⌛ Transcultural Interprofessional Practice Model
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The Importance of Interprofessional Practice
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Note : Tools used to achieve new competencies include continuing education, professional reading, attendance at lectures, TED talks, seeking input and guidance from respected consumers, peers, colleagues, current or past mentors as well as methods using newer technologies, e. Most registered nurses will meet the standard for culturally congruent practice with its associated competencies through the lifelong process of professional development. Nurses gain relevant new information from research, critical reflection, colleagues, and consumers served, and then apply this knowledge to practice. The process requires ever-expanding self-awareness, continuous judgment of current competence, actions for personal and professional growth, and periodic use of evidence-based assessment tools and methods for critical appraisal.
An essential element of professional nursing practice, lifelong learning takes place via formal education , clinical training, self-directed study and observation, and continuing education. Therefore, nurses seek, and advocate for, educational opportunities designed to integrate culturally congruent principles into their care for diverse consumers and populations. Tailored instruction for nursing colleagues creates the opportunity to educate one another on culturally-specific interventions that improve consumer outcomes of nursing care.
Nurses, who generally have had a graduate education, develop and present educational programs to advance culturally congruent healthcare for nurses and colleagues across healthcare professions Steelman, Validated self-assessment tools are available to the public, including the Implicit Association Test IAT used in numerous studies to rate social and racial implicit bias. Haider published three studies using the IAT paired with clinical vignettes: one with medical students Haider et al. Although all groups had implicit biases according to the IAT scores, the nurses and acute care physicians did not reflect their implicit biases in clinical care responses. The first step in self-assessment is to conduct a personal inventory through critical reflection to become aware of biases that may inadvertently affect clinical decisions and care practices.
Reflective thinking permits persons to examine actions on evaluations and to inquire critically about their worldview and assumptions in specific situations Teekman, For example, culture is mentioned in the first six standards—assessment, diagnosis, outcomes identification, planning, implementation which includes coordination of care, health teaching, and health promotion , and finally, evaluation of practice. Standard 8 further expands and explicates the concept of culture by providing explicit competencies for nurses to demonstrate in order to provide culturally congruent care. Cultural assessment of the consumer occurs in the first stage of the nursing process and is facilitated by a variety of tools. Andrews and Boyle provide appendices with five types of assessment tools for culturally diverse consumers, including individuals, groups, refugees, and healthcare organizations.
Purnell and Spector have assessment guides designed for ease of use by the practicing nurse. These tools also help identify the levels of acculturation of the client and any effects of discrimination and oppression experiences. With the information gained from these assessment tools, the nurse is able to diagnose potential cross-cultural challenges to providing care and to plan culturally and linguistically appropriate interventions and health teaching programs.
Finally, no plan can be complete without evaluation as to whether the intervention was effective in achieving the desired outcome and documenting the process and outcomes. When providing care for culturally diverse consumers, evaluation should also include a determination of whether the consumers were satisfied with the process and intervention. If the intervention is not meaningful or desired, these consumers may not continue with the plan of action and experience negative outcomes.
Effective and respectful communication is essential to nursing practice. Tested tools are available to enhance the efficacy of intercultural communication and also to advance clinical competence. Examples include communication tools for use in the care of patients with sickle cell disease Tanabe et al. Knowledge of cultural customs and values is important in understanding the nuances of the culture and its verbal and nonverbal communication patterns and then in conveying necessary respect. Nurses can reduce language barriers by using translators and interpreters and employing nursing skills associated with social and emotional intelligence.
For health consumers with hearing impairments, nurses use advanced technology or interpreters skilled in American Sign Language. In choosing written materials, the nurse engages culture-specific consumers in the community to evaluate the materials for readability and cultural appropriateness before distribution. In every possible case, the nurse considers preferences of the health consumer before choosing how to meet communication needs. Nonverbal behaviors also may require sensitivity to cultural practices. For example, the appropriate face-to-face distance between people in conversation varies among groups. If nurses build carefully supported, trusting relationships, inadvertent missteps in the cultural space are more likely to be averted or forgiven.
When providers use medical jargon, families may become resistant or even hostile. Wiebe and Young suggest simple strategies to increase communication and reduce stress. These strategies include answering every question carefully, teaching by demonstration, providing simple explanations, and demonstrating caring relationships for the building of trust. Searching for culture-specific meaning in interactions , terms, and content of conversations will help the nurse provide culturally congruent communication.
