Discussion: Managing Quality and Risk

Discussion: Managing Quality and Risk ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Managing Quality and Risk Assignment Content Managing quality often means addressing small issues so that they do not escalate into risks for the organization. This week’s learning activities addressed some of the organizational challenges nursing leaders are likely to face. Discussion: Managing Quality and Risk Select one of the topics from this week’s learning activities: Discussion: Managing Quality and Risk Mitigating bullying and lateral violence Managing conflict Using power to influence Improving communication Valuing diversity Develop a plan to carry out your selected topic as a nurse leader on your floor. Consider: Available resources: time, budget, space, industry collateral, personnel. Discussion: Managing Quality and Risk Employee engagement Change management principles Team dynamics Create a presentation to show your CNO how you plan to address the topic. You Have Two (2) Format Options: Format your assignment as one of the following: 7- to 10-slide presentation. Provided detailed speaker notes. Cite the source of the information on for all speaker notes (each speaker note should have a a citation). Format the title slide and the reference(s) slides using APA format. Or 450-word executive summary using UOPX approved format (see tools section below). Provide references to support your work. Format reference section using APA format. reading_chapters.docx incivility_bullying_and_workplace_violence__ana_position_statement.pdf wk_3_nur_451___gra Chapter 9 Cultural Diversity in Health Care This chapter focuses on the importance of cultural considerations for patients and staff. Although it does not address comprehensive details about any specific culture, it does provide guidelines for actively incorporating cultural aspects into the roles of leading and managing. Diverse workforces are discussed, as well as how to capitalize on their diverse traits and how to support differences to work more efficiently. The chapter presents concepts and principles of transculturalism, describes techniques for managing a culturally diverse workforce, emphasizes the importance of respecting different lifestyles, and discusses the effects of diversity on staff performance. Scenarios and exercises to promote an appreciation of cultural richness are also included. Discussion: Managing Quality and Risk Learning Outcomes • Describe common characteristics of any culture. • Evaluate the use of concepts and principles of acculturation, culture, cultural diversity, and cultural sensitivity in leading and managing situations. • Analyze differences between cross-cultural, transcultural, multicultural, and intracultural concepts and cultural marginality. • Evaluate individual and societal factors involved with cultural diversity. • Value the contributions a diverse workforce can make to the care of people. Discussion: Managing Quality and Risk Key Terms acculturation cross-culturalism cultural competence cultural diversity cultural imposition cultural marginality cultural sensitivity culture ethnicity ethnocentrism multiculturalism transculturalism Introduction Culture influences leadership from two perspectives. One is the way in which we meet patient needs; the other is the way in which we work together in a diverse workforce. Effective leaders can shape the culture of their organization to be accepting of persons from all races, ethnicities, religions, ages, lifestyles, and genders. These interactions of acceptance should involve a minimum of misunderstandings. Multicultural phenomena are cogent for each person, place, and time. Connerley and Pedersen (2005) provided 10 examples for leading from a complicated culture-centered perspective. For example, “3. Explain the action of employees from their own cultural perspective; 6. Reflect culturally appropriate feelings in specific and accurate feedback” (p. 29). Therefore culture-centered leadership provides organizational leaders, such as nurse managers and effective team members, the opportunity to influence cultural differences and similarities among their unit staff. Concepts and Principles What is culture? Does it exhibit certain characteristics? What is cultural diversity, and what do we think of when we refer to cultural sensitivity? Are culture and ethnicity the same? Various authors have different views. Cultural background stems from one’s ethnic background, socio-economic status, and family rituals, to name three key factors. Ethnicity, according to The Merriam-Webster Dictionary (Merriam-Webster Inc., 2013), is defined as related to groups of people who are “classified” according to common racial, tribal, national, religious, linguistic, or cultural backgrounds. This description differs from what is commonly used to identify racial groups. This broader definition encourages people to think about how diverse the populations in the United States are. Inherent characteristics of culture are often identified with the following four factors: 1.Culture develops over time and is responsive to its members and their familial and social environments. 2.A culture’s members learn it and share it. 3.Culture is essential for survival and acceptance. 