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Cultural Competence Training Program For African Immigrants

Cultural Competence Training Program For African Immigrants

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Cultural competence can be described as the ability of understanding, communicating, and interacting efficiently with people across cultures (Schouler-Ocak et al., 2015). Cultural competence comprises the process of one being aware of their own view of the world based on their cultural practices and traditions, as well as developing positive attitudes towards the difference in cultures of others (Allison et al., 2016). Cultural competence is an important aspect of healthcare because cultural practices directly impact health care practices (Venters et al., 2019). African immigrants often find themselves in situations of cultural dilemmas because of the differences in culture between their original areas of residence and their new ones (Price et al., 2015).

The main problem witnessed on the project site is the lack of cultural competence among health care providers regarding African immigrants. This problem negatively affects the health care experience of African immigrants (Purnell & Fenkl, 2019). Because of the gap in cultural incompetence, there is a huge disparity in the quality of health services received by the African immigrant population as compared to other population groups in United States (Clough et al., 2013). Evidence points to the fact that the African immigrant population has a lower health score and patient outcomes as compared to other groups with less than 18% of those admitted showing improved results over the course of their recovery (World Health Organization, 2020).

Knowledge gaps existing in practice causing cultural incompetence needs to be addressed because it violated the healthcare sector’s goal of ensuring fairness and equality in the access to services regardless of ethnic or racial orientation (Allen et al., 2012). As the World Health Organization explains, the health care sector aims at ensuring that everyone can be as healthy as possible, including the African immigrants (World Health Organization, 2020). The lack of cultural competence among health care providers that leads to African immigrants having poor health experiences violates this goal. The solution put forth by this project is the development of a cultural training program for African immigrants. This program is aimed at equipping health care providers with the right knowledge and set of skills to address the health concerns of African immigrants. The development of a cultural competence program is important because it will help in the removal of sociocultural factors that negatively impact the health experiences of African immigrants (Omenka et al., 2020).

Background

The number of African immigrants entering and settling in the United States increases almost every year (Purnell & Fenkl, 2019). This is because African immigrants prefer moving to the United States in search of better living conditions, better employment opportunities, and better health care services (Seck, 2015). However, African immigrants have been brought up in entirely different societies with completely different cultural beliefs and practices (Allen et al., 2012).

The African immigrant group has unique health care needs and most of these needs are related to their cultural practices (Purnell & Fenkl, 2019). Purnell and Fenkl (2019), report that health care providers are not devoted to finding methods of addressing these unique health care needs of African immigrants. Omenka et al. (2020), explain that the lack of cultural competence among health care providers is a crucial contributing factor to the poor health of African immigrants. Without cultural competence training, health care providers cannot effectively tackle the health care concerns of African immigrants (Kamya, 2017).

Problem Statement

The main problem faced at the project site is the lack of cultural competence training among health care providers, specifically regarding African immigrants. The facility is a primary care clinic in Garland, Texas that attends to various groups of people and the African immigrants group is one of them. However, the African immigrant group is different in terms of their health care needs since most of their medical needs are related to their culture (Asare & Sharma, 2012). The staff have not received formal training on addressing the needs of this population, therefore they cannot deliver health services that address the cultural, social, and linguistic needs of the African immigrant group. This results in poor health conditions for African immigrants. There are several resources available that are not being used, and this project addresses to address these gaps.

The Center for Disease Control and Prevention (CDC) reports that the failure of health care providers to administer effective health care services to African immigrants puts the group at an increased risk of getting sick (CDC, 2021). The Center for Disease Control and Prevention (CDC) reports that this has been clear, especially during the COVID-19 period as many African immigrants have suffered from and died of COVID-19 (2021). The proposed solution is the development of a cultural competence training program for the health care providers. This program is aimed at enabling the health care providers to gain the knowledge and techniques they can employ to provide quality health care services to African immigrants.

PICOT Question

In healthcare workers caring for African Immigrant groups (P), how can how can an effective cultural competence training program (I) compared to no training program (C) be developed to improve the resource allocation and referrals for African Immigrants (O) in less than 4 weeks (T).

Literature Review

Search Methods

The search strategy for this project included the use of databases, search terms, and keywords. The databases included MEDLINE (PubMed), Web of Science, Google Scholar, and CINAHL Complete. The keywords used were based on the PICO framework. The participants were “African immigrants”, “African incomers”, and “African in-migrants”. The intervention was “cultural competence”, “competence in cultures”, “cultural awareness”, “intercultural competence”, “culturally responsive”, “cultural literacy”, and “culturally informed”. The outcomes were “improved health care”, “better health care”, “enhanced health”, and “raised health care status”. Boolean operators were also used to combine search terms. The search terms were combined to broaden or narrow the search results. “OR” and “AND” were the Boolean operators used. The citation list was reviewed to identify any additional studies that were eligible for inclusion. This was to ensure that no relevant studies were excluded. There was focus on the breadth and specificity of the search.

Predetermined criteria for inclusion and exclusion had already been established and all the citations were reviewed against it. Various types of study designs were included, and these include systematic reviews, cross-sectional studies, and case reports and series. All included studies specifically addressed how cultural competence in the healthcare profession would be useful in improving the health outcomes of African immigrants or how deficiency of cultural competence among health care providers contributed to the poor health of African immigrants. The definition of cultural competency along with all its elements was based on the United States National Library of Medicine-National Institutes of Health (National Library of Medicine, 2019). The library defines cultural competency among health care providers as the ability to collaborate effectually with individuals from different cultures to improve their health care experience and outcomes Health (National Library of Medicine, 2019).

The studies included also specifically compared the cultural competency of health care providers to the health outcomes and experiences of African immigrants. All potential settings, such as hospitals, clinics, community settings, and others that were related to the studies, were included. The studies included specifically had their participants as African immigrants and no other group was substituted for the participants. Studies were exempted because of the following. (a) The study population was not only African immigrants, or there was no separate reporting of the results of African immigrants. (b) The study discussed African Americans instead of African immigrants. (c) The study did not have its core focus as cultural competence among health care providers in relation to African immigrants. (d) The intervention targeted the health care system or the health care providers instead of the patients. However, no studies were excluded based on participant age or sex, or article language.

Review Synthesis

Developing the themes was founded on analysis and examination of previous studies that were related to cultural competence issues among African immigrants. The main themes that emerged include effects of cultural incompetence, how language barriers affect cultural competence, and the impact of cultural competence training on health care workers. These themes are the main points of emphasis when developing a cultural competence program for African immigrants. Focusing on these themes will guarantee the success of the cultural competence program for African immigrants.

Review of Study Methods

Most of the literatures reviewed the qualitative literature review methods to supplement the facts in their studies. The qualitative literature review research was conducted in hospital and clinical settings by assessing redacted medical records. The facts gave insights into how cultural competence affected the quality of patient outcomes among the African immigrant population. The case study aimed at identifying the percentages of hospitals and clinics that acknowledge cultural sensitivity and inclusion through cultural competence training.

Literature Themes

Effects of Cultural Incompetence

The main issue observed in the research is the lack of cultural sensitivity and competence within the health care profession regarding African immigrants. This issue has a negative impact on the health care received by African immigrants. Because of the disparity in cultural competence, the health care providers cannot efficiently deliver health services that cater to the cultural, social, and linguistic needs of the African immigrant patients (Purnell & Fenkl, 2019). As a result, the African immigrant group is seen to have an overall health status score that is lower compared to other groups (Seck, 2015). As the World Health Organization defines, the health care sector has a goal of guaranteeing that everyone’s wellbeing is catered for as effective as possible, including African immigrants (World Health Organization, 2020). Health is determined by various social factors outside of the traditional healthcare setting (Purnell & Fenkl, 2019).

Some of these social determinants of health are housing quality, access to healthy foods, and education. Seck (2015) explained that African immigrants have unfavorable social determinants of health which contribute to their lack of quality healthcare. This leads to their poor health experiences because of the lack of understanding by health care workers regarding these social determinants of health. Lack of representation of African immigrants both in leadership and training is also responsible for the lack of cultural competence programs for African immigrants (Clough et al., 2013). Another reason for the lack of cultural incompetence regarding African immigrants is the fact that even most health care workers are white and without cultural training, it is hard for them to understand the needs of African immigrants (Seck, 2015). Even though the medical field is showing increased diversity, most people working in healthcare are not familiar with the culture of African immigrants, so they do not know how to handle this group (Purnell & Fenkl, 2019).

Cultural incompetence has had negative outcomes for African immigrant patients, such as serious health complications and even death. Clough et al. (2013) explained that, due to cultural incompetence, African immigrants are two to three times more likely to suffer from various health-related issues compared to other groups, like white people. The cultural incompetence of health care workers makes African immigrants suffer severely and longer from easily preventable diseases. Seck (2015) reports that some of these negative outcomes are because of subconscious prejudices and implicit bias about the African immigrant group . Addressing cultural incompetence and its effects is the first step to the development of a successful cultural training program for African immigrants (Purnell & Fenkl, 2019).

Language Barriers and Cultural Competence

Language is an aspect of culture that affects the quality of treatment in African immigrant groups (Seck, 2015). Language barriers play an important role in miscommunication between patients and medical providers, which negatively affects the quality of healthcare services and patient satisfaction regarding the African immigrant group (Allison et al., 2016). Due to language barriers, health care professionals have an incomplete understanding of the situations of patients, poorly assess patients, prescribe treatment incompletely, or cause delayed treatment or misdiagnoses (Wamwayi & Murray, 2019). As a result of language barrier, African immigrants end up having decreased satisfaction with healthcare services, complications arising from medication, and a reduced level of understanding of their diagnosis even if they have access to health care (Venters et al., 2019).

All these elements lead to the reduction in the quality of healthcare experience of African immigrants. One way of overcoming the language barrier is through using technology to bridge the language gap between healthcare professionals and African immigrants (Venters et al., 2019). Health care professionals can make use of voice recognition technologies such as Google Assistant and Google Translate. These are technologies that allow for two-way interpretation and can help in transcribing and translating dictations such as a doctor’s instructions (Wamwayi & Murray, 2019). Another effective way of overcoming the language barrier is the use of online applications, such as Duolingo, which offer new ways of learning different languages. Health care professionals can use these applications which keep things simple and make learning streamlined and easier, to understand elements of the African immigrants’ language and enhance their communication (Wamwayi & Murray, 2019).

Another way of overcoming the language barrier is through the use of an interpreter. The medical facilities can have interpreters specifically for African immigrant groups to enhance communication (Venters et al., 2019). The interpreter can be available physically at the medical facility and if this is not possible, technology has made it easier for the use of an interpreter using virtual platforms such as zoom, Google meet, or Skype (Allison et al., 2016). All these techniques and technologies will help in breaking the language barrier and enhancing effective communication between African immigrants and healthcare professionals. In the long run, the quality of health care services in African immigrants will improve, hence enhancing their overall health care experience and satisfaction.

The Impact of Cultural Competence Training On Health Care Workers

Training programs and cultural competence among health care workers have social, health, and business benefits for healthcare organizations and African immigrants (Omenka et al., 2020). Cultural competence training programs would increase mutual respect and understanding between African immigrants and health care providers (Kamya, 2017). It would also ensure the inclusion of all community members and increased participation and involvement of African immigrants in health issues (Kamya, 2017). Being culturally competent would also enable health care workers to have improved patient data collection for African immigrants and reduce the health care disparities in the African immigrant population (Asare & Sharma, 2012).

Cultural competence training programs for health care workers would help in reducing medical errors, the number of treatments, and legal costs, which increase cost savings (Asare & Sharma, 2012). When healthcare workers undergo cultural competence training programs, they will incorporate diverse ideas, perspectives, and strategies when deciding about African immigrants. Barriers that slow the progress of the healthcare experience of African immigrants would also be decreased and the efficiency of these care services will be improved (Omenka et al., 2020). Cultural competence training would also help health care providers to reduce the literacy gap when handling African immigrants (Omenka et al., 2020).

Most African immigrants come from backgrounds of little or no education which makes it hard for them to gain literacy skills to overcome language barriers or to read and understand instructions and conversations with health care professionals (Omenka et al., 2020). Cultural competence training would provide health care professionals with techniques of dealing with African immigrants with low literacy and explain how to offer them the best care quality. Cultural competence training will also enable health care professionals to coordinate with traditional healers among African immigrants and incorporate culture-specific attitudes and values into health promotion activities for this group (Kamya, 2017).

National Guidelines

Various national guidelines provide standards for culturally and linguistically appropriate services in healthcare. These guidelines aim at making health care services more responsive to the individual needs of patients coming from various cultural backgrounds (U.S. Department of Health and Human Services, 2001). These guidelines include ensuring the provision of health care services in a manner that is compatible with patient cultural health beliefs, practices, and preferred language (U.S. Department of Health and Human Services, 2001). Health organizations are required to establish strategies of recruiting, keeping, and promoting organizational staff and leadership that represent demographic characteristics of the area of service (U.S. Department of Health and Human Services, 2001).