Shared decision-making highlights patient involvement with treatment decisions, which can lead to better health outcomes Mead et al. Mead et al. Nurses can share decision-making with these consumers only if nurses themselves have culturally congruent assessment and communication skills. For example, in some cultures, the woman is the designated caregiver for the children and needs to be actively involved in all child-related healthcare decisions. In other cultures, the father or the parents together assume this role. In shared decision-making , nurses introduce the sharing process, provide information, ascertain preferences, and discuss options to adapt a usual procedure or process, such as screening, treatment, comfort measures, and visitation, among others.
Because the consumer may prefer not to make decisions, and urgency for care may preclude choosing, the extent of sharing will vary. For example, a consumer family may wish to have an end-of-life religious rite that requires a specially scented candle, which would be dangerous in the presence of oxygen. In such cases, the nurse could negotiate for the scents to be released immediately following death and discontinuation of oxygen. For example, a successful clinic-based Diabetes Prevention Program was adapted for several community-based settings because nurses engaged in shared decision-making with their consumers Kramer et al.
Nurses constitute a large professional workforce that engages in and leads changes in health policy; they have considerable opportunity and responsibility to advance the initiative that all people have access to healthcare. Policy discussions involve the effects and impact of discrimination, oppression, and often-related social and environmental determinants of health on cultural groups and the resulting health disparities. Nurses advocate for policies that promote health and prevent harm among culturally diverse, underserved, or underrepresented consumers. For example, nurses advocate for all consumers, especially the culturally diverse and underserved, to receive equal access to services, tests, interventions, and health promotion programs. Achieving this goal requires nurses to advocate for sufficient funding for efficient and effective planning, delivery, and maintenance of culturally congruent care.
Graduate-level nurses, including APRNs and other advanced nurses, are equipped to lead and participate in designing systems of care and organizational policies that reflect respect, equity, and values for diversity and inclusion ANA, a , p. Using national and international standards of care and evidence-based practice, APRNs can model culturally competent adaptation of these guidelines to different life contexts of individuals, families, and communities in order to achieve the best possible outcomes Carpiano, When cultural preferences and norms are incompatible with evidence-based practice, these graduate-level nurses can negotiate a solution based on mutual decision-making.
These nurses are in positions ideally suited to advocate for and lead inter-professional teams to identify the cultural and linguistic needs of the consumer and to design appropriate solutions. Nurse administrators have the authority and the tools to develop recruitment and retention strategies that supply a multicultural workforce for their institutions. Through their positions in health systems, nurse executives and leaders can work with organizational leadership in designing policies and systems to facilitate easier access and the tailoring of high quality care to the special needs of their culturally diverse consumers Douglas et al.
Moreover, through membership in civic and inter-professional organizations, advanced nurses can develop effective coalitions of cross-cultural partnerships to effect change at the local, national, and international levels Jenerette et al. Also, nurse leaders should engage representatives of the cultural groups to participate on institutional committees and assume leadership posts in their healthcare systems to impact their respective populations. The Standard 8 list of competencies will help to formulate a credible assessment tool by which the nurse can conduct an informal self-evaluation of culturally congruent practice. Culturally congruent nursing practice spans all types of consumers, healthcare delivery systems, and nursing roles; therefore, practice evaluation ranges from fairly simple to complex.
The literature shows the beneficial effects of culturally congruent practice on the skills, behaviors, and self-reported practice of healthcare providers and on patient satisfaction Beach et al. However, there remains a lack of comprehensive tools to measure cultural competency, thus limiting the ability to evaluate this aspect of nursing practice; more research is needed to develop these tools Purnell, Standard 8 adds focus and considerable specificity to culture-related care. Because of the specific competencies for graduate-prepared nurses, including APRNs, the standard also guides nurse executives and policymakers.
The aim of research related to culturally congruent practice is to eliminate racial and ethnic health disparities among all populations. Registered nurses from all areas can identify research questions to improve culturally congruent care, and nurses with advanced degrees can evaluate the tools, instruments, and services for culturally diverse populations. These nurses can assess whether evidence-based guidelines of practice for the general population are relevant to specific culturally diverse consumers.
Nurse researchers design and clinically test new interventions for culturally diverse consumers to improve the healthcare experience and health outcomes. The current research into culturally congruent nursing to improve healthcare is sparse, and findings are not usually conclusive. However, across such studies examined with meta-analyses, health outcomes did not significantly improve Conn et al. Similar meta-analytic studies of physical activity interventions showed improvement when underrepresented minority members were involved in delivering the project to those in their communities Conn et al. More research on culturally congruent interventions is needed for understanding the effectiveness of these interventions.
