A clinician sees a Somali patient with a primary complaint of back pain and, following an exam, prescribes a traditional course of western medical action. The patient, however, is reluctant to act on the medical advice because he thinks his back pain is caused by a bad relationship with his parents or guilt over something he did. “It is always good (for clinicians) to have some knowledge about their patient’s culture, to know who they are dealing with,” says Fozia Abrar, MD, of Minneapolis. “It might cost time and money, but you save more money by not getting a misdiagnosis, by improving quality of care.”
Suffering from bacterial gastritis, a Somali woman in Minnesota visits several providers but does not take the medication they prescribe. When met with a smile and a greeting in her native language by Dr. Abrar, the patient complies with the same treatment recommended by the previous providers—Dr. Abrar successfully persuaded the patient to fill a prescription and take the medication because of her knowledge of the patient’s culture. This situation is not new or unique—medical anthropologist and psychiatrist Arthur Kleinman, MD, has spent 30 years championing cultural issues in medicine. He says a great body of evidence shows culture does matter in clinical care.
Every cultural group has traditional health beliefs that shape members’ perspectives about wellness. The increasingly diverse, twenty-first-century patient population requires clear communication and practitioner awareness of patient health perspectives in order to significantly impact patient satisfaction, safety, compliance, and outcomes.
Organizational Culture, Patient Satisfaction, and Safety
Organizational culture informs every worker whether patient satisfaction is a key value. By influencing employee behavior and how employees are treated, culture drives employee effectiveness, safety, and whether employees take advantage of opportunities as they arise. Organizations that dedicate additional employee resources to patient safety signal to employees that both employee effectiveness and patient safety are high priority. In other words, organizational values and beliefs guide employee commitment to patient and worker satisfaction. According to the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report, patient safety improved more at hospitals where they increased employment of staff who reported incidents, compared to hospitals that did not expand the number of employees who reported incidents.
At Atrius Health, a Massachusetts ambulatory care provider with 36 locations, staff can report safety events while updating existing electronic health records (EHRs). This reporting mechanism has increased the number of reported events, and as many as 30% of events reported monthly come in through the EHR tool, according to Ailish Wilkie, patient safety and risk management director for Atrius Health.
In other words, employee accountability shapes workplace and organizational culture.
Patient Culture, Provider Culture
In addition to the effect workplace culture has on patient satisfaction and employee competency, two additional areas of culture impact health care effectiveness. Both a patient’s cultural background and the provider’s scientific/medical culture inform patient and provider wellness perspectives. If patient compliance with the treatment plan is the goal, providers need to understand the patient’s cultural identity.
By the same token, patients need to know that their perspectives are respected. Few health care observational studies have reported sufficient information to support the claim of provider bias, but a 2006 study published in the Journal of General Internal Medicine reported that most internal medicine residents gain cross-cultural skills through informal training, and most stated that delivery of high-quality, cross-cultural care was important but were skeptical about the expectation of learning every little detail about all cultures. Barriers to cross-cultural care included lack of time, not knowing enough about the religion or ethnic group of the patient they were caring for, and/or dealing with belief systems which are different than their own.
A 2000 study in Social Science and Medicine found that physicians rated minority patients more negatively than White patients; the study also reported that physicians viewed minorities as non-compliant and more likely to engage in risky health behaviors. Clearly, providers need reliable resources to add to their understanding of the patient’s perspective.
A 2017 survey of 111 health care providers revealed where providers currently turn to access cultural training and information, and what types of information providers need when they are unsure/unaware of the patient’s cultural profile and its implications for treatment decisions, patient compliance, and safety outcomes. The survey found that providers want more data on their patients’ use of nontraditional medicine; their faith beliefs; and who the health care decision-makers are.
Diversity and Disparities
An increase in racial and ethnic minority health professionals provides greater opportunity for minority patients to see a practitioner who speaks their primary language or is from their own racial or ethnic background. This can improve the quality of communication, patient safety, satisfaction, compliance, and outcomes. In addition to increasing the diversity of practitioners, hospitals are working to improve hiring diversity, employee cultural awareness, and organizational culture.
