Diversity & Equality in Health and Care Open Access

Key words

cultural competence training, hospital staff, management support, multi-hospital implementation and evaluation, training design, trainers’ profiles

Introduction

Europe is becoming more and more ethnically and culturally diverse as a result of increasing mobility within the European Union, tourism and migration (Koehn, 2004). In this context the cultural competence of health professionals and healthcare organisations has become one of the key issues in discussions about health policy and the quality of service provision in relation to health disparities/inequalities fields (Brach and Fraser, 2000). These discussions have been particularly prominent in the United States and with increasing intensity during the last ten years (McBride, 2005). According to Cross et al (1989) ‘cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency, or those professionals to work effectively in crosscultural situations’. This definition has been widely adapted and modified in the past years and has served, especially in the USA, as a basis for further conceptual and practical work, e.g. Health Resources and Services Administration (2001), Betancourt et al (2002) and Goode and Dunne (2003). It has also informed the development of the standards for culturally and linguistically appropriate services (CLAS) (United States Department of Health and Human Services (HHS) Office of Minority Health and Resources for Cross Cultural Health Care, 1999). Cultural competence is considered important because, it is argued, culture influences people’s perceptions of the causes of health and disease, their experiences of illness and how they express their symptoms. In addition, culture impacts on their help-seeking behaviours, decisions about treatment and compliance with recommendations (Cohen and Goode, 2003). It seems only plausible that a clash of diverse expectations or perhaps even a failure to recognise differences in comprehension and expectations is likely to generate conflicts and quality problems.

The traditional approach used in many programmes, projects and initiatives that address cultural competence has been to focus on the intercultural (transcultural/ transnational) behaviour of key healthcare providers like nurses or physicians alongside the dimensions of cultural awareness, knowledge and related skills (see for example Campinha-Bacote, 1994). In this approach, competence is understood as something that varies between individuals and which can be supported by training in the same way as other professional skills. The authors are aware of the ongoing and very important discussion about this approach including new concepts such as cultural humility as an alternative to cultural competence (Tervalon and Murray-Garcia, 1998), transnational competence (Koehn, 2004) and transcultural nursing (e.g. Papadopoulos et al, 2004). However, these are not explored here because the project reported in this paper used the traditionally accepted approach to cultural competence training.

Cultural competence training has been widely promoted as part of continuous professional education and adopted as a measure for quality assurance and improvement in the United States as a likely shortterm impact (Health Resources and Services Administration, 2001; Betancourt et al, 2002). Evidence of the effectiveness of cultural competence training is, so far, not very strong mainly due to a lack of controlled studies, with special weaknesses concerning the measurement of the effects on patients and their health (see a series of newly published reviews: Anderson et al, 2003; Fortier and Bishop, 2004; Beach et al, 2005; Price et al, 2005). However, current literature was sufficiently convincing for eight European hospitals to implement and evaluate cultural competence training for staff as part of the European ‘Migrant-friendly Hospitals’ project (see Box 1). The experiences and outcomes of this implementation are presented in this paper. These outcomes are of direct relevance to hospitals and other healthcare organisations interested in staff support and quality improvement and also have implications for the further research agenda on cultural competence training.

Handling cultural diversity as a common problem area in European hospitals

A needs assessment conducted at the beginning of the project identified staff difficulties in dealing with (ethno) cultural diversity as one of the most important problems in 10 out of 12 hospitals (Schulze et al, 2003). Staff experienced problems in understanding migrant patients’ symptoms, communicating treatment options and decisions and generally developing relationships with patients. Different and unknown assumptions, expectations and conceptions about the client–provider relationship were reported as leading to conflicts between migrants and staff, especially when coupled with a lack of awareness about culture, misunderstandings and prejudices. Eight participating hospitals agreed to conduct a cultural competence training initiative for six months, from January until June 2004. The primary goal was to make staff feel more comfortable in cross-cultural situations by providing them with relevant knowledge and skills. An actual improvement in the quality of care was expected to follow from this, but partners agreed that systematic monitoring of this change would be methodologically difficult and out of the narrow time frame of the project.

Research objectives

The first objective of the initiative was to test the feasibility of cultural competence training in various types of hospitals in diverse national and local situations through the collection of data about factors that enhanced or hindered implementation. A systematic feasibility study was appropriate as only a few European countries, such as theUK, had so far introduced policies, programmes and projects about cultural competence and there was little evidence that ethnocultural diversity played any major role in quality discussions in European healthcare. Given this marginal position, an investigation into the cost-effectiveness and sustainability of cultural competence training seemed useful.

