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Over fifty years ago, Madeline Leininger was on a mission to advance the practice of transcultural nursing. Times have definitely changed in the last fifty years, and transcultural nursing has become a major focus for the government as well as many nursing organizations. Emerging standards of care regarding culturally competent care, is an important aspect of the health care industry, especially nursing. With the growing population, there is an increasing amount of people that are not native to America. As nurses, it is important to understand and respect a multitude of different cultures in order to appropriately care for a diverse patient population. This paper will explore the meaning of culturally competent care as it relates to this nurse’s place of employment (Gwinnett Medical Center), identify populations affected, and show how culturally competent care is implemented, as well as how it can be improved. Culturally Competent Care

The Office of Minority Health defines cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (2013). Culture can be defined as beliefs, values, and traditions that influence a person’s life choices, especially those pertaining to health care. It also includes language and education level native to a person’s country of origin, or region. Nurses see and experience these languages and beliefs first hand. It is important for nurses to care for patients and families with different beliefs in a way that is respectful and incorporates these beliefs for the patient’s well-being.

At this nurse’s place of employment, there have been many advances in providing effective culturally appropriate care. Gwinnett Medical Center is located in one of the fastest growing communities outside of Atlanta, and is a Level II trauma center. With two campuses, containing a total of 553 beds, the service area covers Gwinnett and part of Fulton County. Therefore, many of the patients are from outside the United States. With such a diverse patient population, it is important for nurses and other health care providers to have a knowledge base that allows them to be able to understand, and respect, different beliefs and traditions. Leadership at Gwinnett Medical Center maintains cultural sensitivity as a priority, in turn, ensuring that all employees understand various cultural etiquette, and implements policies to promote cultural care. Their mission is to provide quality health care for the expanding community. Populations

As previously stated, Gwinnett Medical Center is located in a very diverse area. According to the US Census Bureau, there are several minority populations in Gwinnett County. The breakdown is as follows: Black or African American alone – 25.5%, American Indian and Alaska Native alone – 0.9%, Asian alone – 11.1%, Native Hawaiian and Other Pacific Islander alone – 0.1%, Hispanic or Latino – 20.7% (US Census Bureau, 2012). Considering the large amount of Hispanic or Latino and Asian populations, language barriers are a great concern. Gwinnett Medical Center has in-house Spanish interpreters, as the main portion of the non-Caucasian patient population is Hispanic. Many of the staff speak, or have learned to speak Spanish in order to communicate with those patients who do not speak English.

For those patients who speak a language other than English or Spanish, the hospital has a Language Line available on every floor to communicate with patients and families. Many of the nurses employed at Hospital A are from India. They are able to communicate and translate for the patients who speak Hindi or Malayalam. Gwinnett Medical Center also employs physicians that are fluent in Spanish and Korean. Many years ago, Gwinnett County was a very rural area that mainly consisted of farmland. The portion of the population that still live in the area have a different view of the currently expanding culture. Thirty years ago, in this rural area, people did not go to the hospital unless they were in labor or were extremely ill.

Many of the older citizens that still reside in Gwinnett County, did not complete high school because they had to work on the farm. Nurses have to be diligent when assessing the learning capability with this portion of the hospital population, because there are some people who cannot read, some who cannot write, or some who do not understand everything they encounter because of their education level. Just like with the non-English speaking population, education materials and explanations must be appropriate for the reading, writing, and education level of the patient. Standards of cultural competence

There are many resources for nurses on providing culturally competent care. The most influential resources are the work of Dr. Madeline Leininger with the cultural care theory, and Campinha-Bacote’s culturally competent model of care (Leuning, Swiggum, Wiegert, & McCullough-Zander, 2002). These frameworks are taught in nursing schools in order to give future nurses the basic framework for providing competent and holistic cultural care. Although each facility has their own standards of care for employees, there is a universal standard of culturally competent care developed by “the Expert Panel for Global Nursing and Health of the American Academy of Nursing, along with members of the Transcultural Nursing Society” (Transcultural Nursing Society, 2014).

The 12 standards, according to Douglas, Rosenkoetter, Pacquiao, Callister, Hattar-Pollara, Lauderdale, Milstead, Nardi, & Purnell (2014), are as follows: social justice, critical reflection, knowledge of cultures, culturally competent practice, cultural competence in healthcare systems and organizations, patient advocacy and empowerment, multicultural workforce, education and training in culturally competent care, cross cultural communication, cross cultural leadership, policy development, and evidenced-based practice and research. Social justice guides clinical decision making by nurses in regards to patients and families. All patients and families are treated equally, regardless of their socioeconomic status, ethnicity, religious beliefs, or background. This standard not only applies to patients and families, but staff as well. Health care facilities need to consistently evaluate the acute care environment to ensure it is culturally appropriate for employees and patients.

