Increasing cultural diversity and an aging population

Transcription

1 Cultural Competence Among Hospice Nurses Stephanie Myers Schinn, PhD, RN Ardith Z. Doorenbos, PhD, RN Nagesh N. Borse, BPharnn, MS The purpose of this study was to examine variables associated with cultural competence among hospice nurses. In a cross-sectional descriptive design, a convenience sample of 107 hospice nurses from five different hospice agencies completed a survey that included the Cultural Competence Assessment instrument. Regression analysis revealed a significant association between higher education and cultural awareness and sensitivity, as well as an association between diversity training and self-reported cultural competence behaviors. Findings support the need for additional education and training for hospice nurses and provision of more resources targeted toward enhancing cultural competency. K E Y W O R D S cultural competence hospice nurses Increasing cultural diversity and an aging population in the US expand the need for culturally competent hospice and end-of-life (EOL) care. Demographic and cultural changes challenge hospice nurses to manage complex differences in communication styles, attitudes, expectations, and world views, as well as multiple languages.^ Beyond traditional considerations of racial and ethnic differences, issues of culturally competent care for people of different socioeconomic classes, genders, or sexual orientations have become equally important.'^ The provision of culturally competent care is essential in today's hospice and palliative care environments. Professional nurses, in addition to being the major providers of hospice services, can also provide I Stephanie Myers Schim, PhD, RN, is an Associate Professor in Family, Community, and Mental Health Nursing at Wayne State University, Detroit, Ml. Ardith Z. Doorenhos, PhD, RN, is an Assistant Professor in the School of Nursing at University of Washington, Seattle, WA. Nagesh N. Borse, BPharm, MS, is a student at the Bloomberg School of Public Health, Johns Hofjkins University, Baltimore, MD. Address correspondence to Stephanie Myers Schim, PhD, RN, College of Nursing, Wayne State University, 240 Cohn Building, Detroit, MI ( s.schim@wayne.edu). The authors have no conflict of interest. 302 JOURNAL OF HOSPICE AND PALLIATIVE NURSING Vol. 8, No. 5, September/October 2006

2 leadership in enhancing culturally congruent care with diverse populations. The purpose of this study was to examine variables associated with cultural competence among hospice nurses. Culturally congruent nursing care occurs when nurses and clients come together with an attitude of cultural humility and respect. Hospice nurses can then negotiate mutually satisfactory strategies to achieve a "dignified death," as defined by the individual and family needing care. In order for culturally congruent care to occur, nurses need to have a knowledge base, attitudinal framework, and skill set that enable them to engage with others in adaptive ways. Nurses need to appreciate, accommodate, and negotiate cultural and individual variation in beliefs, values, lifestyles, education, and myriad other elements that cultural context comprises. In a 2004 report from the National Hospice and Palliative Care Organization (NHPCO), 77% of hospice patients were identified as Caucasian/white, 8% as black/african American, 6% as Hispanic/Latino, 2% as Asian/Pacific Islander, and 6% as multiracial.^ Although more Hispanic/Latino and multiracial patients and their families were served by hospice in 2004, there continues to be a great gap between the ethnic distribution in the US and those being served by hospice. Better understanding of factors related to cultural competence among hospice nurses suggests directions for future enhancement of practice, education, and research. Three-Dimensional Puzzle Model of Culturally Congruent Care One conceptual model has been described using the analogy of a three-dimensional (3-D) jigsaw puzzle, with pieces representing provider elements.'* Cultural competence is the demonstration of knowledge, attitudes, and behaviors based on diverse, relevant, cultural experiences. It is not expected that healthcare providers achieve complete cultural competence, but rather that they continue to strive to match their competencies to the specific populations, subgroups, and individuals with whom they work. Cultural diversity is a fact. In the US nonwhite groups and those of Hispanic or Latino heritage continue to grow. As of the last census, the African American/black population was 34 million or 12.3%, people of Asian descent accounted for roughly 2.5 million or 3.6%, and 12.5% ofthe population reported being of Hispanic or Latino origin regardless of racial background.^ Additionally, in the US there is a growing awareness of the impact of differences in language, religion, gender, sexual orientation, ability and disability, and access to technology on provider-patient interactions.' Even when a nurse and a client share the same ethnic or racial heritage, other aspects of diversity still remain to be addressed. Cultural awareness is a knowledge phenomenon. Awareness of both intergroup and intragroup variation in lifestyles, values, beliefs, and practices is essential to assessment, planning, and intervention. Knowledge of all groups and individuals is not possible; however, knowledge of patterns of differences and ways to understand specific individual and group variation is not only possible but critical. Cultural sensitivity involves the recognition of personal attitudes, values, beliefs, and practices. Nursing communication skills reflect sensitivity and require the willingness to develop and use listening skills. Nonverbal communication (body language), careful use of silence and touch, respect for conversational distance, and use of language patterns in an attuned manner also characterizes culturally sensitive nursing. Cultural competence is the incorporation of personal cultural diversity experience (fact), awareness (knowledge), and sensitivity (attitude) into everyday nursing practice. In addition to sensitivity to self and others, competence behaviors are dependent on personal exposure, experience with people from diverse groups, and awareness of individual and group similarities and differences. METHODS Design and Procedures A cross-sectional descriptive design was used to examine variables associated with cultural competence among hospice nurses. Approval for the study was granted by the university's Human Investigation Committee. Nurses represented a convenience subsample of hospice employees and volunteers in attendance at hospice meetings where data were collected. Whereas the overall response rate was 95%, the nurse-specific response rate could not be calculated. Each potential participant was approached before the start of the meeting and asked to complete a paper-and-pencil survey. Potential participants were advised that participation was completely voluntary and the survey would take 20 to JOURNAL OF HOSPICE AND PALLIATIVE NURSING VoL 8, No. 5, September/October

