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Article American Academy of Nursing on Policy| Volume 63, ISSUE 2, P227-229, March 2015

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Implementing culturally competent care

        Executive Summary

        Today there are more migrants in the world than ever before — about 232 million international migrants in 2013 (

        United Nations. (2013). Trends in international migrant stock: The 2013 revision- Migrants by age and sex. (United Nations database, POP/DB/MIG/Stock/Rev.2013/Age).

        ). Nurses are one cohort of these migrants as countries increasingly employ immigration as a strategy to address their nursing shortages (
        • International Centre on Nurse Migration
        Nursing self sufficiency/sustainability in the global context.
        ). This movement of peoples across geographic borders and the transfer of nurses from one country to another challenges nurses to understand cultures different from their own in order to provide safe, quality care.
        Cultural competence is a set of behaviors, attitudes, and policies that enables nurses to work effectively in cross-cultural situations (). It is one of the main elements in the strategy to close the health disparities gap among culturally diverse and vulnerable populations. Culturally competent health care can be used to offset the social, economic, political, and environmental disadvantages that often result in inequality of access to health care and poor health outcomes. To advocate for vulnerable populations and reduce health disparities, nurses need guidelines to deliver culturally competent care for diverse populations.
        Ten Guidelines for Implementing Culturally Competent Nursing Care (GUIDELINES) were developed that can be universally applied by nurses around the world in the areas of clinical practice, research, education, and administration, especially by nurses involved in direct patient care. These guidelines include: knowledge of cultures; education & training in culturally competent care; critical reflection; cross cultural communication; culturally competent practice; cultural competence in healthcare organizations and systems; patient advocacy and empowerment; multicultural workforce; cross cultural leadership; and, evidence-based practice and research. Tactics for implementation by caregivers and health care organization leaders and managers are offered. A glossary and an extensive reference list are provided. An online publication of the GUIDELINES can be found at http://tcn.sagepub.com/content/25/2/109.

        Background and Guideline Development

        Cultural competence is based on principles of social justice (
        • Rawls John
        A theory of justice.
        ) and human rights. These principles served as a framework for developing the GUIDELINES. A task force (TF) composed of members of the Expert Panel on Global Nursing and Health (Expert Panel) of the American Academy of Nursing (AAN) and the Transcultural Nursing Society developed the GUIDELINES for nurses to use in providing care to patients regardless of geographic site of care. All members of the TF had experience working as nurses in many cultures world-wide. The GUIDELINES were drafted to be congruent with standards and position statements published by national and international organizations of nurses, and other governmental and non-governmental health related organizations (

        American Nurses Association. (2013). Code of Ethics with Interpretive Statements. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe813.htm.

        ;
        • International Council of Nurses (ICN)
        Position statements. Nurses and human rights.
        ,
        • International Council of Nurses (ICN)
        The ICN code of ethics for nurses.
        ,
        • International Council of Nurses (ICN)
        ;
        • Marmot M.G.
        • Bell R.
        Action on health disparities in the US: Commission on Social Determinants of Health.
        ;
        • Miller J.E.
        • Leininger M.
        • Leuning C.
        • Pacquiao D.F.
        • Andrews M.
        • Ludwig-Beyer P.
        Transcultural nursing society position statement on human rights.
        ;
        • National Association of Social Workers
        Standards for cultural competence in social work practice.
        ; ; ,
        • United Nations
        Office of the High Commissioner for Human Rights. Universal declaration of human rights: Dignity and justice for all of us.
        ;
        • U.S. Department of Health and Human Services
        National partnership for action to end health disparities.
        ;
        • World Health Organization (WHO)
        Alma-Ata 1978: Primary Health Care, USSR, 6-12 September 1978.
        ,
        • World Health Organization (WHO)
        The world health report: Primary health care now more than ever.
        ).
        Comments on the original draft were solicited from nurses around the world by means of a web-based survey (
        • Douglas M.K.
        • Pierce J.U.
        • Rosenkoetter M.
        • Callister L.C.
        • Hattar-Pollara M.
        • Lauderdale J.
        • Pacquiao D.F.
        • et al.
        Standards of practice for culturally competent nursing care: A call for comments.
        ). Seventy-eight nurses in 16 countries responded: most worked in hospitals, and almost equal numbers held baccalaureate and graduate degrees. While respondents indicated a high degree of satisfaction with the GUIDELINES, all suggestions were considered and many were incorporated into the final document (
        • Douglas M.K.
        • Rosenkoetter M.
        • Pacquiao D.F.
        • Callister L.C.
        • Hattar-Pollara M.
        • Lauderdale J.
        • Purnell L.
        • et al.
        Guidelines for implementing culturally competent nursing care.
        ). The GUIDELINES were approved by the full Expert Panel at the AAN annual meeting in 2012. The International Council of Nurses has endorsed these guidelines and shared them with over 130 National Nurses Associations around the world. The ICN website also has posted the availability of the GUIDELINES on 5 of their network forums (Advanced Practice, Education, Regulation, Student, and Rural and Remote Nursing) at http://www.icn.ch/forum/index.php.