4.Culture changes with difficulty. For the nurse leader or manager, the characteristics of ethnicity and culture are important to keep in mind because the underlying thread in all of them is that staff’s and patients’ culture and ethnicity have been with them their entire lives. All people view their cultural background as normal; the diversity challenge is for others to view it as normal also and to assimilate it into the existing workforce. Cultural diversity is the term currently used to describe a vast range of cultural differences among individuals or groups, whereas cultural sensitivity describes the affective behaviors in individuals—the capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people. Spector (2009) addressed three themes involved with acculturation. (1) Socialization refers to growing up within a culture and taking on the characteristics of that group. All of us are socialized to some culture. (2) Acculturation refers to adapting to a particular culture. An example of this might be what a particular society calls a particular food or how healthcare organizations are changing to blame-free environments to encourage safety disclosures. The overall process of acculturation into a new society is extremely difficult. “America” has a core culture and numerous subcultures. For example, think how differently people in rural American regions dress from those in urban centers, or how a city looks on Saturday night versus Sunday morning. In other words, subcultures expand on how the core culture might be described. (3) Assimilation refers to the change that occurs when nurses move from another country to the United States, or from one part of the country to another. They face different social and nursing practices, and individuals now define themselves as members of the dominant culture. An example of this might be when nurses no longer say they are from their country of origin. They say they are from where they live and practice. Providing care for a person or people from a culture other than one’s own is a dynamic and complex experience. The experience according to Spence (2004) might involve “prejudice, paradox and possibility” (p. 140). Spence used prejudice as conditions that enabled or constrained interpretation based on one’s values, attitudes, and actions. By talking with people outside their “circle of familiarity,” nurses can enhance their understanding of personally held prejudices. Prejudices “enable us to make sense of the situations in which we find ourselves, yet they also constrain understanding and limit the capacity to come to new or different ways of understanding. It is this contradiction that makes prejudice paradoxical” (Spence, 2004, p. 163). Paradox, although it may seem incongruent with prejudice, describes the dynamic interplay of tensions between individuals or groups. We have the responsibility to acknowledge the “possibility of tension” as a potential for new and different understandings derived from our communication and interpretation. Possibility therefore presumes a condition for openness with a person from another culture (Spence, 2004). Discussion: Managing Quality and Risk Cultural marginality is defined as “situations and feelings of passive betweenness when people exist between two different cultures and do not yet perceive themselves as centrally belonging to either one” (Choi, 2001, p. 193). This “betweenness” is a time when managers might perceive disinterest in cultural considerations. This situation might actually reflect cognitive processing of information that isn’t yet reflected in effective behaviors. Ethnocentrism “refers to the belief that one’s own ways are the best, most superior, or preferred ways to act, believe, or behave” (Leininger, 2002b, p. 50), whereas cultural imposition is defined as “the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons” (Leininger, 2002b, p. 51). Such practices constitute a major concern in nursing and “a largely unrecognized problem as a result of cultural ignorance, blindness, ethnocentric tendencies, biases, racism or other factors” (Leininger, 2002b, p. 51). Providing quality of life and human care is difficult to accomplish if the nurse does not have knowledge of the recipient’s culture as it relates to care. Leininger believed that “culture reflects shared values, beliefs, ideas, and meanings that are learned and that guide human thoughts, decisions, and actions. Cultures have manifest (readily recognized) and implicit (covert and ideal) rules of behavior and expectations. Human cultures have material items or symbols such as artifacts, objects, dress, and actions that have special meaning in a culture” (Leininger, 2002b, p. 48). Leininger (2002b) stated that her views of cultural care are “a synthesized construct that is the foundational basis to understanding and helping people of different cultures in transcultural nursing practices” (p. 48). (See the Theory Box on p. 157.) Accordingly, “quality of life” must be addressed from an emic (insider) cultural viewpoint and compared with an etic (outsider) professional’s perspective. By comparing these two viewpoints, more meaningful nursing practice interventions will evolve. This comparative analysis will require nurses to