Critical reflection is extremely important for nurses to provide culturally competent nursing care. Nurses need to understand their own views and beliefs to be impartial when caring for a patient with beliefs that differ from his or her own. This standard ties in with the standard of transcultural nursing knowledge. By understanding different cultural views on family, traditions, practices, and health beliefs, a nurse can apply that cultural knowledge into his or her clinical practice, which is the fourth standard. Cultural competency is a continuous learning experience that grows as the population grows and different cultural beliefs enter the community. Nurses also need to communicate with their patients in order to provide the best care possible.

Knowing what language a patient speaks is helpful when trying to educate patients on their plan of care. Utilizing hospital provided interpreters, or language line, is an effective way to communicate with patients and families. This also shows patients that a nurse cares enough to explain things in their native language. While Gwinnett Medical Center has in-house Spanish interpreters and physician fluent in Spanish and Korean, there are those patients admitted who speak languages we do not have access to. The language line is available to all staff to communicate with patients and families via an interpreter on the phone, but sometimes there are patients who speak a dialect that the language line does not have an interpreter for. Another issue is that interpreters for languages or dialects that are less common are not available all the time. When caring for a patient in the hospital setting, it is important to be able to communicate with them at any time, day or night.

The standards set forth by the task force also includes standards for the health care organization. Having the appropriate resources and policies in place and available to nurses allows for effective and appropriate care to various cultures. In order to promote patient satisfaction, hospitals need to have the appropriate educational tools and translators so that patients fully understand their plan of care. It is also necessary to have leaders that believe in these standards as well, and encourage nurses to adhere to the cultural care standards. Health care organizations must also use the most up-to-date evidence based practice when caring for a culturally diverse population. Research advances in health care allow nurses to provide the most effective care possible and reduce health care disparities. Nursing Care

Gwinnett Medical Center has a culturally diverse staff of nurses. Having such a wide variety of nurses, gives Gwinnett Medical an advantage for providing culturally diverse care to the growing patient population. Patients respond well to having nurses and other staff from their home country. With such a diverse staff, nurses and other employees learn beliefs and customs from many different cultures just from their fellow employees. In addition, nurses also learn about different cultures from the varying patient population. Gwinnett Medical Center requires employees to complete an annual cultural diversity learning module in order to maintain the most current knowledge. Servicing such a large area, the patient population includes non-insured persons, Hispanics, Caucasians, African Americans, Indians, Asians, and even local celebrities.

Nurses are aware of the health issues associated with the above mentioned groups. For instance, African Americans and Hispanics have a higher incidence of hypertension. Where some nurses are lacking, is in the knowledge of Eastern medicine practices, like cupping. It is important to be aware of alternative medicine treatments, otherwise false accusations occur. With cupping, marks are visible on the body from placing heated cups on the trunk area. These marks could be construed as abuse if a nurse did not know about the alternative therapy. Even though health insurance is now available to everyone through the Affordable Care Act, there are still patients coming to the hospital with no health care coverage. Although nurses do not initially know if a patient has health care coverage or not, after admission, that information is available from the case manager.

During discharge planning, case managers communicate to nurses and physicians if a patient has insurance in order to arrange post-acute care. After this information comes out, most nurses still provide quality care to the patient and advocate for their well-being. This is an area of concern, however, because some nurses and case managers try to discharge the patient too soon, or have an attitude towards the patient when interacting with them. Gwinnett Medical has made strides in the area of language as is relates to implementation of care as well as the patient’s environment. As mentioned before, physicians are fluent in more than one language. There is also a language line available for use in all clinical areas. Cultural care encompasses more than just being able to communicate with the patient and family. As Leininger states, culture is not only in a person’s beliefs and customs, but in their environment as well. In order to provide a more culture friendlyenvironment, Gwinnett Medical has added Spanish television  channels and has increased menu options to include vegetarian, lactose free, and gluten free choices.

When the hospital expanded, and added a new patient tower, rooms were made larger in order to accommodate larger families or family members that wish to stay with the patient overnight. These additions now allow patients to feel more comfortable and more like they are at home when hospitalized. In order to provide holistic, culturally competent care, nurses need to spend time with their patients and get to know their individual beliefs. This is one area that still needs improvement at Gwinnett Medical Center. Nurses are expected to provide excellent nursing care and spend at least five minutes with each patient discussing something other than hospital care. This time lets patients know that the nurse is interested in a patient’s life and improves the nurse-patient relationship.