A semi-standardised intervention

A common approach to cultural competence training, known as the ‘Pathway’, and modular content (see Krajic et al, 2005) were developed. The common approach was based especially on the work of Like et al (1996), Carrillo et al (1999), Gilbert (2003a), Anand (1999) and Welch (2003). Using the same approach provided common ground for planning and delivering the training, monitoring quality and discussing the outcomes of the evaluation. Although a higher degree of standardisation, including agreement on a shared model, would have been most useful from a research perspective, it was not possible to find a consensus due to time and resource constraints. Nevertheless, the ‘Pathway’ provided guidance and orientation for planning, organising and implementing as well as evaluating cultural competence training.

The core recommendations for implementing the ‘Pathway’ and the modules in each hospital were to:

• obtain strong support frommanagement to ensure that staff would accept and participate in the training and to secure the necessary financial and material resources such as providing a venue, materials and trainer fees

• emphasise that cultural competence training was voluntary but endorsed by management, that it would carry credits for continuing professional education and that it would take place during regular working time

• focus on two or three pilot departments that volunteered to be the first to undergo training although, in the long run, training would be offered to all staff

• conduct needs assessments at department level to identify specific training needs and to facilitate tailoring of the course material to the everyday work encounters and problems experienced by staff

• select competent trainers, either individuals or groups, and work with them to develop specific content around issues of awareness, knowledge, skills and follow-up sessions based on experiential learning

• plan 10 hours training over a period of about 10 weeks to allow for experiential learning

• use interactive teaching designs

• decide on the mix of participants

• evaluate the training in a before-and-after design.

Methodology

The evaluation of the training was based on five criteria: feasibility and acceptability; quality of implementation; effectiveness; cost-effectiveness and sustainability of the training. A range of measures was developed. These included documentation sheets, progress reports, telephone interviews and group discussion with key people in each hospital. To assess the quality of implementation, the ‘Pathway’ and modules served as standards against which to compare qualitative and quantitative information provided by each hospital.

The effectiveness of cultural competence training for staff was measured in questionnaires that were administered before, theCCCTQ-PRE (65 items), and after, the CCCTEQ-POST (59 items), the training. These instruments were developed on the basis of the Clinical Cultural Competency Questionnaire (CCCQ) developed initially for work with physicians by Like (2004) at the UMDNJ–Robert Wood Johnson Medical School, NJ. Like kindly gave permission for the use of the CCCQ, and the tool was further developed for use with a variety of health professionals in seven European languages (see Krajic et al, 2005; www. mfh-eu.net/public/experiences_results_tools/cct_eval_ instruments.htm).

The study measured changes in participants’ awareness, knowledge, skills and comfort levels related to caring for members of culturally diverse populations before and after training. In addition, interest in cultural issues, satisfaction with the training and selfrated impact on everyday practice were checked retrospectively. Data were pooled, but variations between the specific hospitals are also presented below. Changes were analysed and are presented here on the basis of a group comparison. Within the areas of awareness, self-awareness, knowledge, skills and comfort level, the average score of all items has been calculated. For testing significance, a t test was used.

The reliability and internal consistency of aggregated dimensions were tested with confirmative factor analysis for both surveys using SPSS. In the ‘knowledge’ domain, all items were accepted (Cronbach’s alpha score > 0.9 in both pre- and post-survey). In the ‘skills’ domain, two items were excluded, leaving 13 items remaining (Cronbach’s alpha score > 0.87 in pre- and post-survey). In the ‘comfort level’ domain, nine of the 16 items were included (Cronbach’s alpha score > 0.8). In the ‘awareness’ domain, two constructs were identified: ‘awareness’ (Cronbach’s alpha score > 0.84) and ‘self-awareness’ (Cronbach’s alpha score > 0.82). One item had to be removed. See Box 2 for the ‘skills’ domain as an example of the items in the questionnaire.

Characteristics of the population and response rate

Out of 143 participating staff, 122 filled in the prequestionnaire, 98 the post-questionnaire. As not all participants provided information for both surveys or provided the relevant information to link the first with the second questionnaire (date of birth), only 81 persons could be included in the analysis. Useable responses were received from 11 physicians (14%), 50 nurses (62%) and 19 others (24%). The response rate for nurses was 74%, considerably higher than for physicians (48%) and others (50%).

Outcomes of the cultural competence training

Outcomes are presented here with regard to each of the five criteria for the evaluation: the feasibility and acceptability of cultural competence training; thequality of the training; the effectiveness; the cost-effectiveness and the sustainability of the training.