3 - * f!x *,. > 30 minutes to complete. An information sheet on the cover of the survey oudined the study purpose and stated that participants could choose not to participate and could withdraw or stop at any time. Surveys were returned in unmarked envelopes to maintain participant anonymity. Completion and return of the survey constituted informed consent. Instrument The Cultural Competence Assessment (CCA) tool was a 26-item instrument designed to measure cultural diversity experience, awareness and sensitivity, and competence behaviors. Cultural diversity experience was addressed with a single item asking respondents whether they had cared for people of various cultural groups in the past 12.months. The item score was a simple count of the number of groups selected with higher numbers indicating greater diversity of experience. The combined subscale for cultural awareness (knowledge) and sensitivity (attitude) (CAS) was measured with a 5-point Likert-like response set of "strongly agree, agree, disagree, strongly disagree, and no opinion." The subscale for cultural competence behavior (CCB) had response categories of "always, often, at times, never, and not sure." In both cases, no-opinion and not-sure responses were coded at the midpoint (3 of 5). The items were summed for each subscale score; higher scores indicate higher levels of knowledge and more positive attitudes and greater self-reported frequency of competence behaviors. Internal consistency reliability for the CCA has been reported in previous work at over 0.80: construct, content, face validity, and test-retest reliability have been established.^''^ In the current study, CAS subscale reliability was 0.72 and the CCB subscale reliability was Demographic items on the CCA included questions assessing age, prior cultural diversity training (yes/no), self-identified race or ethnicity, and level of educational attainment (associate, bachelor, graduate degree). Cender was not identified in this study to avoid the possibility that unique combinations of other demographic variables, when combined with gender, would breach subject anonymity. Analysis All analyses were performed with SPSS for Windows 13.0 (SPSS, Chicago, IL). An a priori.05 level was used to determine significance. Descriptive analyses were conducted to describe participant characteristics and to evaluate assumptions for regression analysis. Standard multiple regressions were used to determine the amount of variance accounted for by independent variables of (1) age, (2) cultural competency training, (3) educational attainment, and (4) self-identified race or ethnicity on the CAS and CCB subscaies, respectively. Using the Tabachnick and Fidell^ formula (N = m) for a medium-sized relationship between the four independent variables and the dependent variable for each regression analysis assuming an a level of.05 and P of.20, a sample size of 82 would have been sufficient for the analysis. The achieved sample of 107 was deemed to have adequate power to support the regression analysis. FINDINGS Descriptive analysis yielded a profile of the characteristics of the 107 hospice nurses representing five different hospice agencies (see Table 1). The mean age of the nurses was 45 years; 50% (n = 53) of the nurses reported having an associate degree in nursing and the other 53 (50%) reported completing either a bachelor's degree»^, T a b 1 e 1?-_-: Dennographics of Hospice Age Self-identified race/ethnicity Caucasian/white Hispanic/Latino African American/black Asian Native American Other Education Associate degree Bachelor's degree Graduate degree Missing data Prior Cultural Competence Training Yes No Missing data Nurses (n = 107) n (%) Range 22-66; Mean 45 ±11 68 (63) 1(1) 20 (19) 8(7) 6(6) 4(4) 53 (49) 31 (29) 22 (21) 1 (1) 49 (46) 56 (52) 2(2) 304 JOURNAL OF HOSPICE AND PALLIATIVE NURSING Vol. 8, No. 5, September/October 2006