Health care organizations ensure that staff at all levels undergo education and training for culturally and linguistically appropriate delivery of service. Language help services inclusive of bilingual staff and interpreter services at no cost to the patients with limited English proficiency must be offered by health care organizations (U.S. Department of Health and Human Services, 2001). Patients should be informed of the right to receive language help services for their preferred languages. Easy-to-understand materials relating to patients should be made available by healthcare organizations and the development, implementation, and promotion of a written strategic plan outlining clear goals and policies for providing culturally and linguistically appropriate services must be in place (U.S. Department of Health and Human Services, 2001). Internal audits, patient satisfaction assessments, and outcome-based evaluations should be done on integrating culturally and linguistically related measures about the organizations’ conduct. Health records should have slots for collecting the patient’s race, ethnicity, and language, and this should be integrated into the management information system of the organization management (U.S. Department of Health and Human Services, 2002).

An updated demographic cultural profile of the community should be maintained by the organization and collaborative, participatory partnerships with communities should be developed by the health care organizations regarding the designing and implementation of cultural and linguistic related activities (U.S. Department of Health and Human Services, 2002). Conflict and grievances resolution processes should be culturally and linguistically sensitive, also cross-cultural conflicts and complaints should be resolved appropriately by health care organizations (U.S. Department of Health and Human Services, 2002). Health organizations should make available to the public information about progress and successful innovations in implementing the culturally and linguistically appropriate services standards (U.S. Department of Health and Human Services, 2001).

Aims of the Quality Improvement Project

The quality improvement project is aimed at designing a cultural competence training program that will enable health care professionals to understand African immigrants’ expression of health needs. The project is aimed at breaking down barriers that get in the way of African immigrant patients receiving the care they need. It is also aimed at ensuring improved understanding between African immigrant patients and their health care providers. The project is aimed at structuring a cultural competence training program that will accommodate the growing diversity of the United States population demands regarding the African immigrant group and expanding the ability of healthcare professionals to address the needs of this group. Generally, this quality improvement project is aimed at developing a cultural competence training program that will train health care providers on how to incorporate different ideas, perspectives and strategies as they make health decisions about African immigrants which would improve the overall health care experience of this group.

Objectives

The objectives of this project are:

1. To create a cultural competence training program that will help in promoting cross-cultural awareness and competence skills needed for health care professionals to be culturally competent regarding African immigrants.

2. To create an African Immigrant Cultural Competence Toolkit that will be used by care providers to assess and enhance cultural competence in the organization (even after the completion of this project).

3. To create a Resources Toolkit that will be given to African immigrant patients visiting the primary care clinic.

Conceptual Model: Madeleine Leininger’s Cultural Care Theory

The theoretical underpinning or conceptual framework for this project will be provided by Madeleine Leininger’s Cultural Care Theory. Leininger’s theory focuses on the definition of what pertains to transcultural nursing and how nurses comprehend the beliefs and practices of diverse cultural groups (Leininger, 1988). This theory is the most appropriate for this DNP project since it aims at explaining how nurses can provide culturally congruent care through taking actions that are mainly designed to suit the individual’s, group’s, or institution’s cultural values, lifeways, and beliefs (Leininger, 1988). The goal of the Cultural Care Theory is to enable improved health outcomes for individuals of different cultural backgrounds (Leininger, 1988).

Historical Development of the Theory

In the late 1950s, Madeleine Leininger envisioned how the world was increasingly becoming integrated and human beings were interacting on a global scale (Leininger, 1988). Leininger decided that she would go beyond anthropology and emphasize groups of people from diverse parts of the world in expressing her thoughts from a nursing perspective (Leininger, 1988). Leininger had always believed that care is the most essential component of nursing, even before establishing the field of transcultural nursing (Leininger, 1988). Her study of the Gadsup people in Papua New Guinea in the early 1960s was the first transcultural nursing research, and she preceded to establish the initial formal doctoral programs and courses in transcultural nursing in 1965 at the University of the Colorado School of Nursing (Wehbe-Alamah, 2015). The first book to be published regarding Leininger’s Cultural Care Theory was ‘Nursing and Anthropology: Two Worlds to Blend’, which was just published in 1970 (Wehbe-Alamah, 2015). A third and an updated edition of ‘Transcultural Nursing: Concepts, Theories, and Research Practices’ was authored by Leininger and McFarland in 2002 (Wehbe-Alamah, 2015).

Through her discussions of the theory, Leininger continued to elaborate on the significant features of culture care diversity within the context of transcultural nursing. Leininger established the Transcultural Nursing Society in 1974 aimed at serving nurses worldwide through teaching them how to reinforce the quality of culturally competent care aimed at improving the health and well-being of people worldwide (Wehbe-Alamah, 2015). Over the years, Leininger’s theory has been used in training nurses how to provide culturally specific care, which is aimed at improving the health and well-being of people as well as helping them to face unfavorable human conditions, illnesses, or death, in culturally meaningful ways (Wehbe-Alamah, 2015).

The Major Tenets

In developing the major components of the theory, several factors were taken into account by Leininger. These factors were the elements that guided the development of the major tenets of the theory (Leininger, 1988). Leininger explained that wellness and illness are molded by various factors, inclusive of perception and coping skills (Leininger, 1988). Cultural competence is an essential component of nursing and culture affects diverse segments of human life including illness, health, and the search for relief from distress or diseases (Leininger, 1988). Cultural and religious knowledge is a significant aspect of healthcare and the health concepts that cultural groups hold may impact how they seek modern medical care (Leininger, 1988).

Before discussing the major tenets of the theory, it is important to understand the meaning of certain terms related to the theory as defined by Leininger. Care is assisting others in an effort of improving their human conditions of concern or facing death (Wehbe-Alamah, 2015). Caring is an act of providing care (Wehbe-Alamah, 2015). Culture is the learned, shared, and transmitted norms, beliefs, ways of life, and values of a specific group that guides their decision or lifestyle (Wehbe-Alamah, 2015). Cultural care refers to various elements of culture which are responsible for influencing and enabling people to enhance their human conditions or to face illnesses or death (Wehbe-Alamah, 2015). Cultural care diversity describes the differences in meanings, values, or accepted modes of care between or within diverse groups of people, while culture care universality describes the common and similar meanings of care in the cultures (Wehbe-Alamah, 2015).

Theory Application to the DNP Project

Generally, the major tenets of the theory will be used in guiding the research and documentation of how healthcare providers can develop an understanding, appreciation, and respect for the diversity and individuality of African immigrant patients’ values, beliefs, culture, and spirituality, in the context of illnesses, causes of illnesses, treatment, and outcomes (Wehbe-Alamah, 2015). They will be used in the project to research and document how nurses can develop care that fits the values, beliefs, and lifestyles of African immigrants, and which is based on the patients themselves rather than predetermined criteria (Wehbe-Alamah, 2015). The major tenets of the theory will also be used to identify how nurses can bridge the cultural gap to achieve meaningful and supportive care for African immigrant patients and their families (Wehbe-Alamah, 2015). Based on the concepts of the theory, the project will find out how nurses can self-examine their backgrounds, recognize biases and prejudices as well as assumptions about the African immigrant group.

Cultural care preservation or maintenance will be used to identify how the healthcare providers can develop assistive and facilitative professional actions and decisions that can aid the African immigrants to preserve or retain relevant care values that will help them in maintaining their well-being, recovering from illnesses, or facing handicaps or death (Wehbe-Alamah, 2015).

Cultural care accommodation or negotiation will be used in the project to guide the identification and documentation of the assistive, supportive, enabling, or facilitative professional decisions or actions that may help the healthcare providers in training African immigrants to adapt culturally, for improved and satisfactory health outcomes (Leininger, 1988).

Cultural care repositioning or restructuring will be used in the identification and documentation of techniques that the healthcare providers can use to help African immigrants in reordering, changing, or greatly modifying their lifestyles for newer, better, and different health care patterns while respecting the African immigrants’ cultural values and beliefs (Leininger, 1988).

Implementation Model: The Plan-Do-Study-Act Model

Many health care research and reports recommend the Plan-Do-Study-Actmodel as an implementation model for quality improvement projects (Donnelly & Kirk, 2015). The model is made up of four repeating phrases that are cyclical in nature. These are Plan, Do, Study, and Act (Donnelly & Kirk, 2015). Plan is about the effort and background work of proposing change (Donnelly & Kirk, 2015). Do is about implementing the proposed change (Donnelly & Kirk, 2015). Study is about conducting analysis and evaluation of the outcomes of the proposed change (Donnelly & Kirk, 2015). Act is about revisiting and redesigning the previously planned change to take into account the lessons which have been obtained at the Do and Study phases (Donnelly & Kirk, 2015). The PDSA model is selected because it will be effective in giving rise to changes in a short period and facilitating continuous quality improvement (Donnelly & Kirk, 2015). This model will be used to test the proposed change during the implementation process (Donnelly & Kirk, 2015). It will be used to the test the change through planning, trying, observing results, and taking action on the lessons learnt (Donnelly & Kirk, 2015). The model will be used during the course of the project to assess how the project implementation can be done in a manner that will lead to the desired improvement (Donnelly & Kirk, 2015). The model will also be used to evaluate how much improvement can be expected from the change and how best the proposed change can work in the real environment of interest (Donnelly & Kirk, 2015).

Setting

The setting of this project is a primary care clinic in Texas. It is an ideal place for conducting this project because it is home to a huge number of African immigrants (Chikanda & Morris, 2021). According to American Immigration Council, African immigrants are ever growing and constitute a diverse group in the United States (Chikanda & Morris, 2021). According to the American Immigration Council, Texas is one of the locations with the largest number of African immigrants with other areas being California, New York, Virginia, and Maryland (Chikanda & Morris, 2021). This means that because the project addresses cultural competence concerning African immigrants, it will be beneficial both currently and in the future. The practice location is made up of 10 healthcare providers, including a nurse, family nurse practitioner, office administrator, and medical assistants.

The system used as the solution for electronic health records is EPIC. EPIC provides the primary care clinic with a standard range of primary EHR functions and modules can be added depending on specialty (Milinovich & Kattan, 2018). The primary care clinic uses the EPIC system for appointment management, patient history, scheduling, e-prescription, and clinical workflow. The EPIC system will act as a significant source of data during data collection for the project because it contains all the necessary information about the patients who visit the clinic.

Population of Interest

The population of interest for this project will be in terms of direct and indirect population. The health care providers will form the direct population of interest. These health care providers will be the focus of this cultural competence program for African immigrants and they include nurse, family nurse practitioner, office administrator, and medical assistants. The inclusion criteria will focus on health care providers attending to the health concerns of the African immigrant patients. Anyone else who works at the clinic (either temporarily or permanently) but who is not involved in the provision of care for African immigrant patients will be excluded . This means that all other workers who are not involved in the treatment of African immigrants visiting the clinic for primary care services will be excluded from the project.

The African immigrant population visiting the clinic for primary care services will form the indirect population of interest. The inclusion criteria for this population will be any adults who identify as African immigrants and who visit the clinic for primary care services. The exclusion criteria will be any other patients besides African immigrants visiting the clinic for primary health services. This excludes patients from other ethnicities visiting the clinic for primary care services.

Stakeholders

The significant stakeholders in this project are the clinic owner, the medical director, and the health care providers. The owner of the clinic is a significant stakeholder since she is responsible for overseeing the daily operations of the facility (Kirchner et al., 2012). The owner of the clinic also provides administrative support and oversees the hiring, firing, and training of staff members (Kirchner et al., 2012). The owner of the clinic is also responsible for liaising with patients and health care providers, as well as coordinating plans for patient care (Kirchner et al., 2012). The site administrator is significant because he or she is responsible for ensuring that the running of the activities in the clinic is top notch and as expected. He or she also ensures that quality medical care is provided to the community being served by the clinic (Kirchner et al., 2012). The medical director is significant because they are in charge of the daily operations of the clinic and documentation of the patients seen (Kirchner et al., 2012).

Obtaining permission was vital for the sake of the project and it was granted by the owner of the clinic, the site administrator, and the medical director. Obtaining permission helps in ensuring that the activities of the project at the site will be conducted with adherence to both ethical and legal guidelines and considerations (Milinovich & Kattan, 2018). No affiliation agreements were necessary for this project.

Interventions Comment by Elumalai, Calaiselvy – SRDH: Review begins here Comment by Jessica Grimm: Overall, your plan does not seem to match between sections. I think we need to meet. When the plan does not match throughout, this is a high risk of failure. It seems you may be unclear of what you are doing, or it is not coming through in your writing. Please email Dr. Elumalai so we can meet.

The first intervention is the creation of a cultural competence training program that will be attended to by health care providers. This cultural competence training program will include information regarding how healthcare professionals can be culturally competent when handling African immigrant groups. The cultural competence training program will focus on skills and knowledge that value diversity and which enable health care professionals to comprehend and respond to cultural differences regarding the African immigrant groups. The cultural competence program will also include elements for increasing awareness of health care providers and organization’s cultural norms. The cultural competence training program will include provision of facts about the culture of the African immigrant patients as well as the various possible complex interventions such as intercultural communication skills, exploring potential barriers to care, and establishment of policies that are closely related to the needs of the African immigrant patients. The creation of a cultural competence training program is listed as the first intervention because it will also be carried out as the first intervention and the differences between the time prior to the creation of this cultural competence program and the time after will also be addressed. Comment by Elumalai, Calaiselvy – SRDH: Go chronologically here. Prior to the educational session, you will administer the pretest. Will this be done the same day as the educational session or before that? This should occur in week one of the implementation phase. Then discuss how you will present the educational session. How many educational sessions will you provide to cover all the staff? Then you will administer the post test. Will it immediately follow the educational session or will you administer weeks later?