include global views in their cultural studies that consider the social and environmental context of different cultures. Discussion: Managing Quality and Risk Theory How do leaders, managers, or followers take all of the expanding information on the diversity of healthcare beliefs and practices and give it some organizing structure to provide culturally competent and culturally sensitive care to patients or clients? Purnell and Paulanka (2008), Campinha-Bacote (1999, 2002), Giger and Davidhizar (2002), and Leininger (2002a) provided an overview of each of their theoretical models to guide healthcare providers for delivering culturally competent and culturally sensitive care in the workplace. Purnell and Paulanka’s (2008) Model for Cultural Competence provides an organizing framework. The model uses a circle with the outer zone representing global society, the second zone representing community, the third zone representing family, and the inner zone representing the person. The interior of the circle is divided into 12 pie-shaped wedges delineating cultural domains and their concepts (e.g., workplace issues, family roles and organization, spirituality, and healthcare practices). The innermost center circle is black, representing unknown phenomena. Cultural consciousness is expressed in behaviors from “unconsciously incompetent—consciously incompetent—consciously competent to unconsciously competent” (p. 10). The usefulness of this model is derived from its concise structure, applicability to any setting, and wide range of experiences that can foster inductive and deductive thinking when assessing cultural domains. Purnell (2009) described the dominant cultural characteristics of selected ethnocultural groups and a guide for assessing their beliefs and practices. The Purnell Model for Cultural Competence serves as an organizing framework for providing cultural care, which is based on 20 major assumptions. Campinha-Bacote’s (1999, 2002) culturally competent model of care identifies five constructs: (1) awareness, (2) knowledge, (3) skill, (4) encounters, and (5) desire. She defined cultural competence as “the process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client (individual, family, or community)” (Campinha-Bacote, 1999, p. 203). Cultural awareness is the self-examination and in-depth exploration of one’s own cultural and professional background. It involves the recognition of one’s bias, prejudices, and assumptions about the individuals who are different (Campinha-Bacote, 2002). “One’s world view can be considered a paradigm or way of viewing the world and phenomena in it” (Campinha-Bacote, 1999, p. 204). Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Obtaining cultural information about the patient’s health-related beliefs and values will help explain how he or she interprets his or her illness and how it guides his or her thinking, doing, and being (Campinha-Bacote, 2002). The skill of conducting a cultural assessment is learned while assessing one’s values, beliefs, and practices to provide culturally competent services. The process of cultural encounters encourages direct engagement in cross-cultural interactions with individuals from other cultures. This process allows the person to validate, negate, or modify his or her existing cultural knowledge. It provides culturally specific knowledge bases from which the individual can develop culturally relevant interventions. Cultural desire requires the intrinsic qualities of motivation and genuine caring of the healthcare provider to “want to” engage in becoming culturally competent (Campinha-Bacote, 1999). The Giger and Davidhizar Transcultural Assessment Model identified phenomena to assess provision of care for patients who are of different cultures (2002). Their model includes six cultural phenomena: communication, time, space, social organization, environmental control, and biological variations. Each one is described based on several premises (e.g., culture is a patterned behavioral response that develops over time; is shaped by values, beliefs, norms, and practices; guides our thinking, doing, and being; and implies a dynamic, ever-changing, active or passive process). Leininger’s (2002a) central purpose in her theory of transcultural nursing care is “to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups” (p. 190). She uses her classic “Sunrise Model” to identify the multifaceted theory and provides five enablers beneficial to “teasing out vague ideas,” two of which are The Observation, Participation, and Reflection Enabler and the Researcher’s Domain of Inquiry. Nurses can use Leininger’s model to provide culturally congruent, safe, and meaningful care to patients or clients of diverse or similar cultures. See the following Theory Box. National and Global Directives The American Nurses Association (ANA) has a long and vital history related to ethics, human rights, and numerous efforts to eliminate discriminatory practices against nurses as well as patients. The ANA Code of Ethics for Nurses with Interpretive Statements, Provision 8, states, “The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs” (2008, p. 23). This provision helps the nurse recognize that health care must be provided to culturally diverse populations