Emerging Standards of Care, Essay Example

Introduction

The United States is home to representatives of nearly every culture on the planet, making it the most culturally diverse nation in the world and racial and ethnic minorities comprise an increasingly large proportion of the U.S. demographic, constituting the majority of residents in many regions nationwide. Approximately one third of the total U.S. population is of minority descent and it is important for nurses to understand that the perception of the causes for illness and disease varies by culture and these differences affect individual approaches to health care (Lowe & Archibald, 2009). Diversity in the workplace is a global phenomenon and the successful treatment of patients is often the result of the nurses’ knowledge regarding the beliefs and practices of the cultures they encounter so that they can develop a relevant plan of care to assist each individual. The development of emerging standards of care enables the nurses to provide culturally competent care and makes them more effective in establishing rapport with patients so that they can accurately assess, develop, and implement nursing interventions designed to meet patients’ needs (Lowe & Archibald, 2009). This discourse will discuss the significant implications diversification has within the nursing profession due to the rapidly changing demographics of society, as reflected by the patients and the lack of responsive changes within the nursing profession, as most members of the nursing profession continue to be of Caucasian descent (Sanner et al., 2010).

Emerging Standards of Culturally Competent Care

Members of racial or ethnic minority groups are traditionally more likely than non-Hispanic Whites to experience disparities in health and health care services. As the demographics for the United States shift towards increasing diversity, it is essential that this is mirrored in the field of nursing and that they are able to provide culturally competent care by demonstrating cultural sensitivity (Sanner et al., 2010). Diversity in nursing staff is especially important because it enables the nurses to provide culturally competent care and be more effective in establishing empathetic relationships with patients so that they can accurately assess, develop, and implement nursing interventions designed to meet patients’ needs (Lowe & Archibald, 2009). The formation of organizations like the Agency for Healthcare Research and Quality (AHRQ) “is to improve the quality, safety, effectiveness, and efficiency of health care for all Americans” and remove the current service gaps that prevent minorities from having the same access to quality healthcare as whites (AHRQ, 2003). To achieve this end, AHRQ supports research and other activities designed to improve quality and address disparities in health care for racial and ethnic minorities (AHRQ, 2003).

Following a model for promoting cultural competence within the workplace should include cultural tools to develop cultural awareness, knowledge, skill, and desire (Flowers, 2004). Emphasis should be placed on nursing staff should taking care to not stereotype patients based on appearances or assuming that they belong to a “particular culture or ethnic group on the basis of characteristics such as outward appearance, race, country of origin, or stated religious preference” (Flowers, 2004, p.51). Continuing disparities in health care for racial and ethnic minorities include efforts to address these inequalities through the continuing support of AHRQ and their provisioning of research grants, contracts, training opportunities, conferences, partnerships, and publications focused on minority health and disparity reduction (AHRQ, 2003). The policies, procedures, and attitudes of professional organizations, especially healthcare facilities should have developed adaptations of service delivery reflecting an understanding of cultural diversity that permeates all aspects of their organization (Cultural Diversity, 2008). In addition, nursing professionals should value diversity, have the capacity for cultural self-assessment, be conscious of the dynamics that may occur through cultural interactions, and have institutionalized cultural knowledge, all of which should be demonstrated in all of their interactions with their patients (Cultural Diversity, 2008).

Professionals should also possess the linguistic and cultural competencies necessary to demonstrate the current standards of care. Linguistic competence is defined as the ability to provide “readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators” (Putsch, Gupta, Sampson, & Tervalon, 2003). Cultural competence is described as a “set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework” (Putsch et al., 2003). The combination of these ideals defines cultural and linguistic competence as “the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter“(Putsch et al., 2003). Within the diverse atmosphere of the American healthcare system, culture and language may influence a wide array of aspects, including health, healing, and wellness belief systems, how illness, disease, and their causes are perceived by the patient, the behaviors of patients who are seeking health care and their attitudes toward health care providers, and the delivery of services by the provider who looks at the world through his or her own limited set of values, which can compromise access for patients from other cultures.

The emergence of standards of care is promoting the values of cultural competence within the workplace and this requires organizations and their personnel to:

1. Value diversity,
2. Perform self-assessments,
3. Understand the dynamics of cultural differences,
4. Acquire and emphasize cultural knowledge, and
5. Adapt to diversity, the cultural contexts of individuals, and the communities served (AHRQ, 2009)

Within this context, cultural competence mandates that organizations:

• establish a set of core values and principles, and demonstrate behaviors, attitudes, policies and structures that enable them to work effectively in a multicultural setting;
• incorporate the above five principles in all aspects of policy making, administration, practice, service delivery; and
• include consumers, key stakeholders and communities into the folds of cultural tolerance and understanding as demonstrated by the corporation (AHRQ, 2009)

Cultural competence is a developmental process that evolves over an extended period and, although individuals and organizations are at different levels of awareness, knowledge and skills along the cultural competence continuum, it remains a cooperative process (AHRQ, 2009).