In 2015, The Health Research & Educational Trust (HRET) commissioned a national survey of hospitals and health systems to quantify the actions they are taking to promote diversity in leadership and governance, and reduce health care disparities. Data for this project were collected through a national survey mailed to the CEOs of 6,338 U.S. registered hospitals. The response rate was 17.1%, with the sample generally representative of all hospitals.
Minorities represent a reported 32% of patients in hospitals that responded to the survey, and 37% of the U.S. population, according to other national surveys. In contrast, the HRET survey data show that minorities represent only 14% of hospital board membership, 14% of executive leadership positions, and 15% of first- and mid-level positions.
As a sign of progress, though, nearly half of hospitals surveyed had a plan to recruit and retain a diverse workforce matching their patient population. Further, 42% said they implemented a program to find diverse employees in the organization worthy of promotion.
Cultural Data Collection
The HRET data show that 98% of hospitals are collecting patient data on race. Additionally, other areas of data collection included ethnicity (95%) and first language (94%). But, the percentage of hospitals that correlated the impact these factors have to the delivery of care was a mere 18%. Remarkably, in 2011 only 20% of hospitals analyzed clinical quality indicators by race and ethnicity to identify patterns, whereas 14% looked at hospital readmissions, and 8% analyzed medical errors.
A serious flaw in the HRET survey was zero data collected on hospital patient national origin. The report listed myriad reasons why hospitals might be failing to meaningfully use the data, such as fearing potential liability issues after publicly acknowledging disparities in care, concerns about the public relations backlash, and a lack of knowledge in developing clinical programs that would reduce or eliminate inequalities. Plus, some hospitals noted the lack of a “diversity champion” on their staff to help lead the effort.
Hospitals seem to be making progress in educating staff on diversity, with 80% providing cultural competence training during orientation and 79% offering continuing education opportunities on cultural competency, according to the survey.
Hospitals have begun to include leadership goals designed to reduce care disparities by implementing diversity initiatives such as: allocating adequate resources to ensure cultural competency/diversity initiatives are sustainable; incorporating diversity management into budget planning and implementation process; increasing hospital board diversity to reflect that of its patient population; board members demonstrating completion of diversity training; developing plans specifically to increase ethnic, racial, and cultural diversity of executive and mid-level management teams; and executive compensation tied to diversity goals.
Beyond the C-suite, hospitals are developing diversity plans with initiatives that include diversity goals in hiring manager performance expectations; implementation of programs to identify diverse, talented employees within the organization for promotion; documented plans to recruit and retain a diverse workforce that reflects the organization’s patient population; required employee attendance at diversity training; hospital collaboration with other health care organizations to improve health care workforce training and educational programs in the communities served; and education of all clinical staff during orientation about how to address unique cultural and linguistic factors affecting the care of diverse patients and communities.
This increased implementation of appropriate health care and adherence to effective diversity and cultural education programs at every level of health care will ultimately result in improved patient satisfaction, compliance, hospital safety, and patient health outcomes.
Our health care system today has made tremendous progress in providing care to individuals and families. Change is good, but as the health care industry rapidly responds to emerging trends, markets, and opportunities, how staff nurses respond to different kinds of work culture is important, particularly when work culture highly impacts a nurse’s job function.
Work culture is made up of the norms, values, and beliefs that characterize an organization. Several factors, including management, workplace practices, policies and philosophies, employees and their interactions, leadership, expectations, rewards or recognitions, communications, transparency, and support within an organization, can influence work culture. Work culture,which can make or break a workplace, is powerful. It can inspire health care employees to be more productive and positive at work, or it can make them feel undervalued and frustrated. Thus, it plays a crucial role in shaping behaviors in organizations.
Your Work Culture
Ask yourself the following:
- What is the culture like in your workplace?
- Do staff naturally unite and collaborate?
- Are the leadership and executive teams available and transparent?
- What values and principles does your organization express?