        Position Statement of the American Academy of Nursing

        The American Academy of Nursing recommends that these Guidelines for culturally competent care be integrated into nursing curricula and all public health and health care practice settings. Nursing education on cultural competency and workforce diversity is essential to improving clinical skills, attitudes and resource use in all nursing specialties and settings serving culturally diverse populations. Research-based interventions can provide the link between culturally competent nursing care and improved health outcomes. Further research on the outcomes of culturally competent care is needed to identify those interventions that may reduce the health disparities seen in these vulnerable populations.
        The following recommendations are aimed at reducing the disparities in health access and outcomes seen among racially and ethnically diverse populations and to provide culturally sensitive care to all clients
        • 1.
          The Academy endorses the GUIDELINES and encourages other professional nursing organizations, such as, ANA, AONE, AACN, to disseminate them as they see fit for use by faculty, advanced practice nurses, staff nurses, researchers, and healthcare administrators.
        • 2.
          Nurses are urged to use the GUIDELINES to create culturally competent models of care and to develop evidence-based, culturally competent nursing care practices.
        • 3.
          National organizations involved in the education of nurses are urged to include the GUIDELINES in their materials and programs.
        • 4.
          National nursing accrediting bodies are urged to incorporate cultural competency as an essential component of nursing curricula.
        • 5.
          Nursing specialty organizations are encouraged to include cultural competency concepts in their curricula and certification examinations.
        • 6.
          Federal and state government agencies and non-governmental foundations are urged to support research funding to test the link between culturally competent care and health outcomes in vulnerable populations.
        • 7.
          National Institute of Nursing Research is encouraged to set a high priority on the testing of culturally competent nursing interventions.
        • 8.
          International Council of Nurses (ICN) is encouraged to continue to disseminate the GUIDELINES to its members around the world and serve as a repository for evidence-based culturally competent practices.
        • 9.
          The GUIDELINES should be cross walked with the Office of Minority Health's National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care and The Joint Commission's 2015 Standards for the Hospital Accreditation Program to identify areas that need further expansion.
        • 10.
          Healthcare systems are encouraged to include the GUIDELINES for cultural competence in the orientation and proficiency evaluations of all healthcare personnel, from senior management, health professionals, and to any staff member who interacts with clients, such as, an admitting clerk, security personnel, patient account representatives, etc.

        Acknowledgment

        We gratefully acknowledge the following individuals: Marilyn K. Douglas, PhD, RN, FAAN; Jeri Milstead, PhD, RN, FAAN; Lynn Clark Callister, PhD, RN, FAAN; Marianne Hattar-Pollara, PhD, RN, FAAN; Jana Lauderdale, PhD, RN, FAAN; Deena Nardi, PhD, RN, FAAN; Dula Pacquiao, EdD, RN; Larry Purnell, PhD, RN, FAAN; Marlene Rosenkoetter, PhD, RN, FAAN. In addition, we acknowledge the assistance from the Expert Panel on Global Nursing and Health and the Expert Panel on Cultural Competence in contributing to the substance of this policy brief as well as their review and approvals.

        References

        1. American Nurses Association. (2013). Code of Ethics with Interpretive Statements. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe813.htm.

          • Douglas M.K.
          • Pierce J.U.
          • Rosenkoetter M.
          • Callister L.C.
          • Hattar-Pollara M.
          • Lauderdale J.
          • Pacquiao D.F.
          • et al.
          Standards of practice for culturally competent nursing care: A call for comments.
          Journal of Transcultural Nursing. 2009; 20: 257-277
          • Douglas M.K.
          • Rosenkoetter M.
          • Pacquiao D.F.
          • Callister L.C.
          • Hattar-Pollara M.
          • Lauderdale J.
          • Purnell L.
          • et al.
          Guidelines for implementing culturally competent nursing care.
          Journal of Transcultural Nursing. 2014; 25: 109-121
          • International Centre on Nurse Migration
          Nursing self sufficiency/sustainability in the global context.
          (Retrieved from)
          • International Council of Nurses (ICN)
          Vision for the future of nurses.
          (Retrieved from)
          • International Council of Nurses (ICN)
          Position statements. Nurses and human rights.
          (Retrieved from)
          • International Council of Nurses (ICN)
          The ICN code of ethics for nurses.
          Author, Geneva, Switzerland2006 (Retrieved from)
          • Marmot M.G.
          • Bell R.
          Action on health disparities in the US: Commission on Social Determinants of Health.
          Journal of the American Medical Association. 2009; 301: 1169-1171
          • Miller J.E.
          • Leininger M.
          • Leuning C.
          • Pacquiao D.F.
          • Andrews M.
          • Ludwig-Beyer P.
          Transcultural nursing society position statement on human rights.
          Journal of Transcultural Nursing. 2008; 19: 5-8
          • National Association of Social Workers
          Standards for cultural competence in social work practice.
          (Retrieved from http://www.socialworkers.org/practice/standards/NASWCulturalStandards.pdf)
          Date: 2001
          • Nursing Council of New Zealand
          Code of conduct for nurses.
          (Retrieved from)
          • Office of Minority Health
          What is cultural competency?.
          (Retrieved from)
          • Public Health Agency of Canada
          What is health?.
          (Retrieved from)
          • Rawls John
          A theory of justice.
          Belknap Press of Harvard University Press, Cambridge, MA1971
          • U.S. Department of Health and Human Services
          National partnership for action to end health disparities.
          (Retrieved from)
        2. United Nations. (2013). Trends in international migrant stock: The 2013 revision- Migrants by age and sex. (United Nations database, POP/DB/MIG/Stock/Rev.2013/Age).

          • United Nations
          Office of the High Commissioner for Human Rights. Universal declaration of human rights: Dignity and justice for all of us.
          (Retrieved from)
          • World Health Organization (WHO)
          The world health report: Primary health care now more than ever.
          Author, Geneva, Switzerland2008
          • World Health Organization (WHO)
          Alma-Ata 1978: Primary Health Care, USSR, 6-12 September 1978.
          Author, Geneva1978