The culturally and linguistically appropriate services (CLAS) mandates, guidelines, and recommendations, as issued by the United States Department of Health and Human Services Office of Minority Health are meant to “inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services” (Putsch et al., 2003). However, in spite of their ability to considerably progress health care services, advanced clinical decision support services are not widely available in the clinical setting because of the application-specific and institution-specific quality of most current clinical decision support (Kawamoto, Del Fiol, Lobach, & Jenders, 2010).

There remains a vital need for clinical decision support capabilities on a much larger scale through the development and implementation of standards that allow current and emerging clinical decision support assets to be more effectively leveraged across multiple applications and care settings (Kawamoto et al., 2010). Required standards for effective clinical decision support implementation include:

• set terminologies and information models to represent and communicate health care data,
• established approaches to clinical knowledge in both human-readable and machine-executable formats
• set methods for leveraging these knowledge resources to provide clinical decision support capabilities across various applications and care settings (Kawamoto et al., 2010)

Although some guidelines do exist or are being developed, many gaps and challenges remain, including the excessive complexity of current standards, the inadequate accessibility of knowledge resources implemented using standard approaches, and the lack of practical resources to support the efficient adoption of existing standards (Kawamoto et al., 2010). Lack of access to baccalaureate nursing education is largely separate and unequal for our nation’s racial and ethnic minorities even though ethnic and racial minority nurses can offer unique leadership in the development of models of care for minority populations (Barton & Swider, 2009). The American Association of Colleges of Nursing (AACN) (2011) emphasizes the need to attract students from under-represented groups in nursing, specifically men and individuals from African American, Hispanic, Asian, American Indian, and Alaskan native backgrounds, as nursing’s leaders have recognized a strong correlation between a culturally diverse nursing workforces and the ability to provide quality, culturally competent patient care. The disparities in the healthcare services afforded to those of lower economical statuses is apparent in the higher infant mortality rate of African Americans, which is more than twice that of Caucasians, the much higher death rates among African Americans from breast, lung, and colorectal cancer than Caucasians, Hispanics, or Asians, and the higher obesity rates among Hispanics (Barton & Swider, 2009). The National League for Nursing (NLN) has determined that the advances in technology increase the need for diversification and preparing an ethnically and racially diverse workforce of faculty, researchers, and scholars to mentor future nurses and nurse educators (NLN, 2011).

Standards Being Met and Not Being Met

Medical care is frequently a matter of grave concern and a variety of cultures traditionally frown on modern medicine, subscribing to holistic care or their customary methods. There are numerous cultures in America that focus on the development of the spirit, body, and mind in order to heal illness and achieve the full human potential, ethical standards, harmonious coexistence with one’s surroundings, and reincarnation (Edmonds & Smith, 2010). It is important for nursing staff to have knowledge of the culturally relevant medicinal practices indigenous to the culture of their patients. Nurses are required to communicate with colleagues, like doctors and other nurses, as well as patients and their relatives. Using common language that is familiar and universal within medical practices and being able to coherently explain these concepts to patients and their relatives will reduce the probability that the nurse will be misunderstood or their message will be interpreted incorrectly. Open disclosure is also meant to offer supervision to diminish the risk of repetition of health problems by using available details, allowing enhancement and support of social awareness regarding health care safety. As a provision of the nurse’s duty of care, informed consent aims to avoid blame and focus on fostering an environment conducive to the provisioning of best nursing practices (Tabak & Zvi, 2008). Fulfillment of a nurse’s duty of care also includes obtaining clarification about treatments or procedures that could potentially perform more harm than good to the patient and making sure to honor their requests, whether they are culturally derived or not (Tabak & Zvi, 2008).