Sometimes, you might say “it’s challenging.” Defining work culture can be difficult; nevertheless, it is fundamental to good (or poor) practice. Work culture is not often discussed, but clearly, nurses can be negatively or positively influenced by their work culture.
Work culture in nursing is critical to job satisfaction, nurse retention, and patient outcomes. A toxic work culture can lead to increased sick days, stress-related symptoms, and nurse turnover. It also plays a large role in the ability to provide quality nursing care. Work culture can impact everything from the safety of patients to job satisfaction. If yours is negative and discouraging, you cannot just wait for it to change. The first thing you must realize is that it might not change at all without you taking some kind of action.
Understanding your work culture is key to developing practice that aims to improve care. Although a positive work culture is mostly created from the top down, it often happens from the bottom up. Nurses should not undervalue the power of their work culture. Understanding work culture as a learning environment is related to how nurses choose to engage in their workplace and how the workplace normalizes their involvement in activities and interpersonal relations. Nurses can take inspired action, engage in networks, and initiate work culture change. This is not a simple task, but nurses can utilize their own personal power and create cultural transformation in their workplace. Keep in mind that work culture can—and will—change and evolve over time. The first approach is to define and evaluate your work culture—both what it is now and what it should be in the future.
Every workplace has its own work culture. Most of this is unspoken, but a lot can be learned from an employee handbook or company policy. Observation, assessment, and communication are key approaches to help you uncover your work culture. These key approaches can also be utilized by someone who has unique developmental and socialization needs, such as new graduate nurses, international nurses, student nurses, and nurses who are undergoing role status changes or transitioning to a new area. No matter what your status is, here are five ways to help you thrive in your work culture.
- Watch and learn. Give yourself some time to understand the reasons behind workplace behavior and you will be much more successful in understanding the causes. Observe how things are done. Take notes. Keep track. Building relationships with people in your workplace and connecting with someone on your team who has a good understanding of how the workplace culture works can help you better understand and avoid making a mistake.
- Don’t be afraid to ask questions. You don’t need to know everything. Questions are a great way to clear up differences and get to know people. Also, be sure to ask for help whenever you need it. Asking for assistance or an explanation should not be considered a sign of weakness.
- Remain motivated at work. Nurse burnout is real, so it is important to recognize the impacts you make on your patients and workplace every day. Focus on yourself and how you can be a positive influence.
- Be transparent. Let your coworkers know about your background and your career goals. Don’t hesitate to share your ideas and let your team and supervisor know what other skills you have to offer.
- Acknowledge your mistakes. Apologize and laugh it off. Keep your sense of humor and learn from every mistake you make.
Developing the skills and ability to understand and communicate effectively with all your coworkers (including your supervisor) is critical to your success in your own career, as well as the success of your organization. These skills are not innate; they require practice, but anyone can develop these skills. Adapting to a new work culture is an ongoing process. Once you have the skills, you can work more effectively with different groups of people and adjust easily to working in different cultures throughout your career.
A patient needed assistance in the bathroom. An elderly, obese, female with Lupus affecting her legs and hips needed help transferring from her electric wheelchair and some assistance with hygiene and buttoning her pants. It’s something I’ve done a million times and I didn’t think twice about it. What happened later made me think about the differences in cultures between India and the United States and how to approach these differences when they come up with someone in the workplace.
After the job was completed and the patient gone, the episode came up in conversation between the patient’s doctor, who is from India, and myself. While she didn’t exactly dress me down, she was very firm that clinic nurses were not supposed to help patients in the bathroom. She gave me several reasons:
“The patient takes care of herself at home. Why do you need to do it here?”
“If the patient has a caregiver at home, where is the caregiver now?”
“What if you get injured, who is going to take care of you?”
“If you help her in the bathroom this time, she will expect help every time she comes.”
I thought about this conversation for a long time. Without a doubt, I was correct to help the patient. This I know. It’s required by the nursing oath, and it’s required by my own moral code. Why did this doctor see things so differently?