Feasibility and acceptability

Seven out of eight hospitals (from Austria, France, Germany, Ireland, Italy, Spain and Sweden) managed to implement cultural competence training within the time scale of the project. A total of 143 staff participated in parts of the training. Participation varied between hospitals and between professional groups, with more nurses in all hospitals taking part. In two hospitals not a single physician participated (see Table 1).

Quality

The quality of the cultural competence training courses varied a lot. In all seven hospitals, training addressed awareness and knowledge. Skills were covered in five hospitals. Interactive teaching methods were applied in all hospitals. A departmentally focused approach was realised in six hospitals. Specific needs assessments to ensure the practical relevance of training were undertaken in five hospitals. The performance of the trainer was judged unsatisfactory by project coordinators in two hospitals. Follow-up sessions using experiential learning were realised only in two hospitals.

Effectiveness: retrospective assessment

Staff satisfaction with the cultural competence training can be summed up (see Table 2) as rather high in most hospitals, even if in a couple of cases training seemed not to have fully met their expectations; 81% reported an increase in the second indicator, the ‘desire to learn more about culturally competent healthcare’. Nearly all (92%) of the participants reported at least some impact on their everyday practice, but variations between hospitals was considerable, especially in the extreme category:

• satisfaction: ‘very satisfied’ varied between 10% and 86%

• increase of interest: ‘increased a lot’ varied between 20% and 86%

• impact on everyday practice: ‘very significant’ varied between 10% and 60%.

Effectiveness: measured change

The use of the questionnaire before and after cultural competence training confirmed improvements in staff self-rated awareness, knowledge, skills and comfort level in cross-cultural situations. Results on those dimensions pointed to the expected direction and were highly significant (P < 0.01). Only scores concerning self-awareness could not be raised (see Table 3).

Effectiveness results varied considerably between hospitals (see Table 4). The highest differences in increase were measured in the knowledge dimension (1.07 points on a scale of 5) and lowest on the dimension self-awareness (0.3 points). Differences between doctors, nurses and a pooled group of other staff were also measured, with doctors showing the lowest increases and nurses the highest.

Cost-effectiveness

As international comparison of costs is difficult due to different local and national funding and accounting rules and traditions, the project has chosen an approach to ask for a qualitative internal comparison in each of the hospitals. Focal persons were asked to judge the costs of the training as ‘low’, ‘medium’ or ‘high’, comparing them to other hospital training programmes. The additional and external costs of the training (fee for trainer, costs of participants’ working hours, rent for facilities, training materials, etc.) were rated ‘medium’ or even ‘low’ compared to other hospital training programmes, but all hospitals stated that the organisational costs (time needed for planning, recruitment of trainers and participants, negotiating a programme, finding time slots for the training, etc.) were relatively ‘high’.

Sustainability

Cultural competency training will be continued in six out of seven hospitals. Decisions concerning the exact form of continuation of the training were still outstanding at the end of the project. In two hospitals, cultural competence training will be integrated as a standard part of continuing professional education.

Discussion

Cultural competence training was implemented in seven European hospitals using a common ‘Pathway;' adapted to local circumstances, local organisational culture and available resources because the measures were organised and financed out of local hospital funds. Thus, this study involves an implicit comparison of rather diverse training approaches and circumstances. Diversity has been documented, but is complex and multidimensional. The authors were not able to develop a typology simple enough to use for quantitative analysis. Nevertheless, the project provided a wealth of information on the successes and difficulties hospitals experienced before and during the implementation of training, as well as a consensus on specific measures among the group of project co-ordinators. Two of the project co-ordinators provided short sketches of central aspects of their experiences (see Boxes 3 and 4).

Feasibility attained in seven hospitals

The resources needed for cultural competence training were obtained in seven hospitals although the nature, extent and quality of these resources varied considerably. In most cases, key persons reported that much effort was needed to secure staff participation and it proved difficult to find trainers meeting the required profile. Only one hospital could not demonstrate the feasibility of a training course, but implemented ethnic diversity as a criterion in a mirror meeting; that is, a standard quality procedure where patients are interviewed about their experiences and the staff concerned watch from behind a mirror.

What have we done wrong that we need to receive training?

Most training organisers reported that acceptance of a need for cultural competence training required strong ‘communication work’. Staff acceptance required priority setting in relevant structures at departmental level. Staff asking ‘what have we done wrong that we need to receive training?’ is one example for the understanding of training rather as burden than as a support.