Knowing what a patient’s life is like outside the hospital, also allows the nurse to understand the patients culture and adjust the care provided based on the information received. Nurses do learn about a patient’s cultural beliefs when performing the admission assessment. A patient database is completed which includes information such as spiritual beliefs, current living conditions, and any beliefs or restrictions that affects the patient’s care (food, blood transfusions, code status). Although this time does give the nurse insight into the patient’s culture, it is not enough time to truly understand a person’s beliefs and values. Having to care for five or six patients at a time, does not allow a nurse to spend very much time with patients individually. Inadequate staffing affects the quality of care patients receive, thus affecting patient satisfaction. Solutions

With patient satisfaction at the forefront of medical reimbursement, the government has become more aware and concerned with improving the disparities occurring in the acute care setting. For the past eleven years, the Agency for Healthcare Research and Quality (AHRQ) has produced the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) in order to measure trends and report the effectiveness, quality and access to health care (Agency for Healthcare Research and Quality, 2014). Although the quality of care has risen to 70% as of 2010, there is still room for improvement (Agency for Healthcare Research and Quality, 2014). Many different government agencies have developed models to improve culturally competent care. According to Betancourt, Green, Carrillo, & Park (2005), improvement in cultural care has become a potential way to increase the quality of care and eradicate racial/ethnic disparities.

One of the most obvious solutions to improving cultural care is education. With the population becoming more diverse, it is important to provide multicultural education beginning in nursing schools. By preparing nurses to provide cultural care before they are in the workforce, they will have a larger knowledge base and better skill set to care for the many different cultural beliefs and practices they encounter when they do enter a health care facility. Many nursing schools are implementing study abroad programs so students can learn first-hand about other cultures More education for nurses already in the workforce is also needed. Although nurses have resources to provide communication to various populations, the need for knowledge regarding cultural beliefs and practices is still apparent. Betancourt et al. (2005) also mention that some states are beginning to require cultural competence education in order to obtain health care licensure.

Patient education is another area that needs improvement. Many patients have a limited English capacity. It is important to provide education to patients and families in a way they will understand. Education databases like Krames or Micromedex have printouts with pictures available in multiple languages. Nurses need to utilize these databases more than they do now for patients who do not speak English fluently. Showing videos and having patients, or family, return demonstration of a procedure, like self-injection, are also ways to improve education. Adequate staffing is another way to promote effective cultural care. Although it does not seem like staffing would have an effect on cultural competence, it actually does.

When nurses are not overwhelmed with the amount of patients they care for, it allows that nurse time to learn about their patients’ culture. In turn, that nurse adds to his or her cultural knowledge base and can better care for that patient, as well as future patients of the same culture. The government has made great strides in the effort to reduce and eliminate disparities. Making health care available to everyone is a giant step in the right direction. One of the main reasons for so many disparities was the fact that low-income, minority groups, and other vulnerable populations could not get health care coverage.

Now, with the Affordable Care Act, people are able to choose their own health care coverage. Critical reflection is also an area that needs improvement in the acute care setting. Having employees complete a cultural belief self-assessment is a good way to approach the issue. Nurses cannot truly be culturally competent until they understand their own beliefs and those of other cultures. This way, stereotyping certain cultures or populations will be avoided and more culturally competent care will be given. Conclusion

Providing culturally competent care is vital to nursing, especially with the exponential population growth. Education on varying cultures is an ongoing process that affects all staff in an acute care hospital. Leininger’s cultural care theory, as well as standards set by many nursing associations, provides a basis for all nurses to practice culturally competent nursing care. Employing nurses from different backgrounds, as well as setting policies that encompass patient centered care, allow hospitals to improve the care given to patients of diverse cultures and populations. In doing so, nurses become a vital component in improving the quality of care and reducing the amount of disparities in the current population.

Agency for Healthcare Research and Quality. (2014). National Healthcare Quality & Disparities Reports. Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/index.html Betancourt, J.R., Green, A.R., Carrillo, E., & Park, E.R. (2005, March). Cultural Competence And Health Care Disparities: Key Perspectives And Trends. Health Affairs, 24(2), 499-505. doi:10.1377/hlthaff.24.2.499 Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J., Milstead, J., Nardi, D., & Purnell, L. (2014, April). Guidelines for Implementing Culturally Competent Nursing. Journal of Transcultural Nursing, 25(2), 109-121. Leuning, C.J., Swiggum, P.D., Wiegert, H.M.B., & McCullough-Zander, K. (2002, January). Proposed Standards for Transcultural Nursing. Journal of Transcultural Nursing, 13(1), 40-46. doi:10.1177/104365960201300107 The Office of Minority
Health. (2013). Cultural Competence. Retrieved from http://minorityhealth.hhs.gov/ Transcultural Nursing Society. (2014). Transcultural Nursing Standards of Practice. Retrieved from http://www.tcns.org/TCNStandardsofPractice.html United States Census Bureau. (2012). Gwinnett County Quick Facts. Retrieved from http://quickfacts.census.gov/

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