Indian society is rigidly stratified by religious and socioeconomic class. At the bottom are the untouchables who work with waste. This stratification was formalized during British rule with some 60,000 different classifications. With this in mind, I realized that my doctor was actually trying to protect me from performing work outside my caste, which would be degrading to me. From my point of view, all people are created equally. As a nurse, when someone asks for help, I don’t have to decide if that person is worthy of my help or if performing a task is outside of what is permitted by my caste. I just do it.
From the doctor’s point of view, I was performing a task outside of what is permitted by my caste and performing it for a person who is of lower status than myself. I was breaking social norms, degrading myself, and degrading the clinic and other nurses whom she expected would not perform such duties. After doing some thinking, I can now appreciate her point of view, but it is not my point of view. The tricky part is how to address it in the future in a culturally sensitive manner. I don’t want to insult my doctor. She is in a position of power over me. I don’t want to break my nursing oath or my personal moral code to always offer assistance when someone asks. In this case, I’ve decided to simply not bring it up again. I will continue to perform my nursing duties as I always have without mentioning it. I will respect my doctor’s culture by simply avoiding the subject in the future. In a perfect world where I’m king, I would explain to the doctor my point of view and expect her to change her point of view to suit my own. However, the world is not perfect, and I’m not king. So respect, cultural sensitivity, and work relationships will win out over my personal feelings.
Eight nurse leaders from across the country gathered to participate at the Avant Healthcare Professionals CNO Roundtable to share their thoughts on the challenges, solutions, and opportunities that they face.
Benefits of Diversity
Diversity in staffing is known to produce higher quality work and increase productivity, overall. More importantly, diversity makes your recruitment and retention efforts easier, according to a Glassdoor study. Two-thirds of the respondents in the study said that a diverse workforce is an important factor when evaluating companies and job offers. The Glassdoor study also found that 57% of people surveyed think their company should be doing more to increase diversity in its workforce.
For health care staffing, diversity is highly desired as it has a direct impact on care delivery. International health care professionals are more equipped to care for minority patients as they understand diverse backgrounds and can better communicate bedside shift reports to them, according to an American Nurses Association study.
In this article, Avant Healthcare Professionals Founder and CEO Shari Dingle Costantini and Vice President of Clinical Operations Jennifer David asked CNOs how they successfully integrate international RNs into their staff. Below are the suggestions.
Address Staff and Peers
It’s essential to inform your staff that an international nurse will be joining the team. Take the chance to educate your staff on the nurse’s culture and background pre-arrival of the new nurse.
Some countries’ medical terms do not translate accurately in English. Procedures may also vary depending on the country, so educating your staff on the clinical differences is a must. Your staff will be understanding and more willing to help when they are aware of these differences.
Assigning an ethnically diverse preceptor for the new nurse is also very helpful in the onboarding process. If this is the first international nurse on your staff, designate nurse leader support for the international nurse so that they have a “go to person” to depend on when needed.
“We have had a lot of success with international nurses as part of our staffing solution. Understanding what environment these nurses come from and then acclimating them to our environment has been key for our retention program. Our other international nurses also help with that transition in prefacing them.”
– Caroline Stewart, CNO, Citrus Memorial Hospital
The patient experience is the most important aspect of care. Hospital leadership should encourage unit managers and charge nurses to educate patients and the patients’ families on their international nurse’s education, preparation, and experience. Therefore, it’s crucial that the patient understands that they are receiving the best care they can get no matter who their nurse is.
Eliminating patients’ requests in nurse changes will reinforce that the international nurse is a part of the team and will make the patient feel more comfortable about their care.
Address the Community
Whether you live in a diverse community or not, discussing the need for international nurses is important. Reach out to key influencers in the community such as the mayor, the Chamber of Commerce, the Rotary Club, local reporters, etc. Inform them of the nursing shortage and explain how international nurses bring value to the community. The goal is to have political backing for a care environment that welcomes diversity.
One of our partners at Great Plains Regional Medical Center met with the mayor and the school board to introduce diversity education to the North Platte, NE community. These meetings serve as a catalyst to successfully integrate internationals into the hospital as well as the community.