The second intervention will be the creation, administration, and implementation of an African Immigrant Cultural Competence Toolkit (AICCT). This African Immigrant Cultural Competence Toolkit (AICCT) will include information regarding all the issues concerning the African immigrants visiting the health care facility as well as how to respond and react to them. The African Immigrant Cultural Competence Toolkit (AICCT) will be a summary of all the information regarding how healthcare providers can address the health care concerns of African immigrants in an effective manner while observing the cultural differences between the care providers and the African immigrant patients. African Immigrant Cultural Competence Toolkit (AICCT) will be designed in such a way that it can be used by health care providers both during the project and even after the completion of the project. By using the African Immigrant Cultural Competence Toolkit (AICCT), care providers will be able to assess and enhance cultural competence in the organization concerning African immigrant patients. The African Immigrant Cultural Competence Toolkit (AICCT) will be a significant intervention for this quality improvement project because it is aimed at enhancing continuous change both in the present and the future. The African Immigrant Cultural Competence Toolkit (AICCT) will contain information that will act as a benchmark when being used by health care facility’s care providers as they offer health care services to African immigrants. The comprehensiveness of this African Immigrant Cultural Competence Toolkit (AICCT) is necessary and it will be aimed at eliminating all the identified factors that have been discussed above to be causing ineffectiveness when attending to the health care needs and concerns of the African immigrant patients group. Comment by Elumalai, Calaiselvy – SRDH: Please clarify. When does this occur? Comment by Elumalai, Calaiselvy – SRDH: Plan for interventions discussed are realistic with consideration to the timeline of the project. (The full timeline doesn’t need to be included in the paper but your general plan for intervention should be.)

The other intervention will be the creation, administration, and implementation of a resources toolkit for African immigrant patients. This toolkits will include information regarding resources, the organizations dealing with the resources, physical and online addresses, telephone numbers, and available days of the week. The information will originally be created in English but will also be replicated in various other languages based on their prevalence in the state and around the environment of the health care organization. Examples of these resources will include financial assistance organizations for African immigrants, educational assistance organizations for African immigrants, health care organizations, and religious and cultural organizations for the African immigrants. By use of this African immigrant resources toolkit that will be given to African immigrant patients visiting the primary care clinic, the expected goal is that it will be easier for African immigrants to find help not only in matters related to health care but also in other areas of their lives as well. This is because various issues such as their financial background, educational background, and cultural background may impact their health care experience significantly (Allison et al., 2016). Comment by Elumalai, Calaiselvy – SRDH: What is the timeframe for these interventions? Comment by Jessica Grimm: Agree this needs to be clarified. Try to be more concise in your writing and be clear about when you will use each tool in your intervention timeline. I think you can teach the staff how to use what they need all in the first week, then follow up on what was done in the remaining weeks.

Tools

Described below are the various tools that will be necessary for achieving the objectives and carrying out the interventions of the quality improvement project.

African Immigrant Cultural Competence Toolkit (AICCT)

The first tool will be the African Immigrant Cultural Competence Toolkit (AICCT). This tool will be self developed based on available evidence based literature regarding African immigrants and their healthcare experiences in the United states in general and in California as a state. Although self developed, expert consultation through stakeholders and the project team will be sought for the purposes of validating the tool. Comment by Jessica Grimm: I think this is too much. I would recommend making a quick-guide or a guideline. A one page document that is easy to use. Anything more will be too hard to operationalize for providers.

African Immigrant Resources Toolkit

The other tool will be the African Immigrant Resources Toolkit. This tool will also be designed and developed in a way that supports the objectives and interventions of the QI project. The tool will be self developed and expert consultation through stakeholders and the project team will be sought for validation. The tool will be developed while considering evidence based literature regarding the most significant resources needed by African immigrants as well as the best way of providing them. The tool will be designed in a way that is aimed at improving the health care experience of African immigrants and together with the African Immigrant Cultural Competence Toolkit, it is aimed at achieving the overall objective of the QI project. Comment by Elumalai, Calaiselvy – SRDH: This section is confusing and repetitive, revision is needed Comment by Jessica Grimm: I think this should just be a list of resources for the main needs identified. It should be a short one-page document.

Inventory For Assessing The Process Of Cultural Competence Among Health Care Professionals Revised (IAPCC-R) Comment by Jessica Grimm: This wasn’t part of your plan before. If you want to do this- we can talk about it. Do you think it applies to your project? It looks like you have to pay to use it. Have you sought permission? If you do use it, please include all of this information here and give actual reliability/validity data.

The other tool is the Inventory For Assessing The Process Of Cultural Competence Among Health Care Professionals Revised (IAPCC-R). This tool is created for my measuring the level of cultural competence among healthcare professionals and will be used in the assessment of the level of cultural competence among health care professionals in the health care setting (Allison et al., 2016). The tool is an already established tool and it has been validated by previous studies. While using the established tool, there will be need to seek permission for using the tool from Dr. Josepha Campinha-Bacote.

Educational Presentation

Educational presentation will be another tool used for completing the objectives of the project. This tool has already been validated by numerous evidence based studies conducted previously. No permission is needed for using this tool. Comment by Jessica Grimm: Please discuss that you developed the presentation and that it will be reviewed and approved by the project site and team.

Chart Audit Tool

A Chart Audit Tool is a tool that health care providers will use for checking their individual performance, determining how they are doing, and identifying areas where there is need for improvement (Allison et al., 2016). Expert consultation through stakeholders and the project team will be sought for the validation of the tool. Also, no permission is needed for using the chart audit tool. Comment by Elumalai, Calaiselvy – SRDH: Who does the audit? Comment by Jessica Grimm: Agree. What are you auditing? You can audit if the patient facing handout was given to the patient.

Appendices

(Appendix A)

Permission to complete project at the site

(Appendix B )African Immigrant Cultural Competence Toolkit (AICCT).

(Appendix C)

African Immigrants Resources Toolkit (AIRT).

AFRICAN IMMIGRANT RESOURCES TOOLKIT (AIRT)

(This toolkit contains the various resources available for African immigrants in Texas)

ResourceInformation
Food AssistanceAVANCE4301 Dacoma Street. Houston, Texas 77092(713) 812-0033https://www.avancehouston.org/Access Health Bellville WIC800 E. Wendt Street. Bellville, Texas 77418(979) 865-9140https://myaccesshealth.org/services/texas-wic/Braes Interfaith Ministries4300 West Belfort, 77096. Houston, Texas 77035(713) 723-2671http://braesinterfaithministries.org/services/
Legal ServicesBakerRipley Legal Consultations6535 Rookin St. Houston, Texas 77074(346) 867-3871bakerripleyimmigration.as.me/schedule.phpBoat People SOS11360 Bellaire Boulevard, Suite 910, 77072-2531. Houston, Texas 77072(281) 530-6888http://www.bpsos.org/
Housing ServicesAvenue 3602150 West 18th Street, Suite 300. Houston, Texas 77008(713) 426-0027https://avenue360.org/services/housing/Baytown Housing Authority1805 Cedar Bayou Road. Baytown, Texas 77520(281) 427-6686http://www.baytownhousing.org/family-self-sufficiency-fss
Employment ServicesAVANCE Training Center4625 North Freeway, #301. Houston, Texas 77022(713) 239-2656https://www.avancehouston.org/locations/avance-training-center/BakerRipley Workforce Solutions9315 Stella Link. Houston, Texas 77025(713) 661-3220https://www.bakerripley.org/services/workforce-solutions-astrodomeCypress Assistance Ministries11202 Huffmeister, Houston. Houston, Texas 77065(281) 955-7684www.cypressassistance.org
Financial AssistanceAn-Nisa7211 Regency Square Drive. Houston, Texas 77036(832) 324-9111https://www.annisahopecenter.org/about-us/Braes Interfaith Ministries4300 West Belfort, 77096. Houston, Texas 77035(713) 723-2671http://braesinterfaithministries.org/services/
Health ServicesAccessHealth Brookshire Clinic533 FM 359 S. Brookshire, Texas 77423(281) 342-4530https://myaccesshealth.org/services/adult-care/ADAPT Programs2512 N. Velasco, Suite 300. Angleton, Texas 77515(979) 480-3327https://www.adaptprograms.com/services/intensive-outpatient/

(Appendix D)

Inventory For Assessing The Process Of Cultural Competence Among Health Care (Appendix) Professionals Revised (IAPCC-R)

(Appendix E)

Educational Presentation.

(Appendix F)

Chat Audit Tool.

References

Adekeye, O. A., Adesuyi, B. F., & Takon, J. G. (2018). Barriers to healthcare among African immigrants in Georgia, USA. Journal of immigrant and minority health, 20(1), 188-193.

Allen, K. M., Jackson, I., & Knight, M. G. (2012). Complicating culturally relevant pedagogy: Unpacking African immigrants’ cultural identities. International Journal of Multicultural Education14(2).

Allison, K. W., Echemendia, R. J., Crawford, I., & Robinson, W. L. (2016). Predicting cultural competence: Implications for practice and training. Professional Psychology: Research and Practice27(4), 386.

Asare, M., & Sharma, M. (2012). ROLE OF HEALTH BELIEF MODEL ON SEXUAL COMMUNICATION AMONG AFRICAN IMMIGRANTS. American Journal of Health Studies27(2).

Betancourt, J. R., & Green, A. R. (2010). Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Academic Medicine, 85(4), 583- 585.

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Clough, J., Lee, S., & Chae, D. H. (2013). Barriers to health care among African immigrants in

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Leininger, M. M. (1988). Leininger’s theory of nursing: Cultural care diversity and universality. Nursing science quarterly1(4), 152-160.

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Martinez, D. A., Kane, E. M., Jalalpour, M., Scheulen, J., Rupani, H., Toteja, R., … & Levin, S. R. (2018). An electronic Dashboard to monitor patient flow at the Johns Hopkins Hospital: communication of key performance indicators using the Donabedian model. Journal of medical systems42(8), 1-8.

McCalman, J., Jongen, C., & Bainbridge, R. (2017). Organisational systems’ approaches to improving cultural competence in healthcare: a systematic scoping review of the literature. International journal for equity in health16(1), 1-19.

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World Health Organization. (2020, March). Health Equity.

Running head: LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 1

Latinx Immigrants Cultural Awareness Toolkit in a Psychiatric Outpatient Clinic

Roberto E. Gimenez

Touro University

In partial fulfilment of the requirements for the Doctor of Nursing Practice

Jessica Grimm, DNP, RN

Sandra Olguin, DNP, RN

Neoves Diaz, DNP, RN

01/26/2021

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 2

Latino Immigrants Cultural Awareness Toolkit in a Psychiatric outpatient clinic ……………………. 4

Introduction ……………………………………………………………………………………………………………………. 5

Background ……………………………………………………………………………………………………………………. 5

Problem Statement ………………………………………………………………………………………………………….. 6

Purpose Statement …………………………………………………………………………………………………………… 6

Project Question ……………………………………………………………………………………………………………… 7

Objectives …………………………………………………………………………………………………………………….. 7

Coverage and Justification…………………………………………………………………………7

Review of Synthesis……………………………………………………………………………….9

Literature Review………………………………………………………………………………….9

Review of Study Methods………………………………………………………………………..13

Significance of Evidence to Profession………………………………………………………….14

Historical Development of the Theory…………………………………………………………..15

Major Tenets………………………………………………………………..……………………16

Theory application of DNP……………………………………………………………………….18

Setting…………………………………………………………………………………………….18

Population of Interest…………………………………………………………………………….20

Stakeholders………………………………………………………………………………………21

Interventions………………………………………………………………………………………21

Tools………………………………………………………………………………………………23

Data Collection Procedures………………………………………………………………………26

Ethics/Human Subjects Protection…………….…………………………………………………27

Measurable Plan for Analysis……………………………………………………………………28

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 3

Results……………………………………………………………………………………………29

Discussion findings………………………………………………………………………………30

Significance/Implications for Nursing……………………………………………………………32

Limitations……………………………………………………………………………………….34

Dissemination……………………………………………………………………………………36

Sustainability……………………………………………………………………………………36

References………………………………………………………………………………………..38

Appendix A………………………………………………………………………………………45

Appendix B………………………………………………………………………………………46

Appendix C………………………………………………………………………………………50

Appendix D………………………………………………………………………………………52

Appendix E………………………………………………………………………………………62

Appendix F……………………………………………………………………………………….63

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 4

Latino Immigrants Cultural Awareness Toolkit in a Psychiatric outpatient clinic

Latino immigrants who seek mental health services need culturally competent care to

improve their healthcare outcomes. Misunderstandings concerning the cultural needs of the

Latino population are common among healthcare workers. As a result, health care providers are

often unable to identify and understand the role that culture plays in the lives of most Latino

people, including mental health (Luque et al., 2018). Many Latinos do not seek treatment for

mental issues since they do not recognize their symptoms or do not know where to seek help

(Adames, & Chavez-Dueñas, 2016). Current literature demonstrates that the lack of cultural

competence in health workers has resulted in misdiagnosis as well as inadequate treatment of

mental health issues for the Latino population (Adames, & Chavez-Dueñas, 2016). Latino

immigrants, therefore, continue to receive poor quality care when it comes to their mental health

needs.