4 ; '. ' "., ' ' - > fl^^3.ar^.. i. _.. T a b l e 2 Racial/Ethnic Identities of Individuals and Families Cared For in the Last Year Types of Racial/ Ethnic Groups Cared For Sample Percent* Caucasian/white Hispanic African American/black American Indian Asian Other groups Number of other racial/ethnic groups cared for Mean 3.4 loovo ''': 56.?/o.'..;'' 65% ".! 35% ' ; 51% ^' 24% SD-i, 1.4 ;> "Total >100% due to endorsement of more than one group per participant. '^I T a b 1 e 3 ^ ' CCA Behavior Subscale Behavior Subscale I act to remove obstacles for people of different cultures when clients and families identify such obstacles to me. I welcome feedback from clients about how I relate to others with different cultures. I avoid using generalizations to stereotype groups of people. I welcome feedback from coworkers about how I relate to others with different cultures. I find ways to adapt my services to client and family cultural preferences. [ act to remove obstacles for people of different cultures when I identify such obstacles. I recognize potential barriers to service that might be encountered by different people. I ask clients and families to tell me about their expectations for care. I learn from my coworkers about people with different cultural heritages. [ ask clients and families to tell me about their own explanations of health and illness. I include cultural assessment when I do client or family evaluations. 1 document the adaptations I make with clients and families. I seek information on cultural needs when I identify new clients and families in my practice. 1 document cultural assessments. [ use a variety of sources to learn about the cultural heritage of other people. I have resource books and other materials available to help me learn about clients and families from different cultures. Mean in nursing or some graduate level education. The majority of the nurses reported their racial/ethnic background as Caucasian/white (n = 68; 63%). The next most prevalent background was African American/black (n - 20; 19%) followed by small percentages representing other groups. Responses to the cultural diversity experience item are provided in Table 2. The number of groups that hospice nurses reported working with in the past year ranged from one to seven, with a mean of 3.4 (SD = 1.4). All participants reported having worked with Caucasian/ white clients. The second most cited group was African American/black with 65% (n = 69)., followed by Hispanics at 56% (n = 60). Analysis of the behavior subscale of the CCA yielded description of items means and standard deviations (see Table 3). The top-rated behaviors among the hospice nurses were acting to remove obstacles that were pointed out to them by clients, welcoming feedback from clients, and avoiding generalizations. The lowest-rated behaviors were documentation of cultural assessments, using a variety of resources to learn about cultures, and having resource materials at hand. All regression assumptions were met and so no transformations of variables were needed. The regression coefficient {R) for cultural competence knowledge/attitude (CAS) was significantly different from zero (F5107 = 2.43, P <.05). This result indicates that the set of in SD , 1.11 : ^;1.23^/'' ;l.;17^^'',f V., 1:31 ::,; ""'"i.27"^''\ ' ' '' :.'..' " ' l:3'0, \J dependent variables (age, cultural competency training, educational attainment, self-identified race/ethnicity) explains a statistically significant amount (12%) of the variance in cultural competence knowledge and attitudes. From this set of independent variables, only JOURNAL OF HOSPICE AND PALLIATIVE NURSING Vol. 8, No. 5, September/October

5 educational attainment (college or higher) was by itself significantly associated with cultural competence knowledge/attitude {P <.O5). The regression coefficient {R) for cultural competence behavior (CCB) trended toward significance (F5107 = 2.18, P =.06). This result indicates that the set of independent variables (age, cultural competency training, educational attainment, self-identified race/ethnicity) explains a nearly significant amount (11%) of the variance in cultural competence behavior. From the set of independent variables, only prior diversity training was by itself significantly associated with cultural competence behavior (P =.011). DISCUSSION Using the 3-D Puzzle Model of Culturally Congruent Care and the Cultural Competence Assessment instrument developed from it, this research yielded a better understanding of the variables associated with cultural competence. Findings provide new insights into diversity experiences, awareness and sensitivity, and behaviors among practicing hospice nurses. Findings related cultural diversity revealed patterns among both hospice nurses and their clients. The fact that most participants (63%) were Caucasian/white is not surprising given the Midwestern geographic location of the five hospice programs from which they were recruited. Although specific data for the US hospice nursing workforce are not available, findings from the March 2000 National Sample Survey of Registered Nurses suggested that 87% of RNs are white-non- Hispanic.^ That 19% of the nurses in this study selfidentified as African American/black may reflect the inclusion of several hospice programs located in major metropolitan areas with significant African American/ black populations.^" The average number of racial/ ethnic groups encountered was 3.4, which indicate a moderate level of heterogeneity among clients encountered and moderate diversity experience for the nurses. All of the nurses surveyed had worked with Caucasian/ white clients, and many had experience with African American/black and Hispanic groups in the past year as might be expected from the demographics of the agencies' service communities. Cultural awareness and sensitivity, as measured using the CAS subscale of the CCA instrument, was found to be significantly associated with educational levels. Nurses holding BSN or higher academic degrees were significantly more likely to achieve high scores on cultural awareness and sensitivity. This finding may be related to academic content as well as diversity knowledge and attitudes or may be associated with other exposures that occur with higher education. It is interesting to note, however, that in this particular convenience sample, only 50% of the nurses reported preparation at the BSN level or higher. Whereas this pattern may not be typical of hospice nurses, findings would suggest that where there are significant numbers of nurses with less than BSN preparation, greater attention may need to be focused on cultural competence in-service training. Culturally competent behaviors, as measured using the CCB subscale of the CCA instrument, were found to be associated with prior diversity training. This finding suggests that diversity training programs increase the frequency with which cultural competence behaviors are put into practice. The two items from the behavioral subscale that were most often cited (removing obstacles and welcoming feedback) indicate that many hospice nurses are already comfortable with adapting to clientinitiated discussions of cultural needs and desires. However, items that are related to the nurse soliciting specific information on which to base culturally congruent interventions were ranked lower. In-service providers may need to place more emphasis on active assessment of cultural needs tailored to individual situations within a larger cultural context. Another finding from the analysis of the behavioral subscale was that hospice nurses in this sample reported low frequencies for including cultural assessments in client evaluations, documenting adaptations to care, and using a variety of resources to learn about cultural issues. This finding may be related to lack of training regarding the ways to incorporate targeted cultural assessments with the many other tasks required at the time of hospice admission. There may also be organizational barriers to recording cultural assessments and adaptations of care for example, forms may have no space or cues to document these activities. That nurses did not use a variety of resources to learn about cultural issues is not surprising, given that the activity in the last place on the behavioral subscale was, "I have resource books and other materials available to help me learn about clients and families from different cultures." Clearly, attention to ongoing resource availability is as essential in developing and maintaining cultural com- ' petence behaviors as having appropriate diversity training programs. 306 JOURNAL OF HOSPICE AND PALLIATIVE NURSING Vol. 8, No. 5, September/October 2006