Most importantly, the school board should be aware of international families in the community and be prepared on how to integrate these students pre-arrival. Bullying can be an issue in grade schools, which is why the school board should be involved in these meetings.
Involving your staff, patients, and the community in diversity education serves to create a welcoming home for international nurses and internationals, in general. These nurses are looking to be a part of the community as permanent residents. The overall goal is to improve patient care with a staff that better represents the population. Diversifying your community can start with the health care system. Considering international nurses at your hospital is a great start.
About Avant Healthcare Professionals
Avant Healthcare Professionals (AvantHealthcare.com) is the premier staffing specialist for internationally educated registered nurses, physical therapists and occupational therapists. Avant helps clients improve the continuity of their care, fill hard-to-find specialties, and increase patient satisfaction, revenue and HCAHPS scores. Avant is a Joint Commission accredited staffing agency and founding member of the American Association of International Healthcare Recruitment (AAIHR).
Originally published on February 7, 2018 at AvantHealthcare.com
The 2017 clinical excellence conference organized by the National Association of Indian Nurses of America (NAINA) concluded on December 2nd at Houston, Texas. It was for the first time that NAINA as a minority organization ventured to engage in a clinical excellence conference titled “Advancing Health through Excellence in Clinical Practice.” This conference, hosted by the Indian Nurses Association of Greater Houston, Texas (INAGH), was attended by over 200 participants and nurses were provided with 8.91 CEUs by the Southwestern University Hospital, Texas. Participants applauded the organizers for providing an opportunity to network and immerse in a day full of activities that provided thought provoking information to bring back to their own clinical practice.
The APN committee chairperson, Dr. Lydia Albuquerque, set the tone of the conference by welcoming the Houston chapter President Accamma Kallel, MSN, APRN, APN-C, CCRN, president of INAGH and local chapter APN local planning committee chair, to deliver her welcome address. The key note speaker, Melissa Herpel, MSN, APRN, FNP-BC, challenged the participants to embark on pathways to excellence in independent practice as nurse practitioners. As an entrepreneur, she shared success stories of her own business model, how she overcame the challenges that she faced during the process and dared to challenge the participants to go out and start clinics that would provide primary care to the communities. All other speakers delivered their topics of interest and expertise with recent practice guidelines to the participants.
Poster presentations were coordinated by Dr. Letha Joseph, Dr. Solymole Kuruvilla, and Dr. Simi Jesto. Bindu Jacob, BSN, RN (New Jersey) was awarded the first prize, Jessie Kurian, MSN, RN (Dallas) was awarded the second prize, and Dr. Lisa Thomas (Houston) was awarded the third prize. Dr. Rachel Koshy, committee chair of the NAINA Journal, motivated the participants to submit scholarly articles for publication. The NAINA Journal was released by NAINA President, Dr. Jackie Michael. This Journal has been published for the second time with a goal to continue publications at least twice a year.
At this conference, NAINA presented a donation towards the Hurricane Harvey Relief Fund which was accepted by Mr. Zafar Tahir, Houston planning commission representative on behalf of the mayor of Houston. NAINA received a grant from Boston scientific and generous sponsorship from educational and pharmaceutical companies. Our grand sponsor, “APRN world,” an independent educational organization started by Dr. Harila Nair, a nurse practitioner and entrepreneur of Indian origin based in California, needs a special mention for his generous support.
Conference hosting chapter, INAGH, facilitated the Gala night celebration with Bollywood dancing, a grand finale of the Texan dance choreographed by the nurses of Houston chapter, and other entertainment programs. The plenary committee members along with the planning committee were given a standing ovation for conducting an excellent conference which was inspiring, energizing, and remarkable.
The government of Jamaica has asked the United States health sector to cease the poaching of its nurses. “Jamaica Says to Stop Poaching Our Nurses” was a report on National Public Radio earlier this year based on an interview with Mr. James Moss-Solomon, the chairman of the University Hospital of the West Indies in Kingston. He likened the situation to a crisis.
