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Foster cultural responsiveness on your unit

Roberts, Dionne PhD, RN, FNP-C; Moussa, Mahaman DNP, RN, FNP-C; Sherrod, Dennis EdD, RN

doi: 10.1097/01.NUMA.0000403281.42497.a8
Department: Career Scope: Pacific Atlantic

At Winston-Salem State University in Winston-Salem, N.C., Dionne Roberts, Mahaman Moussa, and Dennis Sherrod are faculty members in the Division of Nursing.

The authors disclose that they have no significant relationship with or financial interest in any commercial companies that pertain to this article.

As patient populations become more diverse, the challenge for nurse managers to ensure delivery of individualized, patient-centered care intensifies. Every patient presents with unique healthcare beliefs, values, behaviors, and lived experiences, and their culture shapes and influences health decisions and perceptions of healthcare encounters. Although cultural responsiveness resources and capabilities are influenced by a health organization's leaders and policies, they're directly implemented by nurse managers, nurses, and staff in each patient and family interaction. Equipping your staff with cultural responsiveness knowledge and skills, and helping them to internalize and consistently demonstrate culturally responsive behaviors, will improve patient satisfaction and quality care outcomes on your unit.

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Making a case for cultural responsiveness

Although it's important to understand cultural influences, in the clinical setting it's imperative for nurses to demonstrate culturally responsive behaviors in patient and family interactions. Cultural responsiveness knowledge and skills assist healthcare professionals to effectively communicate with diverse groups to address their health and healthcare needs.1 Cultural responsiveness requires organizations and individuals to be aware of cultural baselines and diversity in patients, allow and respect patients' cultural perspectives, and collaborate with patients to deliver culturally congruent care.2 Culturally responsive behaviors are readily incorporated into nurse-patient assessments and interactions because current nurse-patient collaboration standards require a genuine, warm, empathetic, caring, and professional demeanor.

Nurse managers should recognize, however, that some staff members may experience difficulty integrating culturally responsive behaviors due to cultural differences and/or expectations. For example, social distance may occur between some staff members and patients due to gender, racial, religious, or other cultural differences.3 The goal is to assist your staff members to re cognize and accept cultural differences among colleagues and patients on your unit and to support patient decision making.

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Know yourself

Self-awareness among nurse managers and staff nurses is the first step in becoming culturally responsive.3 Knowledge and understanding of oneself allows the individual to evaluate his or her own cultural background, stereotypes, biases, and prejudices. Consider how your own culture influences your thoughts and actions. Observe for signs of ethnocentrism—the tendency to judge other cultures as inferior to your own. Ethnocentric judgments can pose barriers to meeting patient needs on your unit, and these judgments may be more prevalent than you think.

For example, healthcare personnel have been educated in a healthcare culture that strongly believes pat ients should comply with medical and nursing recommendations. When the patient doesn't comply, there can be resentment or a feeling that they don't want to improve their health; in reality, there may be barriers such as language, culture, socioeconomic status, or other issues that may be influencing the noncompliant behavior. Identify and discuss patient issues on your unit that may be influenced by culture conflicts. Ask staff members to identify their most and least effective nurse-patient interactions and discuss how culture may have played a role in each. In the least effective interactions, help them to realize how self-discovery and understanding their own culture may improve future interactions. Look for opportunities in staff meetings to discuss the influence of race, ethnicity, and culture on clinical decision making.

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Empower others

It's essential to treat all patients with respect and dignity, regardless of their origin, language, color, religion, or social status. Caring and compassion are universal values fundamental to nursing and should be shown to all patients regardless of cultural heritage. Clarify and advocate for patient preferences and req uests. Establishing trusting nurse-patient relationships promotes increased participation in treatment regimens and healthier outcomes.

Discuss cultural issues with patients openly, such as their country of origin, language, values, customs, and traditions. You might even discuss how the patient and his or her family celebrate, grieve, provide social support, or have traditions significant to healthcare. The nurse needs to know enough information to permit the patient to feel heard, seen, and valued.3

As in all nurse-patient interactions, observe for nonverbal cues to redirect the interview as needed and be flexible. For example, if you're discussing visitation rules and notice a visual cue of disappointment or frustration, ask how this rule influences the patient's and family's needs or customs and be flexible in individualizing strategies to meet their requests. Don't make assumptions about patients' cultural heritage or preferences—ask.