A systematic review determined that access to culturally competent care was essential to

increasing health service utilization among the Latino population (Moore, 2017). Additionally, a

study conducted by Govere & Govere (2016) demonstrated that cultural competence training of

healthcare providers significantly improved patient satisfaction and outcomes. This evidence

contributes to the conclusion that in order to increase health service utilization and improve

healthcare outcomes for the Latinos, efforts should be made to provide adequate cultural

competence training to healthcare providers in the United States. Currently, there are no cultural

competence guidelines implemented at the mental health clinic where the DNP project will be

taking place. As a result, the purpose of the DNP project is to implement a Latino immigrant

cultural competence toolkit (LICCT) for healthcare workers at the project site to improve patient

mental health outcomes at the outpatient clinic.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 5

Background

According to Flores (2017), the Latino population accounts for approximately 17.6

percent of the total U.S. population; in 1980, the Latino population represented just 6.5 percent

of the total U.S. population (Flores, 2017). The number of Latinos is projected to grow to 107

million by 2025 (Flores, 2017) due to the ever-increasing rate of immigration of Latinos into the

U.S. Despite the increasing size in the number of Latinos in the U.S., they are still significantly

less represented in the healthcare workforce. According to Fisher (2018), less than 4% of

healthcare providers in the U.S. speak Spanish, with Texas having the highest proportion at 9%

followed by New Mexico and Florida with 8% and 6%, respectively. Additionally, statistics from

the U.S. Census Bureau report show that 29.8% of Latinos are not fluent in the English language

(Office of Minority Health, 2020).

Due to this language barrier, most health providers do not understand how to effectively

deal with diversity, which raises problems for the Latinx immigrant population. Latinx not only

face language and other external barriers to obtaining mental treatment, but also their cultural

perceptions of mental health care prevent them from getting help. (Cabassa, Lester, & Zayas,

2007). Moreover, their culture has various aspects concerning mental health that many health

care providers fail to understand appropriately and hence cannot provide quality care. For

example, primary mental health care providers fail to recognize specific cultural-bound

syndromes that are characteristic of Latinos such as fright, an evil eye, and nerves, among others;

symptoms that are unique to this ethnic group include uncontrollable screaming, crying,

trembling, physical and verbal aggression, seizure-like episodes, as well as suicidal gestures

(Caplan, 2019). To cater to the mental health care needs of this minority group, there is a need

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 6

for health care providers to understand such syndromes and symptoms for purposes of providing

care that considers their cultural perspectives and beliefs (Camacho, 2015).

Problem Statement

Racial and ethnic minorities in the U.S. are generally less satisfied with the health care

services that they receive (Adames, & Chavez-Dueñas, 2016). Although there has been policy

and research emphasis on delivering culturally competent mental health care, there is little

evidence concerning what frontline mental health care providers consider to be culturally

appropriate care (Adames, & Chavez-Dueñas 2016). Existing research also suggests that various

challenges hinder them from delivering culturally appropriate health care in their everyday

practices.

It is essential for healthcare providers to have a proper understanding of the cultural needs

of Latino immigrants surrounding mental health issues. Mental health care providers should also

be sensitized concerning specific aspects of both Latinos’ learning style as well as their illness

perception, along with other perspectives such as authority and physical contact issues (De

Freitas, Crone, DeLeon, & Ajayi, 2018). To achieve this cultural competency among mental

health care providers, it is essential to provide education and training concerning the perspective

of Latinos on mental issues (Cabassa, Lester, & Zayas, 2007). Mental health providers at this

DNP project site, a mental health clinic in urban Florida, do not yet have training on providing

culturally competent care for Latinos.

Purpose statement

This project aims to provide a Latinx immigrant cultural competence toolkit (LICCT) for

healthcare workers in an outpatient mental health clinic. When mental healthcare providers are

able to approach care with cultural competence, they can gain the trust of their patients to

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 7

encourage them to speak freely about their symptoms that can then be used in diagnosis and

treatment. This project aims to eliminate cultural barriers that hinder Latino immigrants from

receiving appropriate mental health care, such as lack of diversity in the mental health

workforce, language barriers, and ineffective communication (Boykin, Schoenhofer, &

Valentine, 2014). This will be achieved through training of health care providers on cultural

norms and expectations of care of Latinos. Latino immigrants will also be provided with a toolkit

of resources to assist them with their mental healthcare.

Project Question

This project shall incorporate the PICOT question method as the guide for answering the

project questions. The project question is:

Does the implementation of a cultural competence toolkit aimed at Latino immigrants

improve culturally competent care and increase resource referral for this population?

Objectives

In the timeframe of this DNP project, the following objectives will be met:

1. To administer an educational seminar for the multi-disciplinary team in the health

facility, consisting of one psychiatrist and two Mental health Nurse practitioners, to train

them on culturally competence practice guidelines and the LICCT.

2. To develop a LICCT and implement it at the mental health clinic project site.

3. To increase the resource referral of Latino immigrants during mental health visits at the

project site.

Coverage and Justification

Limits for the review of literature were set to achieve the desired results. The selection

benchmark used for this review include those examining Latino communities, study design of

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 8

systematic reviews or qualitative and quantitative studies, peer reviewed reports, and involving

the mental health setting.

The PICOT question was used as the primary search method to obtain sources. The

question was: Does the implementation of a cultural competence toolkit aimed at Latino

immigrants improve culturally competent care and increase resource referral for this population?

Govere and Govere (2016) conducted a general review on of literature to evaluate the effect of

cultural proficiency education of physicians on patient satisfaction. They concluded that

culturally competent practitioners had a significant positive impact on patient satisfaction

(Govere and Govere, 2016). Similarly, Jongen, McCalman, and Bainbridge (2018) undertook a

systemic review, and established that culturally proficient training of the health workforce was

the main strategy of reducing healthcare disparities among ethnic minorities.

The search terms used to guide the selection of secondary sources include Latino,

immigrants, minority communities, culturally sensitive healthcare, mental health clinic, and

LICCT. The search results generated over 500 results. Initially, 100 journal articles and academic

books were found to have potentially relevant titles and abstracts. Out of those results, 20

duplications in multiple databases were eliminated. Further specifications were used with

Boolean phrases such as ‘cultural competence among Latino immigrants and mental health,’

‘mental health and Latino immigrants,’ ‘cultural themes in mental health among Latino,’ and

‘culturally competent healthcare service among the Latino group.’ Eventually, the search yielded

ten peer-reviewed journals and academic books that covered the PICOT question, which had

been published in the past five years. A full-text screening followed the screening of titles and

abstracts.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 9

Review of Synthesis

The theme development process was based on an analytic examination of the previous

studies related to various aspects of social phenomena through literature reviews and analysis of

transcriptions. Online data bases use included, Cochrane library, Agency for Healthcare

Research and Quality (AHRQ), PubMed, and Cumulative Index of Nursing and Allied Health

Library (CINAHL). The emerging themes from the review of literature included lack of

knowledge among professionals on the different cultural practices among minority communities,

lack of knowledge about traditional remedies, poor representation of minority communities in

the healthcare workforce, poor cultural competence education, and diagnostic errors emerging

from miscommunication. The themes provided insight into the implications for knowledge,

practice, policymaking, and research on mental health among minorities.

Literature Review

The primary objective of the review of literature was to examine the cultural proficiency

of physicians among minority communities with a specific focus on the Latino group. In this

regard, the project leads used themes that emerged to identify the current state of cultural

healthcare perceptions among professionals, patients, and the community members, identify the

factors and challenges that influence the cultural competence, relationship, and communication

among caregivers and patients, and provide recommendations on how to improve care for

cultural competence. The search terms that guided the selection of articles include minority

representation in the nursing profession, cultural competency training, barriers to cultural

training, and miscommunication in healthcare. An online search produced a total of 800 results.

Out of which 200 were journal articles and published books. The search generated 8 articles

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 10

when it was further narrowed to peer-reviewed sources published from 2010. The articles were

then used to conduct the literature review.

Cultural Knowledge Among Healthcare Workers

The increasing population of minorities in America has triggered the need for an

ethnically proficient workforce. However, most healthcare institutions in America are not

culturally competent to provide services to minority communities due to sociocultural

bottlenecks, namely clinical impediments organizational challenges, and structural constraints

(Oriana, Schilgen, & Mosko, 2019). Organizational challenges impede the accessibility of care

and include things such as the representation of the minority population in the workforce (Oriana

et al., 2019). Structural constraints result from the red tape in healthcare systems. Clinical

impediments occur in the patient-healthcare professional interactions. Healthcare institutions

must invest in cultural competence strategies to mitigate the glaring disparities evidenced in

health outcomes. Barrera & Longoria (2018) performed a systemic literature review to assess

some of the cultural obstacles that Latinx face when seeking mental health treatment. The

researcher established that cultural sensitivity enhance communication between the physician

and the patient (Barrera & Longoria, 2018). Similarly, Larson, Mathews, Torres, and Lea (2017),

in their qualitative study, sought to evaluate the relationship practitioners and elderly Latinx in

rural areas. They found that healthcare providers need to require cultural sensitivity education to

meet the needs of their patients (Larson et al., 2017). Therefore, healthcare stakeholders should

promote culturally sensitive training to promote patient outcomes.

Poor Representation in the Healthcare Workforce

Poor representation of minorities in the healthcare workforce is also a challenge to

providing culturally sensitive care. Even though minority communities constitute 37% of the

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 11

American population, minority nurses only take up 16.8% of the total nursing population (Loftin,

Newman, Dumas, Gilden, & Bond, 2012). Minority representation in the workforce significantly

influences service delivery across all settings because nurses care for all patients regardless of

their background. Loftin et al. (2012) conducted an integrative review to identify the challenges

that nursing students face. They concluded that the most common challenge that nursing students

experience in the course of their education was financial support (Loftin et al. (2012). Most

students work to pay for education and support their families (Loftin et al., 2012). The ever-

increasing college expenses and inadequate information on where nursing students can receive

financial help in the form of scholarships or grants worsens their situation. A recent study survey

indicates that 3 out of 4 Hispanic college students have difficulties completing their coursework

because they are more likely to sign up for part-time classes, which allow them to work and

support their families (Healthypeople.gov, 2020). Thus, financial support to minority students

will increase their completion rate.

Besides, mental illness was another challenge hinder minority student from completing

their nursing education. DeFreitas, Crone, Deleon, & Ajayi (2018) conducted a survey to

determine perceived mental health stigma among African American and Latino students. The

researchers discovered that ethnic minority students were less likely to seek mental health

treatment because of fear of being stigmatized (DeFreitas, 2018). Thus, to improve the

representation of ethnic minorities in the health workforce, financial support and mental health

services are required for nursing students.

Cultural Competence Education

Cultural competence education is vital in promoting healthcare equality. Jongen,

McCalman, & Bainbridge (2018) performed a systemic scoping review to determine the role of

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 12

cultural proficiency training in effecting healthcare interventions. They discovered that the

development and training of healthcare personnel were the most effective means of achieving a

culturally sensitive healthcare system. Likewise, Sanchez, Killian, Eghaneyan, Cabassa, and

Trivedi (2019) employed a pretest-posttest research technique to evaluate the impact of culturally

competent depression education on practitioners understanding of mental health among Hispanic

patients. They discovered that education and cultural training reduces stigma and improves

patient engagement (Sanchez, 2019). Most studies treat patient satisfaction among minority

communities as a secondary issue or tend to have extensive coverage of impacts of cultural

competence (Govere & Govere, 2016). Due to the broad coverage of cultural competence in

healthcare, managers do not have the information they need to understand how their current

cultural knowledge base affects service delivery. Successful cultural competence education

involves developing partnerships between communities and healthcare providers (Bhatt &

Bathija, 2018). The approach guarantees that policies and organizational management will be

reflective of the problems on the ground and representative of the community, respectively.

Among the Latinos in North America, patients were generally satisfied with the healthcare

services because they are the majority in that region due to the availability of provider-targeted

cultural competence in the organizational, clinical, and systemic levels. Cultural competence is

directly associated with an increase in patient satisfaction among minority communities.

Miscommunication

Culture defines the rules of communication. According to the Center for Disease Control

(CDC) (2019), misunderstanding and miscommunication may result when people use ethnic

jargon and dialects, which may lead to increase patients’ risk of misdiagnosis and dissatisfaction.

A systemic research in Northern Australia to determine the cultural impediments to healthcare

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 13

found that language barriers often lead to miscommunication since the aboriginals speak over

100 dialects (Li., 2012). Consequently, lack of speech-language pathologists (SLP) in the region

makes patients vulnerable to misdiagnosis due to miscommunication. Moreover, Amirehsani et

al. (2018) conducted qualitative research on the healthcare experience Latinx adults residing in

North Carolina. They established Amirehsani et al. (2018) that the patients experienced language

barriers since most practitioners are not bilingual, and there are few trained interpreters, which

often lead to misunderstands and medical errors. Therefore, healthcare institutions need to invest

in reducing the cultural disparities that impede healthcare delivery.

