Background

Within health care today, managers and directors are challenged to have considerable expertise in management principles, budgeting and finance, human resource management, stewardship, ethics and diversity. These requirements presuppose that the managers have sufficient understanding of the populations being served, including both those receiving care and their families. It is not uncommon that managers will be overseeing a budget of several million dollars; in acute care settings, nurse managers today can be responsible for budgets that exceed $20 million. In short, today's health care managers must have the skills of a chief executive officer of a small business. Even with training in some of the above-mentioned areas, health care is changing so rapidly that managers report difficulties in staying current with regulatory requirements, new developments in care, and changes in reimbursement.

An added complexity arises from the diversity of residents within the Twin Cities communities. The emergence of a strong and vibrant minority population in the Twin Cities over the last ten years has resulted in a wonderful richness with new challenges. The city of St. Paul is a good example of this extraordinary growth. Not only do minority populations make up 65 percent of student enrollment in the public schools, but languages other than English are spoken in 38 percent of the homes. Moreover, educators report that more than a dozen languages may be spoken by the children in certain schools.

In the past, addressing cultural issues might mean that a manager could hire individuals who mirrored the particular patient population, or encourage employees to learn the language, or convert signs and patient care materials to the relevant language. Those strategies are helpful, but when individuals from multiple cultures are simultaneously seeking care, new approaches must be taken.

Unfortunately, many managers do not have skills in fostering diversity, in adjusting situations to accommodate the practices of different cultures, and in creating environments that support diversity and creativity. This is particularly true when many cultures are simultaneously represented in a care setting. Managers are not willfully resisting; they need training and support to develop new ways of organizing care and the environment so that patients and families who receive care do so in a setting that accommodates and supports their special ways of doing things.

The Institute of Medicine (2002 addresses this issue in its recent report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. They commented that "Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients' insurance status and income, are controlled ... [They] found evidence that stereotyping, biases, and uncertainty on the part of health providers can all contribute to unequal treatment." The authors recommended that patients receive culturally appropriate education but that, more importantly, providers should be exposed to cross-cultural curricula so that they could become more skilled in providing care to individuals from different cultures. This project specifically addresses this issue.

The Project

The purpose of the project is to improve the environment in which care is delivered in ambulatory care facilties by enhancing the cultural awareness and competence of managers/directors. The long-term goal is to decrease health outcomes disparities. The premise is that patients and families will more likely seek care and support care regimens when the health care is delivered in a facility that is sensitive to their particular values and beliefs. We will do this by: (1) offering intensive training and development to nursing leaders in the facilties regarding strategies for creating and sustaining environments sensitive to the needs and perspectives of individuals from multiple cultures; and (2) creating a cohort of leaders who can provide ongoing support, advice and direction to each other as they seek to change the work environments for which they are responsible.

The objectives of the project are to:

1. Expand the cultural competence and leadership skills of managers through enhancing their knowledge, skills, abilities and attitudes
2. Develop learning modules for incorporating cultural competence into effective management, and collaborate with educational institutions to incorporate these into nursing curricula
3. Assist these managers in creating health care environments sensitive to the cultural needs and perspectives of their patients, particularly when the patients come from multiple cultures

Project Outcomes

A successful program will be evident in how the environment supports diversity, what systems and processes are in place, how leaders model behaviors that foster diversity, and how caregivers incorporate considerations of diversity in their work. Examples of criteria that would reflect improvement in these areas would be that staff are competent in comprehensively assessing the needs of their patient populations and in providing care that is culturally sensitive; and systems and processes that are culturally sensitive are in place, resulting in care being individualized, flexible, responsive and respectful.

Project evaluation will be accomplished through pre- and post-intervention assessments. Outcomes of interest are:

• nurse manager knowledge, cultural competence, attitudes
• nurse manager confidence in establishing environments that are culturally sensitive and foster the delivery of care to individuals from multiple cultures
• the existence of systems and processes that foster culturally competent care