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Editorial
Towards a Culturally Competent Nurse Workforce
Rhonda Griffiths
Director, South Western Sydney Centre for Applied Nursing Research; Professor of Nursing, University of Western Sydney; Director, NSW Centre for Evidence Based Health Care, Sydney NSW
John Daly
Dean, Faculty of Nursing Midwifery and Health, University of Technology Sydney, Sydney NSW
Article Text
The cultural diversity of Australia is considered to be a strength that will assist this nation to take advantage of, and meet the challenges that come with participating in the rapidly changing ‘global village'. A culturally diverse society provides its own challenges, and over the past 30 years state and federal Governments have disseminated a range of policies and initiated programs that provide frameworks and benchmarks for meeting the goals of access, equity and inclusiveness (Omeri 2003) for all people living in Australia. Responding to and accommodating cultural diversity poses particular challenges because of the intensely personal meaning that established cultural mores have for individuals, and the tendency for people to cling to their cultural heritage and, in some instances, biases.
Health and education are the mainstays of a nation. Success in the arts, science, humanities and business requires people to have access to a range of educational options and access to quality health care. There is a plethora of research from the social, health and education disciplines that demonstrates unequivocally the nexus between these social foundations. There is also an increasing body of evidence to guide the application of that research to inform the everyday issues that arise in a diverse society.
How is that cultural diversity reflected in education of clinicians and translated to the health system they work in? There is an expansive body of published, peer reviewed research that can be used by individuals and organisations to provide an evidence based approach to transcultural health care.
The Australian National Review of Nursing Education Multicultural Nursing Education reviewed the ways in which nurses are currently prepared for multicultural practice (Commonwealth Department of Education, Science and Training [DEST] 2002). In that document cultural competence is described as:
A set of congruent behaviours, attitudes and policies that come together in a system of agency or among professionals that enable effective interactions in a cross-cultural framework. DEST 2002: 4
The report concluded that there has been an explosion of theories of cultural competence and literature describing its application. Examples from international and local facilities were analysed and included in an extensive list of areas where theories of cultural competence had been applied to nursing in education, research, workforce planning, care delivery in general and speciality settings, and health promotion and community care.
Individuals and organisations have a joint responsibility to create an environment that is conducive to and will foster cultural diversity, be prepared to commit to ongoing review, and when necessary initiate and support change (Omeri 2003). That joint responsibility is a theme that runs through the contemporary literature and is echoed by contributors in this special issue of Contemporary Nurse. In this section of the publication, Carolyn Rutledge et al (2008) describes an education program that uses multimedia resources and experiential learning to assist clinicians overcome many of the barriers to cultural competence they experienced in their workplace. This program could be implemented or adapted to suit various situations to assist positive interactions with people from diverse cultures. While clinicians generally become aware of the construct of cultural competence through modelling by colleagues, Campinha- Bacote (2008) suggests that the actions required to function at that level can also be learned by clinicians as part of their structured education programs. In a longitudinal study, Maltby and colleagues (2008) encouraged a cohort of baccalaureate nursing students to reflect on their attitudes towards nursing clients from diverse populations. The themes that emerged from the data namely: equal treatment; commitment to serve all clients; and ‘it's not easy', challenge clinicians on a daily basis. Papadopoulos et al (2008) developed and tested a tool to measure cultural competence of staff working in Child and Adolescent Mental Health services. Promoting a culture of cultural competence extends beyond client care. The workforce shortages of trained staff that is now a feature of health services, has resulted in the globalisation of the nursing workforce. The article by Brunero et al (2008) highlights an increasingly important issue for health services. The migration of the nursing workforce creates a need for health services to implement strategies that assist Australian trained nurses to appreciate the benefits of a culturally diverse workforce and assists overseas qualified nurses to weather the cultural clash they experience as they ‘rotate' around the world.
Three policy principles that are dominant in the multicultural policy agenda - access and equity and inclusiveness (Omeri 2003) - are also dominant in the health agenda. Best practice in health care for a multicultural society requires consideration of cultural as well as clinical imperatives. The needs of people from culturally diverse backgrounds must be taken into account when developing care. In some instances this will mean different approaches are appropriate, and the outcome of care may also be different.