Review of Study Methods

The emerging themes from the literature review revealed that Latinos are at an increased

risk of poor mental healthcare services due to cultural incompetence. Misunderstandings on the

cultural practices and beliefs of the Latino population are prevalent among physicians, which

complicates patients’ ability to receive care and workers’ knowledge on how to tailor

interventions to suit their needs. Steinberg, Zickafoose, DeCamp, Valenzuela-Araujo, and

Kieffer (2016) performed and secondary data analysis to assess the experience of Latina mothers,

who have limited English Proficiency, seeking pediatric care. Steinberg et al. (2016) found that

many mothers complain of being misconstrued and stigmatized due to language barriers. Others

did not want to attend follow-up visits because they were afraid of being a burden as they would

require interpreters (Steinberg et al., 2016). Such misapprehensions on the patients’ cultural

background or language negatively affect how Latinx receive care.

Another theme in the studies was the common understanding of cultural competencies

regarding mental health, and how their operationalization differed according to profession,

individual, health setting, or locality (Mollah, Antoniades, Lafeer, Bianca Brijnath, 2018). In the

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 14

healthcare workforce, to be culturally competent means having values promotes professional

development, reflexive thinking, and flexibility. Whereas flexibility implies having an open-

minded approach to a patient’s cultural affiliations, reflexive thinking refers to the general sense

of awareness and how it influences the conceptualization of the patients’ health concerns

(Mollah et al., 2018). On the other hand, professional development encompasses having

‘working knowledge’ about various cultural or ethnic groups. The literature review shows that

Latinx workers translate the three values into their mental healthcare conceptualization along

with three realms: procedural, functional, and integrated (Mollah et al., 2018). To improve

mental health among Latinx, the government needs to incorporate systemic measures that

promote the inclusion of people’s cultures into the system to enhance communication between

patients and healthcare workers.

Significance of Evidence to Profession

The LICCT for healthcare workers in an outpatient mental clinic presents an opportunity

for the healthcare sectors to enhance the diversity in its workforce to improve patient outcomes

among Latinos. Dune, Caputi, and Walker (2018) performed a systematic review published

research regarding the practitioners’ attitudes towards linguistically and culturally diverse

patients. They established that cultural competencies improve patient outcomes by enhancing the

client-physician collaboration (Dune et al., 2018). Additionally, the project creates an

opportunity to understand how cultural competence affects mental healthcare service delivery

from an institutional, social, and professional perspective. George, Smith, O’Reilly, and Dogra

(2019) undertook a participatory research to assess the perceptions of patients with mental

disorders and establish ways to promote diversity in healthcare education. They established that

the increasing complexities in healthcare systems demand evidence-based educational models for

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 15

teaching diversity (George et al., 2019). The institutional angle explores the structural and

systemic challenges that impede the creation of a workforce that is representative of the minority

communities (George et al., 2019). That is, how educational attainment or financial resource

allocation affects the incorporation of sociocultural issues in the provision of mental healthcare

services. From a social perspective, this project provides critical insight into understanding how

linguistic challenges among professionals affect patient satisfaction among Latinos. Lastly, the

project highlights aspects of professional development that require improvement to encourage

cultural competence and diversity in the workforce.

Historical Development of the Theory

The Donabedian model was first introduced in the year 1966 by its proponent Avedis

Donabedian. He was at the time a scientist at the University of Michigan. His article “Evaluating

the Quality of Medical Care” investigated the three elements of the model: structure, process,

and outcome. According to the paradigm, quality healthcare has to satisfy all three tenets. The

author focused more on making sure that quality and systems worked effectively for the overall

healthcare of the patient. Quality is usually the attached judgment to an outcome, and, therefore,

it is somewhat subjective (Donabedian, 2005). The Donabedian model was created to avoid the

biases of the definition of quality health care. It became prevalent in the 1970s. Although other

models were later introduced, for example, the World Health Organization patient healthcare

quality model and Bamako initiative, Donabedian has remained a dominant paradigm that

continues to be used to assess health care (Ayanian and Markel, 2016). Part of the reason why

the model has remained popular is because of its empirical nature. Throughout the years, it has

focused on the instrumental goal and shifting the power to patient-centeredness (Berwick & Fox,

2016) to improve patient outcomes.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 16

The Donabedian model played an essential role in the development of the Quality,

Implementation, and Evaluation model. The paradigm comprises healthcare policies, patient

awareness, healthcare physician’s deed, and answerability, among others (Talsma, Mclaughlin, &

Bathish, 2014). The policies are currently used in healthcare facilities globally. One of the

policies used is in the implementation of a pre-operative skin prep that contains alcohol (Talsma,

Mclaughlin, & Bathish, 2014). Some of these programs include aspects of ethics and physician’s

responsibility and tasks for the overall performance of the healthcare facility. It is utilized to

introduce learners into education in the health sciences (Botma & Labuschagne, 2017).

Moreover, it helps students comprehend their identity tasks (Bridges, Davidson, Odegard, Maki,

& Tomkowiak, 2011). The Donabedian model assists learners in realizing the professional roles

that healthcare providers embrace. For instance, through the outcome tenet of the Donabedian

model, learners get to see the importance of ensuring they give clear and concise explanation of

the drug prescription to the patient (Botma &Labuschagne, 2017). A study shows that through

the help of the process tenet in the Donabedian model which looks at what is being done,

educators prefer to move from simple to complex during teaching. The use of this structure helps

learners to understand the content without feeling overwhelmed (Botma &Labuschagne, 2017).

Major Tenets

Structure

The structure includes the features of a setting that provides care. The structure courses

are also known as input measures. The features are both internal and external. The latter include

infrastructure and financial resources. The former comprises the healthcare facility’s organization

and human resources, among others (Larson & Yarzdanny, 2012). If healthcare lacks sufficient

financial resources, it may fail to provide quality treatments and acquire the necessary

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 17

equipment. Scarce funds also lead to healthcare providers going unpaid, which in turn reduces

their motivation to work better. Faulty or outdated equipment, for example, a Computed

Tomography scan, makes the work harder. In case it is faulty, it may provide false results.

Therefore, it is important to ensure all healthcare facility infrastructures have been evaluated

(Larson & Yarzdanny, 2012).

Process

The tenet comprises of all actions that occur during and after the provision of care.

According to Larson and Yarzdanny (2012), the process feature of the Donabedian model

analyses the interaction between the healthcare providers and the patient. It also includes the

ethical and legal procedures of healthcare provision. The relationship between the patient and the

healthcare provider largely depends on their individual judgments on each other’s character.

(Foot & Raleigh, 2010). Therefore, to achieve effective results, evaluation should be done to

ensure that outcomes and interventions are not hindered. The process tenet also focuses on the

length of time the patient has to wait for the treatment and whether or not they are informed

about the delays. An effective process highlights the value of the healthcare facility. All the

underlying issues in the process tenet will impact the quality of the facility.

Outcome

The outcome seeks to answer questions pertaining to the service received. They comprise

the following: Did the patient understand the instructions of his medication? Did the patient

follow the instructions as advised? Did the health condition of the patient improve? The answers

to all these questions describe the outcome, which leads to the determination of the quality of

care. The outcome category emphasizes the impact of healthcare on the patient (Larson &

Yarzdanny, 2012). The tenet also focuses on the mortality, the quality of life after the treatment,

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 18

and the length of admission. From my general deduction, the outcome element is the most

important as patients use it to get a recommendation of quality healthcare facilities from their

friends and colleagues. It also displays the effectiveness of other tenets since an excellent process

and structure seemingly lead to a good outcome.

Theory of Application to the DNP Project

The Donabedian model is well versed in guiding this DNP project. It has been used in

the past to develop systematic and evidence-based systems that are applied to improve the

quality of healthcare (Kunkel, Rosenqvist, & Westerling, 2007). The tenets will be employed as

a guide to implementing this conceptual framework fully. The utilization of the three

Donabedian elements will help divide the project into manageable and organized steps. The

tenets will form the basis of the data collection, which will eventually lead to an empirical

conclusion and recommendation. The application of the Donabedian model is useful as a

conceptual framework for this project.

Structure

The DNP project will benefit from this tenet in the formation of an evidence-based

guideline. The project will research the organization of the healthcare facility and collect data on

how many healthcare providers communicate or are aware of the Latino culture (S1). It will

investigate the cultural diversity of the healthcare facility (S2). The DNP project will look at the

facilities available in the Latino communities and ways in which to promote cultural competence

(S3).

Process

The process tenet is how often do we do what we are supposed to do. To answer this

question, there is need to assess current practices around cultural competence before and after

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 19

(P1). The process also relates to education implementation. An educational seminar will be

administered for the multi-disciplinary team in the health facility to train them on culturally

competence practice guidelines and the LICCT (P2). There will also be a need for attendance of

all members of the healthcare facility including psychiatrist and a Mental health Nurse

practitioner (P3).

Outcome

The outcome tenet deals with the final result after the treatment. A most desirable

outcome is to measure staff cultural competence before and after the intervention. The

implementation of culturally competent toolkit aimed at Latino immigrants will help assess

whether resource referral increases (O1). A culturally competent staff increases trust level with

Latino patients and decreases cultural barriers.

Setting

The project setting is an outpatient psychiatric clinic in Hialeah, Florida. Florida is an

ideal location for this project because it has a large population of Latinx immigrants. Moreover,

the population of Latino immigrants in the USA is set to rise rapidly in the coming years

(Adames and Chavez-Dueñas, 2016). The project is thus useful to the clinic and other psychiatry

practices both now and in the future. The practice is small and consists of one psychiatrist, two

psychiatric-mental health nurse practitioners, one medical assistant, one from desk and one office

administrator. The clinic uses Valant Psychiatric Electronic Record as the system for keeping

clinical electronic health records.

Valant Psychiatric Electronic Record helps minimize labor at the clinic and makes the

provision of services more efficient (Valant, n.d.). It is useful for scheduling patients, billing

them, and keeping records of patient information. It also provides continuous access to patient

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 20

files for the various cadres of health workers at the clinic, thereby ensuring patient care is

seamless. Furthermore, some patients learn about the clinic online because of Valant Psychiatric

Electronic Record. Valant Psychiatric Electronic Record will be a useful source of information

while collecting data for the project since it contains documentation for patients seen at the clinic

(Valant, n.d.).

Population of Interest

This project’s population of interest includes both the health care providers at the

outpatient psychiatric clinic and the patients seen at the clinic. The health care workers will form

the direct population of interest. The staff members are the ones who need to have cultural

competence awareness, and the project will focus on them (Adamson et al., 2011). In the clinic,

the health workers include one psychiatrist, two psychiatric-mental health nurse practitioners,

one front office staff, one medical assistant, and one clinic administrator. The inclusion criteria

will be health workers treating patients with mental health conditions that identify as Latinx

immigrants. The exclusion criteria will be anyone who works at the clinic, permanently or

temporarily, but does not provide care for mental-health patients who are Latinx immigrants, this

inclusion criteria will exclude the front-office staff and any other workers who are not involved

in the treatment of Latinx immigrants who come to the clinic for mental health treatment.

The indirect population of interest will be the Latinx population with psychiatric mental

health illness. The inclusion criteria for the indirect population of interest will be Spanish

speaking adults who identify as a Latinx immigrant and are visiting the outpatient psychiatric

clinic for treatment of mental health conditions. The exclusion criteria will be any patients apart

from Latinx immigrants visiting the clinic; this excludes patients from other ethnicities and

Latinx immigrant patients visiting the clinic for issues other than mental health.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 21

Stakeholders

The key stakeholders in this project are the owner of the clinic, the medical director, and

the health workers. The clinic owner is an important stakeholder since they have significant

control over the clinic’s working (Frasier et al., 2017). The owner has an ultimate say in the

hiring and firing of employees. Moreover, the owner also helps develop policies for employees’

training and the implementation of cultural competence policies (Frasier et al., 2017).

Permission had to be obtained from several people in charge of the clinic at various

capacities. Permission was granted from the site administrator, the owner, and the medical

director. The permission ensures that carrying out the project at the clinic is both ethical and

legal. The site administrator and the clinic owner have oversight over the whole clinic hence the

need to get their permission. On the other hand, the medical director is involved in the clinic’s

day-to-day activities, including the documentation of patients seen and the services offered to

these patients. The permission of the director is thus elemental for the success of this project.

There is no need for affiliation agreements for this project.

Intervention

Several activities have taken place in preparation for the implementation of the

intervention. First of all, there was a selection of the mental health clinic, followed by a signed

agreement that authorizes the intervention to be taken place at the clinic site. The proposed

project was presented to the Touro University of Nevada and approved by the DNP project chair

and members. The site administrator and Medical Director of the site were consulted regarding

the enrolment of participants.

The participants have received detailed information on their role and participation in the

project to reach the end goal.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 22

The activities are expected to take place at the mental health clinic during regular office

hours. The clinic administrator will be in charge of selecting medical assistants whose role will

be to identify the Latinx immigrant, ethnicity which will be evaluated through the patient

demographic intake form at the clinic. Patients that require community resources and assist the

providers with a resource list for them. The project lead will be available to assist the medical

providers with any questions about the LICCT tool, as well as the specifics of each of the

resources within the tool. I will also be available with questions and guidance for the medical

assistants regarding documentation of resources provided to patient. In the event that I am not

available on grounds; a telephone and email contact will be provided to all participants for quick

access. The intervention will take place on November 4, 2020 through December 1, 2020. The

following is a weekly timeline of the implementation.

Week 1: During the beginning of this week the medical providers will take part in

educational training. The training will be presented in a power point and the IAPCCR-R pre-test

and post-test evaluation will be provided to all medical providers prior to the presentation. The

presentation will include a detailed explanation of the resource tool. During the second half of

this week implementation of the resource tool will begin.