in the United States and on all continents of the world. Although a nurse may be inclined to impose his or her own cultural values on others, whether patients or staff, avoiding this imposition affirms the respect and sensitivity for the values and healthcare practices associated with different cultures. This provision is reinforced by the ANA position statement (2010), The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings. The value of human rights is placed in the forefront for nurses whose specific actions are to promote and protect the human rights of every individual in all practice care environments. Similar statements are made with an international emphasis and a specialty emphasis. The ICN Code of Ethics for Nurses (2012) states: The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent to care and related treatment. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. (p. 3) Nurse educators, as a specialty example, are expected to recognize “multicultural, gender, and experiential influences on teaching and learning”; “identify individual learning styles and unique learning needs of international, adult, multicultural, educationally disadvantaged, physically challenged, at-risk, and second degree learners”; and ensure “that the curriculum reflects institutional philosophy and mission, current nursing and health care trends, and community and societal needs so as to prepare graduates for practice in a complex, dynamic, multicultural health care environment.” (National League for Nursing, 2005, pp. 1, 2, 4) These examples illustrate a global concern for cultural sensitivity. Although the emphasis has been on recipients of care, the same attentiveness is needed in the workforce. Patients are aware of how they are treated; and they also see how staff interact with each other. Special Issues Health disparities between majority and ethnic minority populations are not new issues and continue to be problematic because they exist for multiple and complex reasons. Causes of disparities in health care include poor education, health behaviors of the minority group, inadequate financial resources, and environmental factors. Disparities in health care that relate to quality of care include provider/patient relationships, actual access to care, treatment regimens that necessarily reflect current evidence, provider bias and discrimination, mistrust of the healthcare system, and refusal of treatment (Baldwin, 2003). Health disparities in ethnic and racial groups are observed in cardiovascular disease, which has a 40% higher incidence in U.S. blacks than in U.S. whites; cancer, which has a 30% higher death rate for all cancers in U.S. blacks than in U.S. whites; and diabetes in Hispanics, who are twice as likely to die from this disease than non-Hispanic whites. Native Americans have a life expectancy that is less than the national average, whereas Asians and Pacific Islanders are considered among the healthiest population groups. However, within the Asian and Pacific Islander population, health outcomes are more diverse. Solutions to health and healthcare disparities among ethnic and racial populations must be accomplished through research to improve care. Consider how these disparities in disease and in healthcare services might affect the healthcare providers in the workplace in relationship to their ethnic or racial group. It is necessary to increase healthcare providers’ knowledge of such disparities so that they can more effectively manage and treat diseases related to ethnic and racial minorities, which increasingly might include themselves. The healthcare system in the United States has consistently focused on individuals and their health problems, but it has failed to recognize the cultural differences, beliefs, symbolisms, and interpretations of illness of some people as a group. As health care moves toward provision of care for populations, culture can have an even greater influence on approaches to care. Commonly, patients for whom healthcare practitioners provide care are newcomers to health care in the United States. Similarly, new staff are commonly neither acculturated nor assimilated into the cultural values of the dominant culture. Currently, accessibility to health care in the United States is linked to specific social strata. This challenges nurse leaders, managers, and followers who strive for worth, recognition, and individuality for patients and staff regardless of their ascribed economic and social standing. Beginning nurse leaders, managers, and followers may sense that the knowledge they bring to their job lacks “real-life” experiences that provide the springboard to address staff and patient needs. In reality, although lack of experience may be slightly hampering, it is by no means an obstacle to addressing individualized attention to staff and patients. The key is that if the nurse manager and staff respect people and their needs, economic and social standings become moot points. This challenge will intensify as the implications of the Patient Protection and Affordable Care Act of 2010 unfold. If nothing else happens, the diversity of insured patients will increase. Language Translating a message in one language to another language to ensure equivalence