity and what It means to them, how an episode of illness can effect the patient and their family, what the illness means to the patient, and how a cultural competent approach may help or hinder the patients care (NHS Flying Start 2014 , Kleinman and Benson 2006).

By eliciting the patients and their families views and explanations of their illness the model allows for patient centred care. Also the cross cultural communication and recognition of any conflicts in values and beliefs which need negotiating produces culturally competent care (Hark and DeLisser 2009, Misra-Herbert 2003). The model has further strengths which also allow for high quality care as recognised by Kleinman and Benson (2006) who state that the model allows practicioners to set there knowledge alongside the patients own views and explanations which avoids an ethnocentric attitude. On the other hand the model is focused on the interaction between doctors and patients so it is therefore questionable as to wether this model can be applied to the nursing care of a diverse service user population (Misra-Hebert 2003).

The acceleration of globalisation and therefore increase in migration means that the NHS have to care for an increasingly diverse service user population. To give high quality nursing care to their patients nurses must understand apply the concepts of diversity, equality and cultural competence. This essay has shown how this can be done by ensuring their practice is underpinned by legal and ethical principles and through respecting the diversity of all through treating patients as individuals and avoiding stereotypical and ethnocentric attitudes. Respecting diversity can also endorse equality which nurses can also encourage through promoting equal access to healthcare for all. Finally nurses must be culturally competenet practicioners by respecting diversity and equality and through the implication of models although further research is needed as cultural competence is a developing concept with other principles such as patient centered care also being seen as essential in nursing practice.

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