Week 1-4: Implementation of resource to patients during in-office visits. Ongoing

education and support to participants will be available through these weeks. Data collection and

assessment of compliance will be conducted on a weekly basis in order to capture any

opportunities needed for re-training.

Week 5: During this week compiling of data for analysis should be completed and

statistical testing should be performed.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 23

The implementation phase shall commence on November 4, 2020, and end on December

1, 2020. Later, the project lead and the medical providers are expected to have a meeting and

share the final data collected and analysis at the end of the intervention.

Tools

The tools that will be utilized during this DNP project include IAPCC-R, the LICCT,

educational presentation, and chart review tool. The following is an explanation of each tool.

LICCT (Appendix B)

The LICCT tool is composed of several resource assistance organizations with their

address and phone numbers. The five resources included in this tool are food assistance,

clothing, vocational training, employment services, and interpretation services.

The food assistance organizations provide USDA food distribution of canned goods,

fresh products, and groceries. The centers also provide emergency food, breakfast, lunch, and

dinner in different days of the week for those in need.

The clothing assistance organizations clients may obtain free hot showers for men and

women multiple days a week and a free exchange of clean clothing, shoes, and shower programs.

They also provide blankets and accessories to meet the needs of children, victims of crime, and

people affected by poverty, and homelessness.

The vocational training assistance organizations provide the tools and resources

necessary to help minorities to achieve financial stability. The services they offer include

financial coaching and education, credit counseling, free income tax preparation, and income tax

return, job training, interviewing skills and resume building, job orientation and training, resume

writing, vocational training, and job placement.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 24

Employment services provide job placement referrals in addition to various course and

training through community programs.

Interpretation services will be available to assist the patient with translation of

documents, onsite interpretation, and telephonic interpretation.

IAPCC-R (Appendix C)

The Inventory for Assessing the Process of Cultural Competence Among Healthcare

Professionals-Revised (IAPCC-R) will be used as a pre/post questionnaire before

implementation and after all interventions to assess the providers’ knowledge. According to

Transcultural CARE Associates (2015), the IAPCC-R© was developed by Dr. Campinha-Bacote

in 2002. It is a revision of the Inventory for Assessing the Process of Cultural Competence

Among Healthcare Professionals (IAPCC). The IAPCC, which is no longer available for use,

was developed by Campinha-Bacote in 1997 and is based on her cultural competence model, The

Process of Cultural Competence in the Delivery of Healthcare Services (1998). Cronbach’s alpha

of the IAPPC© was established at .81 (Wilson, 2003). The IAPCC only measured four of this

model’s five constructs (cultural awareness, cultural knowledge, cultural skill, and cultural

encounters) and not the fifth construct of cultural desire. In 2002, Campinha-Bacote revised the

IAPCC by adding five additional questions to measure the fifth construct of cultural desire. This

revision led to the instrument’s last name. Further research was conducted on IAPCC-R© to be

used with students, and a student version (IAPCC-SV) is currently available (the IAPCC-R

website). Permission for the use of the (IAPCC-R) to assess the level of cultural competence of 3

mental health providers was granted on August 29, 2020. The total cost was $48 for 6 tools

which will be divided in 3 pre/post questionnaires. The permission only grants administration of

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 25

the tool via an onsite pencil and paper method which will be personally hand administered. All

other formats of administration are against contractual agreement.

Educational Presentation (Appendix D)

According to Bhui, Warfa, Edonya, McKenzie, & Bhugra (2007), cultural competency is

considered an essential requirement for medical providers in the specialty of mental health,

providing care to culturally diverse patient groups. Ongoing education and training have proven

to yield improved compliance in medical management and healthcare quality for ethnic groups

(Bhui, Warfa, Edonya, McKenzie, & Bhugra, 2007). Due to the considerable confusion about

what constitutes cultural competence at the organization, the need for competence training is

deemed crucial for the project’s success. An educational presentation has been developed by the

project lead using a PowerPoint presentation, pre/post survey, and LICCT handouts. The

training’s goal is to provide consistency among the providers of the clinic on how cultural beliefs

and practices of Latino immigrants may affect their perception of mental health illness, health

behaviors, and acceptance of resource assistance. The training will take place at the organization

and will be conducted by the project lead with the medical director and administration’s

permission. A three-hour session will be allotted for the educational presentation.

Chart Review Tools

Two chart audit tools have been incorporated in the project. The first tool has been

composed of two sections (Appendix E) to evaluate participant’s knowledge of cultural

competency through educational presentation and pre/post questionnaire. The second tool

(Appendix F) is a scale tool to evaluate the knowledge in cultural competence of the participants

and the need for further education. Both tools have been developed by the project lead and

reviewed for quality by the project team and the stakeholders at the site. In addendum the

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 26

participants will also be evaluated for their compliance in providing and discussing the available

resources with the patient and documenting the plan accordingly during the office visit.

Data Collection Procedures

Data collection in the healthcare sector is a sensitive activity. Under the stipulated

nursing and healthcare principles, it must be done avoiding infringing patients’ privacy,

confidentiality, or disclosing their essential information to the public and third parties. Data will

be made anonymous for confidentiality by hiding patient identities, locations, and addresses.

This approach will help protect the patient’s information and reaching unintended people.

When collecting data, the project lead will undertake both pre- and post-survey results

assessments to profoundly impact the possible statistical analyses’ choice to be conducted at the

group level (Alessandri et al., 2017). The data will be stored in digital form to avoid

manipulation by other parties since it may potentially result in incorrect data.

The IAPCC-R survey will be administered as a pre-test to evaluate cultural knowledge by

participants. Immediately after this survey is completed by the providers an educational training

via a power point presentation will be conducted by the project lead delineating the purpose,

goal, and each step of the project. Following the education training all providers will receive the

same survey to evaluate their level of learned competency. Both surveys will be provided to the

participants at the same time before the educational session. Since the surveys are the same, the

lead will label the surveys as Pre-1 for pre-test 1 and Post-1 for post-test as identifiers. Surveys

will be labeled with each participant name but will be entered in the code book with unidentified

initials. Directly after the collection of all pre/post survey questions, the audit tool (Appendix F)

will be completed, and results entered in the codebook. Once medical provider competency has

been established, the intervention will begin, and data will be collected weekly. Data will consist

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 27

of whether each Latino immigrant patient seen by a medical provider at the clinic receives the

resource information according to their needs. The medical providers will be required to address

the resources provided in their assessment and plan portion of their progress note. The

compliance of the intervention will be collected weekly by the project lead and entered in the

codebook. Finally, once the four weeks of implementation have ended, data analysis will be

conducted using the appropriate audit tool (appendix E).

Ethics/Human Subjects Protection

The project site does not have and Institutional Review Board (IRB) committee therefore

as per Touro University research guidelines an IRB determination form was used to determine

whether that this project does not require IRB review due to being a quality improvement

project. The required ethical standards including the data collection and privacy will be met

during the project. The project meets the minimum requirements for a quality improvement

project and the proposed interventions are viable in the healthcare industry.

While in the process of implementation, the project lead will have access to the data to

protect the participant’s confidentiality. Equally, data identifiers will be removed and destroyed

to keep the information anonymous and attributed to meet the project principles.

All participants will be enlightened on the benefits and risks of participating in the

project. Benefits include providing the needed data to help identify interventions that can help

bridge healthcare gaps, more so to the Latino people. For instance, the data will help determine if

healthcare providers are aware of the Latino culture. This may lead to development of a system

that can help health caregivers to determine this population health perception and the care to

prioritize. The risks of participation include loss of confidentiality and privacy. However, the

project lead will mitigate such risks by appropriately and rigorously reviewing the data collection

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 28

process and ensure participants’ rights are protected and adhere to ethical norms (Vanderbilt

Kennedy Center [VKC], 2020). The participants will not be compensated as per the agreement

made with the facility.

Measurable Plan for Analysis

Data were first tested for requisite statistical assumptions prior to data analysis. All

assumptions were met, including normality of the distribution of score. However, because the

analysis was non-parametric in nature, violations of assumptions are not problematic because

non-parametric statistics are employed when requisite parametric assumptions are not met such

as sample size or normality. The data collected from the pre- and post-interventions will be

assessed through SPSS Statistics software to get insights for an informed conclusion. Because

the sample size is small, Fishers’ exact test will be applied to analyze the data of the chart review.

The data collected from the three participants will be first cleaned by ensuring that there are no

null data sets. The Fisher’s exact test is a non-parametric test used to determine the correlation

between two variables (Datascienceblog, 2018). In this case the comparison would be with no

protocol pre-implementation and a newly developed cultural competence protocol implemented

at the mental health clinic a practice changes to improve provider competency. The improvement

in cultural competence will be evaluated by the pre/post survey using the IAPCC-R Scoring Key

(Appendix F), and a descriptive statistic with a simple percentage to report improvement will be

utilized. Code book will be developed to collect all data using unidentifiable code names. All

project information will be stored in a designated computer provided by the site with project lead

only access.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 29

Result

Table 1 presents descriptive statistics and the Pearson’s r between pretest and posttest

IAPCC-R scores for the sample of providers. Figure 1 displays the pretest and posttest IAPCC-R

score whereas Figure 2 presents the IAPCC-R change score.

Table 1

Descriptive Statistics and Zero-Order, Bivariate Correlation of Pretest and Posttest Inventory

for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised

(IAPCC-R) Scores

Variable Pretest Posttest r

M SD M SD IAPCC-R Score 87.30 4.73 98.00 2.00 0.21

N = 3

Note. M = Mean; SD = Standard Deviation; r = Pearson’s zero-order correlation coefficient.

Figure 1. Pretest and posttest IAPCC-R scores for each provider.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 30

Figure 2. Change in pretest to posttest IAPCC-R score, taken by subtracting the pretest score

from the posttest score, and thus, indicating growth in score.

Results revealed that there was a 10.25-point increase (95% confidence interval = 7.00,

16.00) in IAPCC-R score from pretest to posttest. However, results of the Fisher’s Exact Test for

dependent samples were not statistically significant, χ2 (2) = 6.00, p = .103. However, it is

important to note that the effect size, Glass’ Δ = 2.34, is considered a large effect size, suggesting

that although statistical significance was not met, the results are practically significant.

Regarding provider compliance, providers complied 75.9% of the time (frequency = 60),

with non-compliance occurring 24.1% of the time (frequency = 19). The 95% confidence

interval for compliance percentile is 71.1% to 80.7%.

Discussion of findings

The project question was, “does cultural competence toolkit implementation focused on

Latinx immigrants enhance cultural competence care and raise resource referral for the

population?” The outcome answered questions regarding received services and rates of resource

referral. The project successfully implemented the LICCT that focused on Latinx immigrants.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 31

The project intervention had a positive effect on the providers’ cultural competence scores and

resource allocation to patients in the clinic. The effective process highlighted the value of the

clinical facility.

The project highlighted professional development features requiring advancement to

improve cultural competence and the workplace. Latinx immigrants looking for mental health

services needed cultural competence care to enhance healthcare results. Misunderstanding of the

Latinx population’s cultural needs is rampant among clinical professions (Furman, Negi,

Iwamoto, Rowan, Shukraft, & Gragg, 2009). Healthcare providers find it hard to identify and

understand the role culture plays in Latino people’s lives (Barrera & Longoria, 2018).

Mental health provider cultural competence was measured through the IAPCC-R pre and

post-test. The results of these finding revealed an increase in 10.25-point increase (95%

confidence interval = 7.00, 16.00) in cultural competence and applicability of the knowledge

attained. During the scrutiny of the pre and post-test responses by the medical providers, results

revealed various areas of improvement post educational training. Most of the providers

expressed more knowledge about worldwide views, beliefs, practices, and lifeways of Latinx

groups. Also, there was a noted increase in recognition of stereotyping attitudes, preconceived

notions, and feeling the providers felt towards this population group which aligns with current

literature (Sanchez, Killian, Eghaneyan, Cabassa, & Trivedi 2019). The increased knowledge in

these crucial aspects of cultural competency directly impacted the increase in scores. These

findings meet the first objective of this project to train all medical providers at the project clinic

site on culturally competent practice. Existing research supports the conclusion that culturally

competent healthcare is important because it increases health service utilization and improve

healthcare outcomes for the Latinx population (Govere & Govere, 2016).

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 32

Regarding the compliance of the medical providers, a retrospective chart review was

conducted. The chart review indicated a 75.9% % compliance to providing the LICCT to all

Latinx immigrant populations visiting the mental health clinic through the project’s

implementation phase. Lastly, the results also indicated some medical providers that did not

comply with providing the LICCT to patients. During one of the post statistical analysis

meetings with providers to evaluate the project’s results, the medical providers admitted to

skipping this step during a few visits as they were not accustomed to this intervention in the day-

to-day service to their patients at the clinic. According to Moore, Lavoie, Bourgeois, & Lapointe

(2017), access to culturally competent care by healthcare providers is key to increasing health

service utilization, increase.