includes maintaining the same meaning of the word or concept. Equivalency is accomplished through interpretation, which extends beyond “word-for-word” translation to explain the meaning of concepts. When providing care to a language diverse patient, the nurse must realize that the process of translation of illness/disease conditions and treatment is complex and requires certain tasks. Two important tasks are “(a) transferring data from the source language to the target language and (b) maintaining or establishing cross-cultural semantic equivalence” (International Council of Nurses, 2008, p. 5). The current practice seems to be one of using interpreters rather than translators when speaking with non–English-speaking patients and clients. Why? Purnell and Paulanka (2008) advocate that trained healthcare providers as interpreters can decode words and provide the right meaning of the message. However, the authors also suggest being aware that interpreters might affect the reporting of symptoms, using their own ideas or omitting information. It is important to allow time for translation and interpretation and to clarify information as needed. Promotion of culturally competent care with a translator has legal implications in the United States. The legal foundation for language access lies in Title VI of the 1964 Civil Rights Act, which states: No person in the United States, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefit of, or be subjected to discrimination under any program or activity receiving federal financial assistance (Chen, Youdelman, Brooks, 2007, p. 362). The federal government has interpreted and treated language as a proxy for national origin, and language assistance should be pursued. These activities supported by the Civil Rights Act include access to health care. Additionally, once a healthcare provider accepts any federal funds (e.g., Medicaid payments), the provider is responsible for providing language access to all the provider’s patients. Meaning of Diversity in the Organization Leading and managing cultural diversity in an organization means managing personal thinking and helping others to think in new ways. According to Noone (2008), nursing leaders need a workforce that can provide culturally competent care. In addition, nursing’s goal is to create a workforce that reflects the population it serves. This diversity can occur across roles, including advanced practice registered nurses, managers, and chief nurse executives. Managing issues that involve culture—whether institutional, ethnic, gender, religious, or any other kind—requires patience, persistence, and much understanding. One way to promote this understanding is through shared stories that have symbolic power. Staff who know what is valuable to patients and to themselves can act accordingly and derive satisfaction from work. Having a clear mission, goals, rewards, and acknowledgment of efforts leads to greater productivity from a culturally diverse staff who aspire to unity and uniqueness. (The following Research Perspective illustrates this point in providing end-of-life care.) When assessing staff diversity, the nurse leader or manager can ask these two questions: •What is the cultural representation of the workforce? •What kind of team-building activities are needed to create a cohesive workforce for effective healthcare delivery? Discussion: Managing Quality and Risk Cultural Relevance in the Workplace Although the literature has addressed multicultural needs of patients, it is sparse in identifying effective methods for nurse managers to use when dealing with multicultural staff. Differences in education and culture can impede patient care, and uncomfortable situations may emerge from such differences. For example, staff members may be reluctant to admit language problems that hamper their written communication. They may also be reluctant to admit their lack of understanding when interpreting directions. Psychosocial skills may be problematic as well, because non-Westernized countries encourage emotional restraint. Staff may have difficulty addressing issues that relate to private family matters. Non-Asian nurses may have difficulty accepting the intensified family involvement of Asian cultures. The lack of assertiveness and the subservient physician-nurse relationships of some cultures are other issues that provide challenges for nurse managers. Unit-oriented workshops arranged by the nurse manager to address effective assertive techniques and family involvement as it relates to cultural differences are two ways of assisting staff with cultural work situations. Respecting cultural diversity in the team fosters cooperation and supports sound decision making. Nurse leaders and managers who ascribe to a positive view of culture and its characteristics effectively acknowledge cultural diversity among patients and staff. This includes providing culturally sensitive care to patients while simultaneously balancing a culturally diverse staff. For example, cultural diversity might mean being sensitive to or being able to embrace the emotions of a large multicultural group comprising staff and patients. Unless we understand the differences, we cannot come together and make decisions that are in the best interest