Standard 8 can help nurses at all levels so as to advance research to improve outcomes for culturally diverse consumers. The demand for culturally congruent practice in Standard 8 and accompanying competencies prevails in clinical, educational, and research settings. Within quality-focused practice settings, nurses take the opportunity to learn about the cultures of the consumers for whom they provide care and support. Nurse managers are advised to use standard onboarding, continuing education, and annual reviews to advance individual and unit development for culturally congruent practices. Development sessions could include such topics as ways to understand diverse, non-verbal communication patterns, how to negotiate culturally conflicting situations, and how and when to access language services when consumers have limited English proficiency.
It is important that quality healthcare systems serving diverse populations pay attention to providing appropriate language services that include provision of interpreters and translators, especially for all informed-consent processes, consumer-rights documents, and consumer-education materials. Educational institutions should incorporate cultural content throughout all nursing curricula, including specialties. In addition, nursing programs striving to be culturally competent will want to recruit and then support 'underrepresented in nursing' minority faculty and students.
Professional organizations and regulatory bodies are strongly encouraged to disseminate rapidly the new Standard 8 and its competencies to larger audiences through poster and podium presentations, publications, and social media. Nurse researchers are encouraged to build substantial research programs beyond descriptive investigations. The essential next step is to design and test interventions that have meaning for populations from different cultures and improve their health and quality of life.
Because this step requires sample sizes large enough to support meaningful conclusions, nurses and supporters need to advocate for more funding for these studies at the national level. Such research can help to eliminate the dismal inequities seen in diverse-consumer health outcomes. By implementing the standard, culturally competent nurses will increasingly serve as role models for novice clinicians, colleagues, and consumers and as leaders of change.
The new standard for culturally congruent practice sets the bar for registered nurses' educational, legal, and societal accountability. Cultural congruence is part of the fabric of nursing practice because of the social contract between the profession and society; and the new Standard 8 advances all of nursing practice within the contract. By implementing Standard 8 and its accompanying competencies, nurses will RAISE the bar See Figure below and make important contributions toward reducing racial and ethnic disparities in both health outcomes and healthcare services. Readers can use the Call to Action strategies listed in the Box to guide their own plan to advance culturally congruent nursing practice.
A ssessing the document and contemplating what it means to you and your practice. I ntegrating the scope and standards into practice by developing culturally congruent care in every situation and setting. S haring the word and encouraging other nurses to integrate the scope and standards into practice. E xcelling in using knowledge and conducting and applying research to achieve the highest quality, evidence-based care. By implementing Standard 8 and its accompanying competencies, nurses can make an important contribution toward reducing racial and ethnic disparities in both health outcomes and healthcare services. Over 30 years, she worked to develop national nursing standards, including coauthoring the first American Nurses Association nurse practitioner scope and standards and the current nursing scope and practice standards.
Her NIH and other funded research evaluates health behavior change interventions designed by nurse practitioners for persons and groups from challenging walks of life. As a family nurse practitioner, she cared for people who were at highest risk due to poverty, racial discrimination, homelessness, immigration, abuse, and mental and other illnesses. Lavin is an Associate Professor Emerita at Saint Louis University where she taught doctor of nursing practice students, served as founding director of clinical services at Casa de Salud, and as principal investigator of a federal Office of Rural Health Policy outreach demonstration grant in Washington County, Missouri.
Nancy K. She received her diploma at St. Her research interests include professional nursing care documentation, nursing students and their preceptors, and nursing in older adults. She is a delegate in the American Nurses Association and a current member of the workgroup for the Revision of Standards and Scope of Practice for the organization. She is a past Jonas Nurse Leaders Scholar , and her research interest lies in the area of professional socialization. As a community health nurse, she has cared for individuals of various ages, socioeconomic status, and cultural backgrounds. Elizabeth L. Thomas led the workgroup charged with production of the third edition of Nursing: Scope and Standards of Practice , published by ANA in A consultant in school health, Mrs.
Thomas, manages and provides professional development for the Delaware Comprehensive Induction Program for School Nurses. Carol J. Her portfolio includes development and revision of nursing scope and standards of practice documents, consultation services to specialty nursing organizations seeking ANA recognition, workgroup support, and document development. Bickford was an integral member, contributor, and facilitator of the initial nursing scope and standards revision workgroup and the subsequent smaller group creating this discussion about the new professional performance standard addressing culturally congruent practice.
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