Organisational difficulties in releasing staff

Organisational difficulties were apparent in releasing staff from the departments concerned. Key persons reported that timelines for inviting participants were often considered too short to arrange shifts. In addition, staff shortages and unexpectedly busy workloads limited participation. Short-term cancellation of a training module due to the illness of a trainer turned out to be rather disruptive for the whole course and was interpreted by the key person in the hospital concerned as one source of a rather critical evaluation result.

Doctors’ absence

Different acceptance of the cultural competence training was evident among the professional groups, physicians, nurses and other staff. The fact that in several cases it was nurses who organised and were responsible for the training might explain some of the difficulties involved in getting physicians on board. Difficulties might also be related to the different work and learning cultures of professional groups, including different concepts of priorities and time management. It would seem worthwhile to direct further research at this difference, investigating whether it is general and what are the causes – especially those that can be addressed.

An integrated 10 hours’ training: beyond time budgets?

The overall time frame of approximately 10 hours, distributed over 3–5 modules, was considered too long for busy hospital schedules. The logistics of fitting these modules into the 24-hour services including night shifts was reported as being extremely complicated, and to shift cultural competence training into leisure time is not a good alternative although some of most successful cases operated on this basis.

Practical relevance is worthwhile

The ‘Pathway’ was designed to ensure practical relevance by conducting a specific needs assessment in the targeted departments, including skills training and using experiential learning such as case work. Hospitals that had been especially successful concerning effectiveness attributed their success to efforts in relating to practical problems and needs. On the other hand, key persons in two of the hospitals that did not target improvements in practical skills felt that this had been a limitation to the training. Finally, the importance of follow-up sessions, that enabled exploration of experiential learning, was highly valued by key persons, although it was rarely realised.

Competent trainers

The requirements for conducting cultural competence training in hospital settings were considered to be extremely high already at the outset of the project. The subject of cultural competence relates to the specific work realities of staff. These are very diverse within hospitals and, to be accepted, a trainer needs specific expertise, not just basic knowledge. As Gilbert (2003b) points out, ‘Nothing renders a workshop for physicians and nurses, for example, more ‘‘dead in the water’’ than for a trainer to be unfamiliar with the exigencies of day-to-day patient care’. At the same time, issues in cultural competence have the potential to arouse strong feelings, inducing conflict or suppression, and thus trainers need expert psychosocial and group moderation skills. Finally cultural diversity and its implications is an area of expertise by itself. Training organisers had to realise that finding trainers or teams that combine all the necessary competences would be almost impossible. For the authors, this difficulty indicated a major problem in following the integrated approach suggested in the literature and proposed in the ‘Pathway’, and led to radical conclusions, recommending a split between cultural competence training and cultural competence in normal quality work.

Effectiveness: limitations

Data quality and possibilities for analysis were limited by the lower response rates on the second survey, especially from doctors and the group of ‘others’. This may indicate limited acceptance of cultural competence training by doctors. The group of ‘others’, which included many non-clinical workers, rightly felt that the questionnaire, focusing on clinical work, was not sufficiently tailored to their diverse work reality. Further limitations lie in limited standardisation of the training intervention between hospitals and in the lack of a control group. Also, the impact of other developments, such as the terrorist attack in Spain referred to in the case report from the hospital in Algeciras, cannot be completely excluded, but given the rather short interval between the first and second surveys in most hospitals, we suggest that most of the observed changes can be attributed to the training.

Cultural competence training is appreciated by participants

As staff had participated on a voluntary basis in all hospitals, the good results can be partly understood as the result of a selection process and partly as the outcome of convincing communication about relevance by project co-ordinators and, finally, of good training. The positive results are consistent with qualitative reports by key persons and trainers with a lot of interest and enthusiasm. Especially promising seems the self-perceived impact on practicalwork.Even though actual effects on everyday practice could not be measured within the project timelines, this impression is supported by reports from key persons.

Training makes a difference

In general, the outcomes regarding effectiveness seem encouraging. Staff awareness, knowledge, skills and comfort level with cross-cultural situations improved significantly, although self-awareness did not increase. Findings varied between hospitals, probably in part because of differences in training approaches, types of trainers, participants and contexts. Consensus among training organisers, supported by the evaluation results, showed that:

• it is possible, as a result of cultural competence training, to demonstrate increases in knowledge, skills and comfort levels among staff

• participants’ perceptions of the quality of the trainer are very important

• approaches that are highly practical and respond to staff problems and the reality of their daily work have better impact.