The disparities in the healthcare services afforded to those of lower economical statuses is apparent in the higher infant mortality rate of African Americans, which is more than twice that of Caucasians, the much higher death rates among African Americans from breast, lung, and colorectal cancer than Caucasians, Hispanics, or Asians, and the higher obesity rates among Hispanics (Barton & Swider, 2009). Lack of access to baccalaureate nursing education is largely separate and unequal for our nation’s racial and ethnic minorities even though ethnic and racial minority nurses can offer unique leadership in the development of models of care for minority populations (Barton & Swider, 2009). The American Association of Colleges of Nursing (AACN) (2011) emphasizes the need to attract students from under-represented groups in nursing, specifically men and individuals from African American, Hispanic, Asian, American Indian, and Alaskan native backgrounds, as nursing’s leaders have recognized a strong correlation between a culturally diverse nursing workforce and the ability to provide quality, culturally competent patient care. The National League for Nursing (NLN) has determined that the advances in technology increase the need for diversification and preparing an ethnically and racially diverse workforce of faculty, researchers, and scholars to mentor future nurses and nurse educators (NLN, 2011).

It is imperative that nurses and health care providers are trained to ask questions sensitively and to show respect for different cultural beliefs. Most important, nurses need to listen to their patients carefully so that they can create a care plan that respects the desires of the patient. An example of a cultural belief that all nurses should be aware of is that of Jehovah Witnesses since they do not believe in blood transfusions an, when deriving a care plan for such a patient, this is something that the nurse must be aware of so they can respect the wishes of the patient without passing judgment upon them. The main source of problems in caring for patients from diverse cultural backgrounds is the lack of understanding and tolerance. Very often, neither the nurse nor the patient understands the other’s perspective.

Solutions for Standards Not Being Met

Organizations focus on sustaining the operational use of standards relevant for clinical decision support because currently technology use suffers from barriers that limit their deployment, including complex operational functions, limited uses, and poor documentation on how the standards should be used in operational clinical settings (AHRQ, 2009). Improvements include making these standards easy to implement over a wide scale, simplification of the instructions where possible, supporting the dissemination of improved equipment, and improved documentation on how to make use of the standards (AHRQ, 2009). The lack of comprehensive standards of care that are applicable on a multicultural level is interpreted by many as an infringement of Title VI of the Civil Rights Act of 1964, which mandates that no person in the United States shall, on ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance and the Bureau of Primary Health Care, in its Policy Information Notice 98-23 (8/17/98), indicates that: “Health centers serve culturally and linguistically diverse communities and many serve multiple cultures within one center (AHRQ, 2009). Under such federal statutes, organizations and programs are required to comply with Federal, state and local regulations for the delivery of health services. Although race and ethnicity are often thought to be dominant elements of culture, health centers should embrace a broader definition to include language, gender, socioeconomic status, housing status and regional differences (AHRQ, 2009).

Issues of Population Vulnerability

There are numerous cultures in the U.S. that do not believe in various forms of medical treatment many Americans think of as common, such as vaccinations, like Buddhists, Hindu’s, and Jehovah’s Witnesses. There are various reasons why a patient may refuse a myriad of care options and it is important for nurses to be educated on different cultures in order to provide culturally competent care to each patient. Knowing the beliefs and practices of different cultures is necessary because nurses must develop a plan of care to assist each individual patient according to their wishes. It is the duty of the nurse to explain all the options available to the patient, listen to their wishes, and create a plan that will honor those wishes according to all known best practices. The criteria for development of a successful diversity inclusion strategy must ensure that the plan will be effective at overcoming barriers, both real and perceived (Barton & Swider, 2009).

Health centers should develop systems that ensure participation of the diverse cultures in their community, including participation of persons with limited English-speaking ability, in programs offered by the health center. Health centers should also hire culturally and linguistically appropriate staff. Organizational behavior, practices, attitudes and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served. The Maternal and Child Health Bureau, through its program efforts related to state accountability and Healthy People Year 2000/2010 Objectives includes an emphasis on cultural competency as an integral component of health service delivery (Cohen, Goode, & Dunne, 2003). In addition, the National Health Promotion and Disease Prevention Objectives emphasize cultural competence as an integral component of the delivery of health and nutrition services (Cohen, Goode, & Dunne, 2003). An increasing number of state and Federal agencies are relying on private accreditation entities to set standards and monitor compliance with established standards and both the Joint Commission on the Accreditation of Healthcare Organizations, which accredits hospitals and other health care institutions, and the National Committee for Quality Assurance, which accredits managed care organizations and behavioral health managed care organizations, support standards that require cultural and linguistic competence in health care (Cohen, Goode, & Dunne, 2003).

