Leininger’s Transcultural Nursing Theory, which focuses on concepts such as “cultural competence, cultural awareness, and acculturation,” guides nurses to provide “culturally congruent, safe, and meaningful care to culturally diverse clients” (Leininger, 2002, p. 190). According to Leininger and McFarland (2002), a culturally competent nurse acknowledges the fact that cultures affect the nurse-client relations and incorporates the client’s personal, social, and cultural needs and beliefs into the treatment plan. Although Transcultural Nursing Models provide nurses with the basis necessary for caring for their culturally diverse clients, the process of Cultural Competence in the delivery of Healthcare Services by Campinha-Bacote will be used as the conceptual framework for this DNP project. Campinha-Bacote developed her model, “Cultural Competence in the delivery of Healthcare Services” originally in 1998 and revised it as “the process of Cultural Competence in the delivery of Healthcare Services” in 2002.
According to Campinha-Bacote (2011), cultural competence (CC) is a process in which nurses continually tries to attain the skill and the readiness to successfully work within the cultural setting of their clients to provide high-quality client-centered care. Campinha-Bacote (2011) described CC as a “process of becoming culturally competent” utilizing these concepts rather than “being culturally competent”. According to Campinha-Bacote (2011), the process of Cultural Competence in the delivery of Healthcare Services Model can be used as a framework for developing and implementing culturally competent training for staff. One of the assumptions made when applying this model is that cultural competence (CC) is an ongoing process of becoming culturally competent rather than being culturally competent using the five inter-related components: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote (2011). Campinha-Bacote’s model requires nurses to be culturally competent in order to a conduct cultural assessment to provide care based on the uniqueness of each client. Another assumption identified by Campinha-Bacote (2011) of this model is that there is a positive and direct relationship between the nurses’ level of CC and positive patient outcomes. Clients tend to be non-compliant with the treatment plan if their cultural needs are not met leading to unfavorable health outcomes. Cultural competency training of staff has been identified as one strategy to address racial and ethnic health disparities in healthcare by providing quality care that meets client’s cultural needs (Truong, Paradies & Priest, 2014). The five concepts identified by Campinha-Bacote in this conceptual model are cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.
Cultural awareness is the process of examining and exploring one’s cultural background and biases, preconceptions, assumptions toward other cultures (Campinha-Bacote, 2011). Campinha-Bacote further explained that without recognizing the influence of personal cultural values, the risk of the nurse engaging in cultural imposition, which is the tendency of nurses to impose their personal beliefs and values on the culture of their clients, is greater. Renzaho, Romios, Crock, and Sonderlund (2013) stated that the lack of awareness about cultural differences could lead to a compromise nurse-client relationships making it difficult for the client to achieve appropriate care. Cultural competence training will not only enables the nurses to recognize their own prejudices and tendency to stereotype but also to provide culturally competent care by identifying how culture shapes behaviors and thinking towards various treatments.
Cultural knowledge is defined by Campinha-Bacote (2011) as the process in which the staff seeks and obtains educational background about people from diverse cultures. Nurses must focus on the integration of cultural values, health-related beliefs, and practices in order to acquire cultural knowledge. Campinha-Bacote (2011) further explained that acquiring cultural knowledge is critical to remember that no one individual is a stereotype of one’s culture requiring the nurse to conduct a thorough cultural assessment with each individual client. Cultural competence training will enable the nurses to have the cultural knowledge to develop the ability to conduct a cultural assessment with each client.
Cultural skill is the capability of the nurse to conduct a cultural assessment to gather pertinent cultural data regarding the client’s presenting problem as well as accurately conducting a culturally congruent physical assessment (Campinha-Bacote (2011). Having cultural skill enables the nurses to create an acceptable and culturally appropriate plan of care for each patient
Campinha-Bacote (2011) further explained that cultural skills acquired through CC training enable nurses to identify a client’s physical, biological, and physiological variations, which influence the nurse’s ability to conduct an accurate and appropriate physical evaluation
Cultural encounter is the process of nurses directly engaging in face-to-face cultural interactions with clients from diverse backgrounds, which will improve or transform pre-existing personal beliefs about any particular cultural group and prevent possible stereotyping (Campinha-Bacote (2011). Campinha-Bacote stated that the assessments of linguistic needs are also part of cultural encounters enabling the use of a trained interpreter facilitating communication during cultural assessment. The use of amateur interpreters, friends, or family members is not recommended due to lack of knowledge, which can lead to gathering data incorrectly.
Cultural desire is the inspiration of the nurse to “want to” rather than “have to” involve in the process of becoming culturally aware, knowledgeable, skillful, seeking cultural encounters. It is a sincere passion to be accessible to others, acknowledging their differences, building on similarities and be willing to learn from others, which is referred to as “cultural humility” (Campinha-Bacote (2011). Cultural encounters are considered as the essential concept of CC that offers the vitality and basis for one’s voyage towards cultural competence.
Implementing change in any organization can be challenging. Identifying and using a change theory can influence the success of a planned change process (Kassean & Jagoo, 2005). Kurt Lewin’s Change model, which incorporates three steps process of unfreezing, changing and refreezing, will be used as the change model for this project. (Sutherland, 2013). According to Lewin, the process of organizational change involves planning, implementing and evaluating by identifying the need for a change; creating the motivation to change, then move towards implementing the change and finally sustaining the change (Kassean & Jagoo, 2005). Identifying “driving forces” and the “restraining forces” within the organization is essential for developing strategies to strengthen the “driving forces” and weaken the “restraining forces” (Sutherland, 2013).
Step 1. Unfreezing
The goal during the unfreezing stage is to prepare the organization for the change by creating awareness about the identified problem such as declining patient satisfaction reports or Justice Center’s report on clients’ complaints and the need for the proposed change, which is the implementation of cultural competency training for the nurses. Communicating with all key stakeholders, including nurses, administrators, and organizational leaders are vital in this initial stage to create an atmosphere of trust allowing them to verbalize their concerns and perceptions of the identified problem and proposed change (Sutherland, 2013). Meeting with stakeholders will help to identify barriers and restraining forces, which may need planning to overcome including the shortage of staff and/or unmotivated staff, etc. Identifying the driving force and ensuring support from leadership is also important for the success of the planning of the project in the initial stage of planning. According to Kassean and Jagoo (2005), the inclusion of nurses in this initial stage fosters a feeling of inspiration that motivates and enables them to understand the importance of providing culturally competent care to the ethnically diverse client they serve.
Step 2. Changing
This stage involves the implementation stage of the proposed project, which includes the cultural competency training of the staff and the pre and posttest using the assessment tool. Sutherland (2013) recommended actively involving all nursing staff during this stage through effective communication for the success of the project. During this stage, the staff is learning new knowledge; new skill and new behavior preparing them to provide culturally competent high-quality care to their clients. Interpersonal relationships and strong leadership support are crucial to during this stage as they are getting accustomed to the change. According to Kassean and Jagoo (2005), the nurses should be reminded of the reasons for the change and how the change will benefit both them and their clients.
Step 3. Refreezing
Lewins’ final stage of the change process is refreezing, which symbolize the act of emphasizing, sustaining or solidifying the new stage after the implementation of the training (Sutherland, 2013). The result of the training will be evaluated with the post-test and followed-up in staff meetings. Champions or super-users will be designated as the resource person and support groups and journal clubs will provide further resources.