One warning concerning the simplified presentation of the cultural competence approach used in this project: an increase in awareness of cultural differences and their consequences might lead to a decrease in self-estimated knowledge, skills and comfort level, in which case the result of training could then be understood as an increase in cultural humility (Tervalon and Murray-Garcia, 1998). This again underlines the need for further conceptual clarification and more sophisticated measurement strategies, neither of which can be provided in this paper.

Differences between professional groups

Effectiveness results varied between doctors, nurses and the group of ‘others’, with doctors showing the least impact and nurses the highest. This is in line with other outcomes such as more participation by nurses in training and evaluation, but control analysis showed that, in this study, these differences cannot be separated from the contexts of the hospitals. The numbers of doctors and those in the ‘others’ group were too small for more detailed analysis. Further research is needed to take a closer look at variations of effectiveness between professional groups.

High developmental cost

High organisational training costs can be considered as part of the development and they will decline once training has become routine within the hospital’s organisation. However, the high effort needed to convince staff of the relevance of the issue is more worrying. Cost-effective ways to work on resistance should be searched for. On the other hand, it is rather promising that the investment was considered worthwhile by all hospitals.

Planned modifications of the training

Cultural competence training will continue in six out of the seven participating hospitals. However, the intentions of the training organisers to modify training have been voiced clearly. The training time frame will be reduced and the training planned well in advance. To increase the specificity of training measures and thus raise acceptability, single departments or small units will be targeted. An increased practical training approach is on the agenda for future interventions.

Conclusions and recommendations

As a result of this investigation the authors propose to reshape the training into a two-step process:

1 generic basic training, combining knowledge about cultural diversity in clinical practice, awarenessraising techniques and communication skills, organised in 1–2modules with a total of 4–6 hours’ duration

2 integration of practical cultural competence skills development as part of quality management routines at departmental or ward level, adapted to the different professional needs and cultures using a range of strategies such as case discussions supported by experts for cultural diversity and mirror meetings with migrant patients. Many US authors have considered what integrating cultural competence into a broader quality framework might mean (for a new example, see National Initiative for Children’s Healthcare Quality, 2005) especially as healthcare disparities seem to be more and more accepted in US health professions and organisations. Quality improvement and patient safety strategies are well received among healthcare professionals (personal communication.RobertC. Like, 31 October 2005). Onthe European level, we would like to refer also to the concepts, experiences and results of implementing ‘migrant-friendliness’ in the quality structure and culture of hospitals.

A final lesson is that it has proven helpful to tackle a diverse and also difficult issue in a multi-hospital benchmarking approach which had, in addition, the prestige of a European project. Cultural competence training within the ‘Migrant-friendly Hospitals’ project had the big advantage of the commitment in principle of top management to put the issue of ethnocultural diversity and migration-related problems higher on the hospital agenda. The prestige of the European project has been an asset in convincing reluctant staff, and local organisers had the support of a group of others in similar position.

Resistance to the complex and controversial issues inherent in cultural competence training should not be underestimated, and support by hospital management and the wider healthcare and health policy environment will be urgently needed to make cultural competence development part of standard training, and everyday quality work in more than a handful of hospitals in Europe. To keep the issue on the agenda and to provide practical support for European hospitals, a Task Force for Migrant-friendly and Culturally Competent Hospitals has been set up within the World Health Organization Network of Health Promoting Hospitals, co-ordinated by the Italian Health PromotingHospitals – Network of the Emilia Romagna (a member of the WHO Network of Health Promoting Hospitals). Information on the task force will be made available via www.hph-hc.cc.

ACKNOWLEDGEMENTS

The authors would like to express their gratitude to Beate Schulze for the development of a fact sheet, Marlies Presser for the literature review and support in development of the pathway for the intervention and Robert Griebler for his expertise in statistical analysis. Special thanks to the many partners in the pilot hospitals who implemented training courses and were most helpful in evaluation. Representing their teams, we would like to thank the subproject co-ordinators Alice Bertozzi, Olivier Bouchaud, Karoline Kandel, Dilshad Khan, Manuel Fernandez, Hanneke Hartog, Angela Hughes, Beate Lieske, Corrado Ruozi, Antonio Salceda de Alba and Werner Schmidt. Thanks to Anita J Arnold, Philadelphia, who provided expert support in the inital phase. Finally, we are especially grateful to Robert C Like of the UMDNJ-Robert Wood Johnson Medical School, NJ, USA, who was most helpful in providing advice and guidance as a distinguished expert and scientist to the project and this paper, and also as a good, supportive friend to all the partners.

CONFLICTS OF INTEREST

None.

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