Conclusion

The United States is becoming more diverse and the way the healthcare system works must be adjusted to conform to these changes. Understanding that health care is a cultural construct, arising from beliefs about the nature of disease and the human body is an important aspect in moving forwards towards establishing emerging standards of care, and cultural issues are actually central in the delivery of health services treatment and preventive interventions (Wolff, 2010). By understanding, valuing, and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health care organizations, practitioners, and others can support a health care system that responds appropriately to, and directly serves the unique needs of populations whose cultures may be different from the prevailing culture (Wolff, 2010). It is important for nurses to be educated on different cultures in order to provide culturally competent care to each patient. Knowing the beliefs and practices of each culture is vital because nurses must be able to develop a plan of care to assist each individual patient according to their wishes. In order to effectively and actively demonstrate an ability to work in a diverse environment, the first step is to develop knowledge. The criteria for development of a successful diversity inclusion strategy must ensure that the plan will be effective at overcoming the barriers they were designed to overcome and that the model can be replicated (Barton & Swider, 2009). The number of minority high school and non-traditional students in the pre-nursing system must increase dramatically before there is an increase in the number of applications to nursing programs from minority groups, since minority populations are poorly informed about nursing careers (Roth & Coleman, 2008). Encouraging diversity within institutional structures and educational strategies that intentionally provide opportunities for cross-cultural encounters promote both learning outcomes and racial/cultural understanding (Sanner et al., 2010).

References

AHRQ (Agencies for Healthcare Research and Quality). (2003, February). Planning culturally and linguistically appropriate services: A guide for managed care plans summary. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/populations/planclas.htm

AHRQ (Agencies for Healthcare Research and Quality). (2009, December). Activities to reduce racial and ethnic disparities in health care, Program Brief. AHRQ Publication Number 09(10)-P008, Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/qual/disparities.pdf

American Association of Colleges of Nursing (AACN). (2011, July15). Fact Sheet: Enhancing Diversity in the Nursing Workforce. Retrieved from http://www.aacn.nche.edu/media-relations/diversityFS.pdf

Barton, A.J. & Swider, S.M. (2009). Creating diversity in a Baccalaureate nursing program: A case study. International Journal of Nursing Education Scholarship, 6(1) Article 14, pp.1-14, doi: 10.2202/1548-923X.1700. Retrieved from http://www.bepress.com/ijnes/vol6/iss1/art14

Cohen, E., Goode, T.D. & Dunne, C. (2003). Rationale for cultural competence in primary care. National Center for Cultural Competence. http://www11.georgetown.edu/research/gucchd/nccc/documents/Policy_Brief_1_2003.pdf

Cultural Diversity. (2008). Cultural Competency. Retrieved from: http://www.culturediversity.org/cultcomp.htm

Edmonds, R. L. & Smith, R. J. (2010). China. World Book Advanced, World Book, 2010. Retrieved from http://www.worldbookonline.com/advanced/article?id=ar111400&st=chinese+culture

Flowers, D.L. (2004). Culturally Competent Nursing Care A Challenge for the 21st Century. American Association of Critical-Care Nurses, Critical Care Nurse, 24, pp.48-52. Retrieved from http://www.cconline.org

Kawamoto, K., Del Fiol, G., Lobach, D.F. & Jenders, R.A. (2010). Standards for scalable clinical decision support: Need, current and emerging standards, gaps, and proposal for progress. The Open Medical Informatics Journal, 4, pp.235-244. Retrieved from http://www.benthamscience.com/open/tominfoj/articles/V004/SI0233TOMINFOJ/235TOMINFOJ.pdf

Lowe, J. & Archibald, C. (January-March 2009). Cultural diversity: The intention of nursing. Nursing Forum, 44(1), pp.11-18.

Putsch, B., Gupta, I.S., Sampson, A., & Tervalon, M. (2003). Reflections on the CLAS standards: Best practices, innovations and horizons. U. S. Department of Health and Human Services (DHHS) Office of Minority Health. Retrieved from http://minorityhealth.hhs.gov/assets/pdf/checked/reflections.pdf

National League for Nursing. (2011). Global/Diversity Initiatives. Retrieved from http://www.nln.org/aboutnln/globaldiversity/index.htm

Roth, J. & Coleman, C.L. (2008). Perceived and real barriers for men entering nursing: Implications for gender diversity. Journal of Cultural Diversity, 15(3), pp.148-152,

Sanner, S. et al. (2010, Summer). The impact of cultural diversity forum on students’ openness to diversity. Journal of Cultural Diversity, 17(2), pp.56-61

Tabak, N. & Zvi, M.R. (2008, March-May). When parents refuse a sick teenager the right to give informed consent: the nurse’s role. Australian Journal of Advanced Nursing, 25(3), pp. 106-111. Retrieved from http://www.ajan.com.au/Vol25/AJAN_25-3_Tabak.pdf

Wolff, A.C. (2010). Beyond generational differences: a literature review of the impact of relational diversity on nurses’ attitudes and work. Journal of Nursing Management, 18, pp.948–969.