Identify and address cultural barriers on your unit. Make sure that signage, health education materials, pre- and postprocedure instructions, informed-consent forms, and advance directives are provided at the appropriate level of health literacy, language proficiency, and cultural norms.4 Consider cultural food choices in your cafeteria or food services menu. Identify the availability of religious services and places of worship that meet the needs of your patients. Make sure that accommodations and surroundings reflect patients' cultural norms.

Language barriers can impede access to healthcare and increase the risk of adverse health outcomes among patients with limited English proficiency. Inadequate language and communication skills in healthcare negatively impact access, quality, patient satisfaction, and costs.5 Nurses should use interpreter services effectively to interview patients and illuminate the implications of symptoms as they're expressed by individuals from different cultures. Recognize personal communication limitations in second languages and consider learning new languages and techniques that help to connect communication gaps.6

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Staffing strategies

Hire nurses and staff members who reflect the ethnicity and cultures of the population you serve. Staff insight and in-depth understanding of cultures representing your patient population provides additional expertise for optimally meeting patient needs. In applicant interviews, describe the diversity of patients your unit serves and ask the applicant how he or she would meet those patient needs. As the applicant responds, listen closely for stereotypes and bias versus genuine concern and specific strategies for meeting diverse patient needs.

Include cultural assessment, communication, and negotiation skills as basic requirements for nursing staff and provide feedback relating to these areas in evaluations. Encourage staff to be inquisitive about culture and open-minded and res pectful in all patient encounters, recognizing that although patient and family decisions may differ from staff members' professional and personal values and opinions, the patient is the key decision maker for his or her preferred healthcare outcomes.

Also include cultural competence skills as a part of your healthcare system's annual continuing education offerings. Training should relate to the history, culture, language, and traditions of cultural groups seen in your clinical setting. Annual continuing education and performance evaluation should focus on knowledge and skills related to cultural responsiveness practices.

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Quality improvement

Implementing culturally responsive behaviors on your unit promotes quality care. Unresolved cultural differences may cause conflicts among staff and with patients, which can disrupt the delivery of quality patient-care services. These conflicts may arise from patterns of communication, work habits, and even expectations of quality care.3 You should assist staff to consistently implement culturally responsive behaviors. If situations arise beyond your level of expertise, you may consider using cultural lay advisors or consultants to provide guidance concerning best practices to enhance culturally congruent care.3

Include community leaders and representatives in your unit or organizational planning as part of an advisory group to provide thoughts and suggestions regarding the delivery of culturally congruent services. Conduct focus groups to assess how your unit is meeting the healthcare needs of community members and identify areas of improvement. Promote the participation of representatives of the cultural groups served by your unit in your quality improvement meetings.4

Develop tools to assess the health beliefs and behaviors of the community members that utilize your unit services. Analyze the race/ethnicity and language preferences of patients admitted to your unit and discuss the findings with staff. Also include this information in unit orientations to prepare staff and provide insight related to cultural groups and expectations that staff members can expect to encounter.

Identify language barriers to determine the impact on poor comprehension and/or compliance. Make sure patient survey methods are culturally and linguistically appropriate and reflect the needs of multicultural and minority populations. Identify and implement processes to assist all patients in navigating the health system and becoming active partners in their healthcare decision making.4

Make sure your unit's patient satisfaction survey is available in languages spoken by your patient population and encourage feedback in areas related to addressing cultural and diversity needs.1 You might request that patient satisfaction survey results be stratified by patient age (older versus younger), gender, race and/or ethnicity, religion, or other cultural demographic factors if you collect this information in your survey data. These findings will help you assess whether your unit is meeting quality improvement goals with specific cultural groups.

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Be responsive!

A culturally responsive staff understands the impact of their own culture; identifies and addresses cultural barriers; delivers informative, empathetic, and compassionate care; and advocates on behalf of the patient as the primary healthcare decision maker. Strategies such as a diverse staff, an educational focus on cultural competence knowledge and skills, and an emphasis on addressing cultural group needs and preferences in your quality improvement processes can assist your unit to meet the evolving healthcare needs of a progressively diverse patient population. Culturally competent and culturally responsive nurses and staff can assist your unit to provide quality patient-centered care.

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1. Bowen S. Beyond self-assessment— assessing organizational cultural responsiveness. J Cult Divers. 2008;15(1): 7–15.
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