The exodus has forced Jamaican hospitals to reschedule some complex surgeries because of a lack of nursing staff on their floors, according to the report. Moss-Solomon says the United States, Canada, and the United Kingdom are, in his words, “poaching” Jamaica’s most critical nurses. “Specialist nurses is the problem. We have tons of regular nurses,” he told NPR. He was talking about nurses trained to work in such settings as intensive care units, oncology, infectious disease, operating rooms, and emergency rooms. They are the ones being lured away and their English language skills heighten their appeal. “We do very well training our specialist nurses here at a fraction of the cost of what it costs you in the United States or Canada or the UK; so, the issue is an economic one for us,” he explains.
In February, as part of the Jamaica Medical Mission, I discussed this issue with Althea Davis, RN, MHA, as I sat with her in a church hall in the city of Port Maria. For 27 years the mission has served the people of Jamaica under the auspices of the St. James Episcopal Church of Leesburg, Florida. The 55 members of the team represented physicians, dentists, hygienists, optometrists, pharmacists, nurses, physician assistants, and support staff. They came from Los Angeles, Ottawa, New York, San Francisco, Maryland, and Florida.
The team brought state-of-the-art health care to the people of that region for eight days and with tremendous energy and dedication delivered competent care to over 1,700 patients, who for the last 5 years have had their medical records computerized and accessible when the team visits.
Davis, a supervisory public health nurse, serves four health districts. “The nurses are expected to provide service in every aspect of care and are held to a very high standard. In the case of the public health nurse, the Jamaican nurses rank among the best worldwide,” she says.
According to Davis, the training model that Jamaica has followed came out of work done back in the 1970’s and is continuously updated. Over time, specialists have been added in areas such as nutrition, health promotion, information technology, and electronic records management, which is intended to provide a more robust care delivery system and improve patient satisfaction. “Because of training provided, we were well prepared to deal with the Ebola outbreak, and the highly contagious Chikungunya virus,” says Davis.
However, Davis quickly hastened to add that the problem facing the nursing sector is that the profession is “under resourced.”
Davis’ conclusion is an echo of Moss-Solomon’s. The skilled staff are stretched. The referral process for advanced treatment that cannot be handled at the nurses’ level is inadequate at best and unavailable at worst. “It is not just the compensation that influences nurses to leave the island,” Davis says. “It’s also the sense that nurses are not accorded the appreciation for what they do even by health care agencies.”
According to the World Bank, “these shortages have tangible impacts that may compromise the ability of English-speaking [Caribbean] countries to meet their key health care service needs, especially in the areas of disease prevention and care. In addition, the shortage of highly trained nurses reduces the capacity of countries to offer quality health care at a time when Caribbean countries aim to attract businesses, visitors and retirees as an important pillar of growth,” the report states.
In Jamaica, about three out of every four nurses trained have migrated to developed countries. But the Jamaican experience is not unique. In the case of the UK, a recent report by the Royal College of Nursing stated that the nursing workforce has moved from a situation of “net inflow of nurses to a position of net outflow in recent years.” This means that more nurses are moving abroad than are coming to the UK to practice. The main destinations are Australia, Canada, New Zealand, and the United States.
The NPR program stated that Jamaica has been offering free training for nurses to get advanced degrees. The nurses agree to work for three or four years in Jamaica in exchange for the heavily-subsidized education. “But U.S. recruiters,” says Moss-Solomon, “simply pay the fine for contract violation and the nurses fly off to lucrative jobs in the U.S.”
Jamaica’s response to these losses? They are bringing 25 nurses from Cuba to help staff some floors and have plans to recruit nurses from India and the Philippines and have recruited nurses from as far away as Burma/Myanmar.
Increased international recruitment of nurses requires that several policy issues be explicitly addressed. The international debate over the responsibilities of recruiting nations toward countries whose nurses are being recruited, many of which are developing countries, necessitates provision of ethical recruitment guidelines and codes of practice inclusive of possible financial compensation for sending countries in the face of a global nurse shortage.