Significance/Implications for Nursing

According to the United States Census Bureau (2011), an estimated 25% of Latino fall

under the poverty lines. Low socioeconomic status has significant implications in patient’s

health, access to care, affordable care. Culturally competent care needs to include appropriate

services and resources to eliminate these barriers (Cabassa, Zayas & Hansen, 2006;

Kouyoumdjian, Zamboanga & Hansen, 2003). The LICCT for healthcare professionals presented

platforms for the healthcare sector to promote diversity and increase outpatient resources. It was

composed of many resource organizations, including phone numbers and addresses. The tool’s

five resources were food assistance, vocational training, clothing, interpretation, and employment

services. Food assistance firms offer USDA food distribution of groceries, fresh products, and

canned goods. The center gives emergency food, lunch, breakfast, and dinner.

Likewise, the clothing assistance clients receive hot showers in exchange for clean

clothing, shower programs, and shoes. They also offer accessories and blankets to meet the

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 33

requirements of kids, the homeless, and victims of crime. Vocational training assistant firms

offer resources and tools vital in helping minorities achieve financial stability. The services are

financial coaching, free income tax education, credit counseling, job training, and interview

skills. Employment services give referrals for job placement, courses, and training using

community programs. Interpretation service is necessary for assisting the patient to gain

documents translation, onsite, and telephone interpretation.

Mental health workers need sensitization regarding specific features of Latinx styles of

learning and illness viewpoints. Mental health practitioners at the DNP project site located in

urban Florida did not have cultural competence training to handle Latinx resource needs. The

project offered LICCT for healthcare providers in an outpatient psychiatric clinic. Generally,

mental health providers who approached care concerning cultural competence received trust

among patients and encouraged them to talk about their needs (Camacho et al., 2015). The

project eliminated cultural barriers, which hindered Latinx immigrants from getting adequate

mental health resources. They included language problems, limited workforce diversity, and

ineffective conversation. Authorities achieved it through training healthcare workers on cultural

expectations and norms associated with Latinx.

The project’s success involved community assistance programs in collaboration with

medical providers at the clinic site; the strategy guaranteed policies and organization

management reflecting on Latinx problems with mental health resource concerns. According to

Cabassa, Zayas, & Hansen (2006), Latinx low economic and insufficient knowledge of where to

seek care and services have served as barriers for this underserved group. Patients had general

satisfaction with healthcare services due to the presence of provider-inclined cultural

competence. Cultural competence had a direct link with patient satisfaction among Latinx

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 34

communities. Through Florida Health, translation services were available as part of the LICCT

in non-bilingual medical providers to lower communication barriers. However, these services

were not used since all providers during the implementation process were fluent in Spanish. It is

fundamental for healthcare organizations to invest in cultural diversity and promote healthcare

delivery to the minority population (Flores, 2017). Through the implementation and use of this

LICCT tool, healthcare systems can ensure all Latinx immigrant patients have access to

community resources that centers on their individual’s distinct needs. By evaluating and training

a diverse healthcare workforce to represent the patient population they serve, healthcare systems

could provide better access to care and reduce disparities.

Limitations

 Project Design Limitation: The project design of QI project has limitations of producing

biased data.

 Data Recruitment Limitation: The setting of the project is single healthcare facility, which

cannot provide complete data for implementing an efficient LICCT for healthcare workers.

 Data Analysis Limitation: The post statistical analysis meetings with providers to evaluate

the project’s results were skipped on several visits, which can also result in biased opinions.

The project design of QI project has limitations of biased data because the use of specific

technology, staff being involved and negative behavior of managers towards quality

improvement can significantly influence the outcome. An element of bias can also be the

healthcare facility failed to provide copies of LICCT due to a technical fault. The shortcoming

can have a significant impact on the findings, which should be considered as a limitation.

Although the unresponsive respondents have been acknowledged, their exact statistics are not

provided, which can potentially lead to biased data.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 35

Additionally, the project is set at a single healthcare facility, which cannot provide

complete data for implementing an efficient LICCT for healthcare workers. Every organization

has specific environment and culture, which guides employees to engage with each other for

achieving different objectives. As Latinx have significant representation in American population

(17.6%), they are virtually present in every state (Flores, 2017). Hence, representative data for

such large population cannot be obtained from a single location. Thus, the results of the project

cannot be generalized for the nurse practitioners working in healthcare organizations across the

country.

Additionally, ethnic minorities living at different geographical locations have diverse

values and perception about mental health. Therefore, health workers working at one facility

cannot claim to have complete knowledge about cultural norms of a specific community. The

literature review reveals that scholars recognize specific cultural-bound syndromes that are

characteristic of Latinx such as fright, an evil eye, and nerves, among others; symptoms that are

unique to this ethnic group include uncontrollable screaming, crying, trembling, physical and

verbal aggression, seizure-like episodes, as well as suicidal gestures (Caplan, 2019). However,

all these symptoms and abilities to address them cannot be found at a single location. Thus, the

findings of the study might have been more reliable if the sample population would be scattered

at various geographical locations.

Another limitation in the project is the fact that the post statistical analysis meetings with

providers to evaluate the project’s results was skipped on several visits, which can also result in

biased opinions. Hence, the project may have some reliability issues due to these limitations.

Further projects should be conducted to verify the findings of the present project.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 36

Dissemination

Developing an effective dissemination strategy is necessary for increasing awareness

about the project findings among the potential audience, which will be helpful in optimizing the

impact of the research. Appropriate dissemination will entail getting the study findings to the

target group and stakeholders. The project’s key stakeholders include the clinic owners, medical

director, and health care professionals. The project lead engages with these primary audiences,

engaging them from the study planning to findings dissemination the investigator will establish

networks, utilize conferences, social networking platforms, and websites to share knowledge and

improve awareness of the project. Powerful opinion leaders, including the media and political

representatives, will be deployed to serve as champions. I will send the manuscript of my project

to different nursing journals for having opinion of the audience. I will also submit my project to

the doctorsofnursingpractice.com repository to share my findings with the professionals of my

field. I will also produce posters for placing at various places in the nursing conference taking

place at our institution during the next month. The project will also be lead can also supplement

the publication with formal presentations (formal talks and roundtable discussions), which have

numerous opportunities to share the research findings.

Sustainability

The project meets the criteria for sustainability because it uses LCCIT as an intervention

resource to teach cultural competency to the medical practitioners of the mental health care

clinic. Thus, the findings will also be relevant for the staff of the site in future. The staff will only

need LCCIT to learn about cultural values of Latinx population to provide them quality

healthcare. The only resource required will be a photocopier or printer to produce multiple

copies of the toolkit for the medical staff. Hence, the cost will be almost insignificant to apply

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 37

the intervention used in the project in the future. Thus, the literature of the project will

considerably contribute to create awareness among healthcare professionals about Latinx

population.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 38

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Appendix A

DNP project site attestation.

DNP project site.

From: Manuel Garcia

([email protected]) To:

[email protected]

Date: Tuesday. March 31, 2020,

11:53 PM EDT

I, Dr. Manuel Garcia, with this email, confirm that Roberto Gimenez has my approval to conduct the DNP project at Manuel A. Garcia, MD, PA office. Our facility does not require a clinical or affiliation agreement. If any further questions, please, do not hesitate to contact our office.

Manuel. A. Garcia, MD Psychiatrist/ Neurologist [email protected] ahoo.com. Main phone: (305) 328-9115

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 46

Appendix B

Latino Immigrant Cultural Competence Toolkit (LICCT)

Food assistance Asistencia de alimentos

Open Arms – Emergency Assistance Program (305) 263-3259 5556 SW 8th St, Coral Gables, FL 33134. Email: www.openarmscommunitycenter.org We speak English, and Spanish, open at 9:00am the 2nd and 4th Thursday of the month.

Open Arms – Emergency Assistance Program (305) 263-3259 5556 SW 8th St, Coral Gables, FL 33134. Email: www.openarmscommunitycenter.org Se habla Español y Ingles, abierto a las 9:00am el 2do y 4to Jueves de cada mes.

Pass It on Ministries (305) 681-1594 14617 NW 7th Ave, Miami, FL 33168 We speak English, and Spanish. Open at 10:00 am – 3:00pm from Monday-Friday.

Pass It on Ministries (305) 681-1594 14617 NW 7th Ave, Miami, FL 33168 Hablamos Español y Ingles. Abierto de Lunes a Viernes de 10:00 am a 3:00 pm.

Missionaries of Charity – Mother Teresa Home for Women In Distress (305) 326-0032 724 NW 17th St, Miami, FL 33136. We speak English, and Spanish. Emergency Shelter: 4:00 pm – 6:30 am from Friday to Wednesday. Soup Kitchen: 9:30 am – 11:00 am from Friday – Wednesday (Closed Thursdays).

Missionaries of Charity – Mother Teresa Home for Women In Distress (305) 326-0032 724 NW 17th St, Miami, FL 33136. Se habla Ingles y Español. Abiertos de Viernes a Miercoles de 4:00 pm a 6:30 pm para refugio y se ofrese comidas de Viernes a Miercoles de 9:30 am a 11:30 am. Cerramos los Jueves.

Salvation Army – Community Pantry (305) 637-6720 1907 NW 38th St, Miami, FL 33142 Email: www.salvationarmymiami.com. We speak English, Spanish, and Creole. Open at 8:30 am from Monday to Thursday.

Salvation Army – Community Pantry (305) 637-6720 1907 NW 38th St, Miami, FL 33142 Email: www.salvationarmymiami.com. Hablamos Ingles, Español, y Creole. Abierto a las 8:30 am de Lunes a Viernes.

Vocational Training Entrenamiento Vocacional

Association for The Development of The Exceptional. (305) 573-3737. 2801 N Miami Ave, Miami, FL 33127. We speak English, Spanish. Open at 8:00 am – 4:00 pm from Monday to Friday. Email: www.ademiami.org.

Association for The Development of The Exceptional. (305) 573-3737. 2801 N Miami Ave, Miami, FL 33127. Hablamos Ingles y Español. Abrimos a las 8:00 am – 4:00 pm de Lunes a Viernes. Email: www.ademiami.org.

Centro Campesino. Tel: (305) 245-7738 x 225. 35801 SW 186th Ave, Florida City, FL 33034. Email: www.centrocampesino.org. We speak English, and Spanish. Open at 9:00 am – 6:00 pm from Monday-Friday.

Centro Campesino. Tel: (305) 245-7738 x 225. 35801 SW 186th Ave, Florida City, FL 33034. Email: www.centrocampesino.org. Hablamos Ingles y Español. Abrimos 9:00 am – 6:00 pm de Lunes a Viernes.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 47

Community Coalition: Refugee Program. (305) 887-4140. 300 East 1st Ave, Suite 201, Hialeah, FL 33010. We speak English, and Spanish. Open at 9:00 am – 5:00 pm from Monday to Friday. Email: http://www.communitycoalition.info/#!/cktc

Community Coalition: Refugee Program. (305) 887-4140. 300 East 1st Ave, Suite 201, Hialeah, FL 33010. Hablamos Ingles y Espanol. Abiertos de 9:00 am – 5:00 pm de Lunes a Viernes. Email: http://www.communitycoalition.info/#!/cktc

Employment Empleos

Abriendo Puertas, Inc. (305) 649-6449. 1401 SW 1st St, Suite 209, Miami, FL 33135. Open at 9:00 am – 5:00 pm from Monday-Friday. We speak Spanish, and English. Email: abriendopuertasfl.org. Provides job placement referrals in addition to various classes and trainings through the Adult and Community Education Program.

Abriendo Puertas, Inc. (305) 649-6449. 1401 SW 1st St, Suite 209, Miami, FL 33135. Open at 9:00 am – 5:00 pm from Mon-Fri. We speak Spanish, and English. Email: abriendopuertasfl.org Provides job placement referrals in addition to various classes and trainings through the Adult and Community Education Program.

Branches United Way Center for Financial Stability. Email www.branchesfl.org/home/programs- 2/achieve/united-way-cfs/. We speak English, Spanish, and Creole. Open 9:00 am – 5:00 pm from Monday-Friday. Call for appointment.

Branches United Way Center for Financial Stability. Email www.branchesfl.org/home/programs- 2/achieve/united-way-cfs/. Hablamos Ingles, Español y Creole. Abierto a las 9:00 am – 5:00 pm de Lunes a Viernes. Llame para cita.

Casa – Social Program: Employment and Referral. (305) 463-7468 x10. 10300 SW 72nd St, Building 300, Suite 387, Miami, FL 33173. We speak English, Spanish. Open 9:30 am – 5:00 pm from Monday to Thursday and 9:30 am – 2:00 pm Friday. Email: www.casa-us.org

Casa – Social Program: Empleos y refereridos. (305) 463-7468 x10. 10300 SW 72nd St, Building 300, Suite 387, Miami, FL 33173 Hablamos Ingles y Espanosl. Abiertos de 9:30 am – 5:00 pm de Lunes a Jueves y de 9:30 am – 2:00 pm los Viernes. Email: www.casa- us.org

Centro Campesino- Tel: (305) 245-7738 x225. 35801 SW 186th Ave, Florida City, FL 33034. Email: www.centrocampesino.org. Open doors 9:00 am – 6:00 pm from Monday- Friday. We speak English, and Spanish.

Centro Campesino- Tel: (305) 245-7738 x225. 35801 SW 186th Ave, Florida City, FL 33034. Email: www.centrocampesino.org. Abiertos de 9:00 am – 6:00 pm de Lunes a Viernes. Hablamos Ingles y Español.