Having access to evidence is only one part of the formula for effective transcultural nursing. In all Western countries, the health sector consumes a large proportion of Government funding; however, we have little evidence to demonstrate the effectiveness of interventions, processes and models of care. Research has made a major contribution to health care, particularly in technology led areas for example pharmacology, diagnostics and surgery. Some interventions are outstandingly effective in reducing mortality and morbidity, and ‘high profile' interventions receive attention. However, at the bedside, clinical decision making continues to reflect convention and tradition (Grimshaw & Eccles 2004; Grol & Grimshaw 2001; Johnson & Griffiths 2001). Why is this the case? A variety of reasons for the sustained theory/practice gap have been presented. The culture of health care facilities has been implicated, as has the nursing culture, clinical priorities, issues of leadership and communication and resources (Johnson & Griffiths 2001). Reasons for this situation have been proposed, including the task oriented nature of clinical practice, the absence of guiding frameworks, and lack of detailed exploration about how to implement research.
The notion of clinician-led research introduces an alternate paradigm to health services research that has challenged the traditionally designed and accustomed roles of researcher and clinician. Factors that militate against clinician led change have been proposed and include (Grol & Wensing 2004; Johnson & Griffiths 2001; Rycroft-Malone et al 2004):
- lack of support and lack of authority to implement change
- lack of research training for clinicians
- the absence of organisational and research information systems; and
- the constraining nature of the nursing role
Getting evidence into practice
Enacting strategies designed to promote social a responsibility at both the organisational and individual level. That is, providing quality care to a diverse population requires both systematic responses ... and the delivery of care by skilled and sensitive providers. Grol & Wensing 2004: 3
Despite the emphasis on evidence based care and the development of resources and support to assist clinicians to access evidence, the gap between the evidence and practice has not narrowed (Grol & Wensing 2004).
Increasingly undergraduate and post graduate curricular include discrete learning opportunities to promote skills and knowledge to achieve cultural competence and outcomes against which learning can be measured. Nurses who translate those skills into clinical practice have the potential to change national health policy (Boyle 2000).
Ignaz Semmelweis (1818-1865) and Joseph Lister (1827-1912) had the idea that infection was associated with poor hygiene by hospital staff. Although their colleagues forcefully rejected their hypothesis they persevered and were vindicated. The researchers and clinicians who have contributed to this special issue of Contemporary Nurse have put out the challenge. Providing culturally competent care is a universal standard that, when achieved, will save and change lives for recipients and providers of health care.
References
Boyle J (2000) Transcultural nursing:Where do we go from here? Journal of Transcultural Nursing 11: 10-11.
Brunero S, Smith J and Bates E (2008) Expectations and experiences of recently recruited overseas qualified nurses in Australia, Advances in Contemporary Transcultural Nursing 2nd edn, Contemporary Nurse special issue 28(1-2): 101-110.
Campinha-Bacote J (2008) Cultural desire: ‘Caught' or ‘taught'? Advances in Contemporary Transcultural Nursing 2nd edn, Contemporary Nurse special issue 28(1-2): 141-148.
Commonwealth Department of Education Science and Training (DEST) (2002) National Review of Nursing Education. Multicultural Nursing Education. DEST, Canberra.
Grimshaw J and Eccles M (2004) Is evidence-based implementation of evidence-based care possible? Medical Journal of Australia 180: S50-S51.
Grol R and Grimshaw J (2001) From best evidence to best practice: Effective implementation of change in patient's care, Lancet 363: 1225-1230.
Grol R and Wensing M (2004) What drives change? Barriers to and incentives for achieving evidence-based practice, Medical Journal of Australia 180: S57-S60.
Johnson M and Grifiths R (2001) Developing evidencebased clinicians, International Journal of Nursing Practice 7: 109-118.
Maltby HJ (2008) A reflection on culture over time by Baccalaureate nursing students, Advances in Contemporary Transcultural Nursing 2nd edn, Contemporary Nurse special issue 28(1-2): 111-118.
Omeri A (2003) Meeting diversity challenges: Pathways of ‘advanced' transcultural nursing practice in Australia, Contemporary Nurse 15(3): 175-187.
Papadopoulos I, Tilki M and Ayling S (2008) Cultural competence in action for CAMHS: Development of a cultural competence assessment tool and training programme, Advances in Contemporary Transcultural Nursing 2nd edn, Contemporary Nurse special issue 28(1-2): 129-140.
Rutledge CM, Barham P, Wiles L, Benjamin RS, Eaton P and Palmer K (2008) Integrative simulation: A novel approach to educating culturally competent nurses, Advances in Contemporary Transcultural Nursin, 2nd edn, Contemporary Nurse special issue 28(1-2): 119-128.
Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B and Titchen A (2004) An exploration of the factors that influence the implementation of evidence into practice, Journal of Clinical Nursing 13: 913-924.
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