6 This research had several limitations that suggest the need for interpretive caution. The use of a convenience sample of hospice nurses limits the generalizability of the findings. Recruitment of nurses from only five agencies in one state also limits the findings, even though the agencies from which the sample was drawn represent a broad range of diverse communities. CONCLUSIONS From this project, it is clear that both nursing education and ongoing in-service training are important in supporting cultural competence among hospice nurses. Fortunately, there are a number of national efforts, such as the End-of-Life Nursing Education Consortium project, that are working to expand discussions of cultural aspects of EOL care across programs that prepare professional nurses for practice.^^ Hospice and palliative care programs and agencies can also support the development of cultural awareness, sensitivity, and competence behaviors through in-service education, documentation enhancements, and provision of resources appropriate to the specific populations in the service community. Professional organization supports for cultural competence development are also important. Members of the Hospice and Palliative Nurses Association have recognized and endorsed the need for more articles and educational products specific to cultural diversity in EOL care.^'^ Enhancement of cultural competence among hospice nurses creates exciting opportunities at the intersections of nursing practice, administration, education, and research that hold the promise of improving EOL care. References 1. Fortier JP, Bishop D. Setting the Agenda for Research on Cultural Competence in Healthcare: Final Report. Rockville, MD: US Department of Health and Human Services Office of Minority Health and Agency for Healthcare Research and Quality; Abrums ME, Leppa C. Beyond cultural competence: teaching about race, gender, class, and sexual orientation. / Nurs Educ. 2001;40(6): National Hospice and Palliative Care Organization. NHPCO's 2004 facts and figures. Available at: bttp:// public/facts_figures_for2004data.pdf. Accessed December 22, Scbim SM, Doorenbos AZ, Borse NN. Cultural competence among Ontario and Michigan healthcare providers. / Nurs Scholarsh. 2005;37: US Census. All across the USA: population distribution and composition, Washington, DC: US Bureau of the Census. Available at: chapo2.pdf. Accessed June 19, Schim SM, Doorenbos AZ, Miller J, Benkert R. Development ofa cultural competence assessment instrument. ] Nurs Meas. 2003; 7. Doorenbos AZ, Schim SM, Benkert R, Borse NN. Psychometric evaluation of the cultural competence assessment instrument among healthcare providers. Nurs Res. 2005;54: Tabachnick BC, Fidell LS. Using Multivariate Statistics. 4th ed. Boston, MA: Allyn & Bacon; Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing. The Registered Nurse Population: Preliminary Findings. Rockville, MD: US Department of Health and Human Services; US Census. American community survey. Washington, DC: US Bureau of the Census. Available at: Accessed February 5, End-of-Life Nursing Education Consortium (ELNEC). Training Program Manual. Washington, DC: American Association of Colleges of Nursing and City of Hope Medical Center; Hospice and Palliative Nurses Association Membership survey. Available at: Accessed January 13, JOURNAL OF HOSPICE AND PALLIATIVE NURSING Vol. 8, No. 5, September/October

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