of the patient. Transculturalism sometimes has been considered in a narrow sense as a comparison of health beliefs and practices of people from different countries or geographic regions. However, culture can be construed more broadly to include differences in health beliefs and practices by gender, race, ethnicity, economic status, sexual preference, age, and disability or physical challenge. Thus, when concepts of transcultural care are discussed, we should consider differences in health beliefs and practices not only between and among countries but also between genders and among, for example, races, ethnic groups, and different economic strata. This requires us to consider multiple factors about all individuals. The range of attitudes toward culturally diverse groups can be viewed along a continuum of intensity (Lenburg et al., 1995, p. 4) from hate to contempt to tolerance to respect and ending with celebration/affirmation. Managers need to be aware of this continuum so that they can apply strategies appropriately to the workforce—for example, contempt versus affirmation. These responses are equally reflected in employee groups. Variables that may influence the nurse’s response may include how the illness is perceived by the culture and the cultural competency of the healthcare provider. If the nurse’s culture is different from the patient’s, whose cultural perspective dominates? It might not be possible to adapt care totally to the patient’s perspective. However, knowing that a difference exists allows for a mutual conversation related to the rationale for care. Similarly if a workplace dispute occurs, trying to see “the other view” can create new insights into a situation. To make cultural competence relevant to clinical practice, Engebretson, Mahoney, and Carlson (2008) linked a cultural competency continuum, in which they identified the levels of competence, to values in health care. They cited the levels as cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence and proficiency that would be complementary to patient care. The “clinically relevant continuum” included behaviors of maleficence, incompetence, standardization, and outcomes focused (positive health outcomes). A model was developed that integrated the cultural competence continuum with the clinically relevant continuum and the components of evidence-based care; namely, best research practice, clinical expertise, and patient’s values and circumstances. Discussion: Managing Quality and Risk Their goal was to suggest how to make cultural concerns relevant to clinical practitioners at the level of the patient-provider encounter. To understand, value, and use diversity, nurse managers need to approach every staff person as an individual. This same strategy works for all of us. Although staff of different cultural groups may be diverse in appearance, values, beliefs, communication patterns, and mannerisms, they have many things in common. Staff members want to be accepted by others and to succeed in their jobs. With fairness and respect, nurse managers should openly support the competencies and contributions of staff members from all cultural groups with a goal of achieving quality patient care. Nurse managers hold the key to allowing the full potential of each person on the staff. Body movements, eye contacts, gestures, verbal tone, and physical closeness when communicating are all part of a person’s culture. For the nurse manager, understanding these cultural behaviors is critical in accomplishing effective communication within the diverse workforce population. As if language differences aren’t challenging enough, add on the slang, idioms, and fads inherent to U.S. culture. It is no surprise that culturally sensitive communications is difficult to achieve. Nurses need to ensure that ineffective communication among staff, with patients, and with others does not lead to misunderstandings and eventual alienation. Failure to address cultural diversity leads to negative effects on performance and staff interactions. Nurse managers can find many ways to address this issue. For example, in relation to performance, a nurse manager can make sure messages about patient care are received. This might be accomplished by sitting down with a nurse and analyzing a situation to ensure that understanding has occurred. In addition, the nurse manager might use a communication notebook that allows the nurse to slowly “digest” information by writing down communication areas that may be unclear. For effective staff interaction, the nurse manager also can make a special effort to pair mentors and mentees who have different ethnic backgrounds and encourage staff to learn another language, one prominent among the population served. Even a “word a day” approach could alter a team’s ability to interact with patients. Individual and Societal Factors Nurse managers must work with staff to foster respect of different lifestyles. To do this, nurse managers need to accept three key principles: multiculturalism, which refers to maintaining several different cultures; cross-culturalism, which means mediating between/among cultures; and transculturalism, which denotes bridging significant differences in cultural practices. Each of those principles operates in t