Creative Staffing. (305) 362-5300. 6625 Miami Lakes Dr. Suite 382, Miami Lakes, FL 33014. Open 9:00 am – 5:00 pm from Monday – Friday. We speak English, and Spanish. Email creativestaffing.com.

Creative Staffing. (305) 362-5300. 6625 Miami Lakes Dr. Suite 382, Miami Lakes, FL 33014. Abiertos de 9:00 am – 5:00 pm de Lunes a Viernes. Hablamos Español. Email creativestaffing.com.

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 48

Clothing Ropa Camillus House, Inc. (305) 374-1065 x 429. Address: 1603 NW 7th Ave, Miami, FL 33136. We speak English, Spanish, and Creole. Email/correo electronico www.camillus.org.

Camillus House, Inc. (305) 374-1065 x 429. Address: 1603 NW 7th Ave, Miami, FL 33136. Hablamos Ingles, Español, and Creole. Email/correo electronico www.camillus.org.

First United Methodist Church of Miami – Breakfast Club Ministry, 305-371-4706, ext. 400, Biscayne Blvd, Miami, FL 33132. We speak English, and Spanish. Open at 7:30am until food runs out, Wednesdays, Friday, and Sunday. Email: www.fumcmiami.com.

First United Methodist Church of Miami – Breakfast Club Ministry, 305-371-4706, ext. 400, Biscayne Blvd, Miami, FL 33132. Hablamos Ingles y Español. Abiertos de 7:30am hasta que se acabe la comida. Abiertos Miercoles, Viernes y Domingos. Email: www.fumcmiami.com.

Neat Stuff, Inc. (305) 638-5878 2624 NW 21st Ter, Miami, FL 33142. Email: neatstuffhelpskids.org

Neat Stuff, Inc. (305) 638-5878 2624 NW 21st Ter, Miami, FL 33142. Email: neatstuffhelpskids.org

Part of The Solution Foundation, Inc. 786- 486-2895. 6023 NW 22nd Ave, Miami, FL 33142 We speak English, and Spanish. Open from 7:30 am – 7:00 pm from Monday-Friday

Part of The Solution Foundation, Inc. 786- 486-2895. 6023 NW 22nd Ave, Miami, FL 33142. Hablamos Ingles y Español. Abiertos de 7:30 am – 7:00 pm de Lunes a Viernes.

Part of The Solution Foundation, Inc. 786- 486-2895. 6023 NW 22nd Ave, Miami, FL 33142. We speak English, and Spanish. Open from 7:30 am – 7:00 pm from Monday-Friday.

Part of The Solution Foundation, Inc. 786- 486-2895. 6023 NW 22nd Ave, Miami, FL 33142. Hablamos Ingles y Español. Abiertos de 7:30 am – 7:00 pm de Lunes a Viernes.

Interpretation and Translation Services Servicios de interpretación y traducción Florida Health 4052 Bald Cypress Way, Tallahassee, FL 32399 850-245-4444; [email protected] Subject to available funding, the Refugee Health Program provides bilingual staff in county health departments whose provide on- site interpretation, telephonic interpretation, and document translation.

Florida Health 4052 Bald Cypress Way, Tallahassee, FL 32399 850-245-4444; [email protected] Sujeto a los fondos disponibles, el Programa de Salud para Refugiados proporciona personal bilingüe en los departamentos de salud del condado que brindan interpretación en el lugar, interpretación telefónica y traducción de documentos.

South Florida Translations Miami Office By Appointment Only 14 NE 1st Ave Miami, FL 33132 305-907-6676 We provided variety of personal documentation translated into English to get a

South Florida Translations Miami Office By Appointment Only 14 NE 1st Ave Miami, FL 33132 305-907-6676 Proporcionamos una variedad de documentación personal traducida al Inglés

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 49

job, find legal help, immigration, get driving privileges and more.

para conseguir un trabajo, encontrar ayuda legal, inmigración, obtener privilegios de conducir y más.

Josef Silny & Associates 7101 SW 102 Avenue Miami, FL 33173 (305) 273-1616 Our Purpose is to assist international students, U.S. citizens, and permanent residents educated abroad in foreign credential evaluation and translation to determine the foreign education equivalency in the United States. JS&A is a Member of the National Association of Credential Evaluation Services (NACES) and a Corporate Member of the American Translators Association (ATA).

Josef Silny & Associates 7101 SW 102 Avenue Miami, FL 33173 (305) 273-1616 Nuestro propósito es ayudar a los estudiantes internacionales, ciudadanos estadounidenses y residentes permanentes educados en el extranjero en la evaluación y traducción de credenciales extranjeras para determinar la equivalencia de educación extranjera en los Estados Unidos. JS&A es miembro de la Asociación Nacional de Servicios de Evaluación de Credenciales (NACES) y miembro corporativo de la Asociación Estadounidense de Traductores (ATA).

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 50

Appendix C

Permission letter for the use of The Inventory for Assessing the Process Of Cultural Competence

Among Healthcare Professionals- Revised (IAPCC-R)

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Appendix D

Educational Presentation

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Appendix E

Chart review tool

Developed by Roberto Gimenez RN, AGNP-BC

Chart Review Tool

Medical providers were present for cultural competence presentation? Yes/No

Medical providers completed an IAPCC-R evaluation pre implementation? Yes/No

Medical providers provided resources information to patients according to LICCT tool?

Yes/No

Medical providers completed an IAPCC-R evaluation post implementation Yes/No

LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 63

Appendix F

IAPCC-R Scoring Key

Intervention

Several activities have taken place in preparation for the implementation of the

intervention. First of all, there was a selection of the mental health clinic, followed by a signed

agreement that authorizes the intervention to be taken place at the clinic site. The proposed

project was presented to the Touro University of Nevada and approved by the DNP project chair

and members. The site administrator and Medical Director of the site were consulted regarding

the enrolment of participants.

The participants have received detailed information on their role and participation in the

project to reach the end goal.

The activities are expected to take place at the mental health clinic during regular office

hours. The clinic administrator will be in charge of selecting medical assistants whose role will

be to identify the Latinx immigrant, ethnicity which will be evaluated through the patient

demographic intake form at the clinic. Patients that require community resources and assist the

providers with a resource list for them. The project lead will be available to assist the medical

providers with any questions about the LICCT tool, as well as the specifics of each of the

resources within the tool. I will also be available with questions and guidance for the medical

assistants regarding documentation of resources provided to patient. In the event that I am not

available on grounds; a telephone and email contact will be provided to all participants for quick

access. The intervention will take place on November 4, 2020 through December 1, 2020. The

following is a weekly timeline of the implementation.

Week 1: During the beginning of this week the medical providers will take part in

educational training. The training will be presented in a power point and the IAPCCR-R pre-test

and post-test evaluation will be provided to all medical providers prior to the presentation. The

presentation will include a detailed explanation of the resource tool. During the second half of

this week implementation of the resource tool will begin.

Week 1-4: Implementation of resource to patients during in-office visits. Ongoing

education and support to participants will be available through these weeks. Data collection and

assessment of compliance will be conducted on a weekly basis in order to capture any

opportunities needed for re-training.

Week 5: During this week compiling of data for analysis should be completed and

statistical testing should be performed.

The implementation phase shall commence on November 4, 2020, and end on December

1, 2020. Later, the project lead and the medical providers are expected to have a meeting and

share the final data collected and analysis at the end of the intervention.

Tools

The tools that will be utilized during this DNP project include IAPCC-R, the LICCT,

educational presentation, and chart review tool. The following is an explanation of each tool.

LICCT (Appendix B)

The LICCT tool is composed of several resource assistance organizations with their

address and phone numbers. The five resources included in this tool are food assistance,

clothing, vocational training, employment services, and interpretation services.

The food assistance organizations provide USDA food distribution of canned goods,

fresh products, and groceries. The centers also provide emergency food, breakfast, lunch, and

dinner in different days of the week for those in need.

The clothing assistance organizations clients may obtain free hot showers for men and

women multiple days a week and a free exchange of clean clothing, shoes, and shower programs.

They also provide blankets and accessories to meet the needs of children, victims of crime, and

people affected by poverty, and homelessness.

The vocational training assistance organizations provide the tools and resources

necessary to help minorities to achieve financial stability. The services they offer include

financial coaching and education, credit counseling, free income tax preparation, and income tax

return, job training, interviewing skills and resume building, job orientation and training, resume

writing, vocational training, and job placement.

Employment services provide job placement referrals in addition to various course and

training through community programs.

Interpretation services will be available to assist the patient with translation of

documents, onsite interpretation, and telephonic interpretation.

IAPCC-R (Appendix C)

The Inventory for Assessing the Process of Cultural Competence Among Healthcare

Professionals-Revised (IAPCC-R) will be used as a pre/post questionnaire before

implementation and after all interventions to assess the providers’ knowledge. According to

Transcultural CARE Associates (2015), the IAPCC-R© was developed by Dr. Campinha-Bacote

in 2002. It is a revision of the Inventory for Assessing the Process of Cultural Competence

Among Healthcare Professionals (IAPCC). The IAPCC, which is no longer available for use,

was developed by Campinha-Bacote in 1997 and is based on her cultural competence model, The

Process of Cultural Competence in the Delivery of Healthcare Services (1998). Cronbach’s alpha

of the IAPPC© was established at .81 (Wilson, 2003). The IAPCC only measured four of this

model’s five constructs (cultural awareness, cultural knowledge, cultural skill, and cultural

encounters) and not the fifth construct of cultural desire. In 2002, Campinha-Bacote revised the

IAPCC by adding five additional questions to measure the fifth construct of cultural desire. This

revision led to the instrument’s last name. Further research was conducted on IAPCC-R© to be

used with students, and a student version (IAPCC-SV) is currently available (the IAPCC-R

website). Permission for the use of the (IAPCC-R) to assess the level of cultural competence of 3

mental health providers was granted on August 29, 2020. The total cost was $48 for 6 tools

which will be divided in 3 pre/post questionnaires. The permission only grants administration of

the tool via an onsite pencil and paper method which will be personally hand administered. All

other formats of administration are against contractual agreement.

Educational Presentation (Appendix D)

According to Bhui, Warfa, Edonya, McKenzie, & Bhugra (2007), cultural competency is

considered an essential requirement for medical providers in the specialty of mental health,

providing care to culturally diverse patient groups. Ongoing education and training have proven

to yield improved compliance in medical management and healthcare quality for ethnic groups

(Bhui, Warfa, Edonya, McKenzie, & Bhugra, 2007). Due to the considerable confusion about

what constitutes cultural competence at the organization, the need for competence training is

deemed crucial for the project’s success. An educational presentation has been developed by the

project lead using a PowerPoint presentation, pre/post survey, and LICCT handouts. The

training’s goal is to provide consistency among the providers of the clinic on how cultural beliefs

and practices of Latino immigrants may affect their perception of mental health illness, health

behaviors, and acceptance of resource assistance. The training will take place at the organization

and will be conducted by the project lead with the medical director and administration’s

permission. A three-hour session will be allotted for the educational presentation.

Chart Review Tools

Two chart audit tools have been incorporated in the project. The first tool has been

composed of two sections (Appendix E) to evaluate participant’s knowledge of cultural

competency through educational presentation and pre/post questionnaire. The second tool

(Appendix F) is a scale tool to evaluate the knowledge in cultural competence of the participants

and the need for further education. Both tools have been developed by the project lead and

reviewed for quality by the project team and the stakeholders at the site. In addendum the

participants will also be evaluated for their compliance in providing and discussing the available

resources with the patient and documenting the plan accordingly during the office visit.

Data Collection Procedures

Data collection in the healthcare sector is a sensitive activity. Under the stipulated

nursing and healthcare principles, it must be done avoiding infringing patients’ privacy,

confidentiality, or disclosing their essential information to the public and third parties. Data will

be made anonymous for confidentiality by hiding patient identities, locations, and addresses.

This approach will help protect the patient’s information and reaching unintended people.

When collecting data, the project lead will undertake both pre- and post-survey results

assessments to profoundly impact the possible statistical analyses’ choice to be conducted at the

group level (Alessandri et al., 2017). The data will be stored in digital form to avoid

manipulation by other parties since it may potentially result in incorrect data.

The IAPCC-R survey will be administered as a pre-test to evaluate cultural knowledge by

participants. Immediately after this survey is completed by the providers an educational training

via a power point presentation will be conducted by the project lead delineating the purpose,

goal, and each step of the project. Following the education training all providers will receive the

same survey to evaluate their level of learned competency. Both surveys will be provided to the

participants at the same time before the educational session. Since the surveys are the same, the

lead will label the surveys as Pre-1 for pre-test 1 and Post-1 for post-test as identifiers. Surveys

will be labeled with each participant name but will be entered in the code book with unidentified

initials. Directly after the collection of all pre/post survey questions, the audit tool (Appendix F)

will be completed, and results entered in the codebook. Once medical provider competency has

been established, the intervention will begin, and data will be collected weekly. Data will consist

of whether each Latino immigrant patient seen by a medical provider at the clinic receives the

resource information according to their needs. The medical providers will be required to address

the resources provided in their assessment and plan portion of their progress note. The

compliance of the intervention will be collected weekly by the project lead and entered in the

codebook. Finally, once the four weeks of implementation have ended, data analysis will be

conducted using the appropriate audit tool (appendix E).

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