Mechanisms Driving Postgraduate Health and Social Science Students' Cultural Competence: An Integrated Systematic Review.

PURPOSE: The COVID-19 pandemic revealed a global urgency to address health care provision disparities, which have largely been influenced by systematic racism in federal and state policies. The World Health Organization recommends educational institutions train clinicians in cultural competence (CC); however, the mechanisms and interacting social structures that influence individuals to achieve CC have received little attention. This review investigates how postgraduate health and social science education approaches CC and how it accomplishes (or not) its goals. METHOD: The authors used critical realism and Whittemore and Knafl's methods to conduct a systematic integrated review. Seven databases (MEDLINE, CINAHL, PsycINFO, Scopus, PubMed, Web of Science, and ERIC) were searched from 2000 to 2020 for original research studies. Inclusion criteria were: the use of the term "cultural competence" and/or any one of Campinha-Bacote's 5 CC factors, being about postgraduate health and/or social science students, and being about a postgraduate curriculum or a component of it. Thematic analysis was used to reveal the mechanisms and interacting social structures underlying CC. RESULTS: Thirty-two studies were included and 2 approaches to CC (themes) were identified. The first theme was professionalized pedagogy, which had 2 subthemes: othering and labeling. The second theme was becoming culturally competent, which had 2 subthemes: a safe CC teaching environment and social interactions that cultivate reflexivity. CONCLUSIONS: CC conceptualizations in postgraduate health and social science education tend to view cultural differences as a problem and CC skills as a way to mitigate differences to enhance patient care. However, this generates a focus on the other, rather than a focus on the self. Future research should explore the extent to which insight, cognitive flexibility, and reflexivity, taught in safe teaching environments, are associated with increasing students' cultural safety, cultural humility, and CC.

Using internationalization-at-home activities to enhance the cultural awareness of health and social science research students: A mixed-method study.

BACKGROUND: Despite healthcare scholars valuing diversity, current cultural awareness training does not address mechanisms that drive societal patterns, that generates cultural insensitivity and reinforces stereotypes of minority groups. The influence of culture on thinking is an important issue because of potential ethnocentric biases on the design, data collection, analysis, and dissemination of research. OBJECTIVES: Using internationalization-at-home activities to explore the mechanisms that enhance the development of cultural awareness in postgraduate health and social science research students. DESIGN AND METHODS: A pragmatic critical realist study, qualitatively dominant, using mixed-methods to integrate and analyze qualitative and quantitative data. Data were collected pre- and post-internationalization-at-home activities. Qualitative data were collected from online discussion forums and focus groups, and quantitative data were collected from a pre-test and post-test measure of cultural awareness. SETTING AND PARTICIPANTS: Eighteen research students in postgraduate health and social science programs from three universities (Australia, Hong Kong, and Sweden) participated in five formal internationalization-at-home webinars and informal international group activities. RESULTS: Participants reported four mechanisms counteracting structures (i.e., ethnocentric biases) toward the emergence of cultural awareness: 1. awareness of cultural issues motivating people toward achieving a common goal; 2. reflexivity within psychological safety; 3. deliberations that challenge the veracity of individual assumptions; 4. courage coupled with curiosity. When some or all the mechanisms occurred, properties of enhanced cultural awareness emerged, as confirmed by the quantitative data. CONCLUSIONS: Cultural awareness training should emphasize social relations to allow cultural safety to develop for postgraduate health and social science research students. Without skills revealing unconsciously held ethical values, this study argues that postgraduate health and social science students may inadvertently reconstitute and reinforce in their research the discrimination of underserved groups.

Communication patterns in nurse-led chemotherapy clinics: A mixed-method study.

OBJECTIVE: To determine patterns of nurse-patient communication in fulfilling patients' informational/psychosocial needs, effects of longer consultation/operational aspects on person-centred care experiences. METHODS: Mixed-method design; secondary analysis of transcripts of nurse-patient communication within nurse-led chemotherapy clinics in UK [3]. Purposive sampling (13 nurses); non-participant observations (61 consultations). Qualitative content analysis of audio-recorded transcripts. Quantitative analysis using the Medical Interview Aural Rating Scale [14] to compare mean differences in the number of cues and level of responding using one-way ANOVA, and correlational analyses of discursive spaces. RESULTS: Nurses responded positively to informational cues, but not psychosocial cues. Longer consultations associated with more informational and psychosocial cues (p <  .0001), but not nurses' cue-responding behaviours. Four main themes emerged: challenges/opportunities for person-centred communication in biomedical contexts; patients' "life world" versus the "medical world"; three-way communication: nurse, patient and family; implications of continuity of care. CONCLUSIONS: The challenges/opportunities for cue-responding in nurse-led chemotherapy clinics were evident for informational and psychosocial support of patients. Shifting from a biomedical to biopsychosocial focus is difficult. PRACTICE IMPLICATIONS: Further evaluation is needed to integrate biopsychosocial elements into communication education/training. Careful planning is required to ensure continuity and effective use of time for person-centred care.

Training in communication and interaction during shift-to-shift nursing handovers in a bilingual hospital: A case study.

AIM: To explore the perceptions and practices of nurses on handovers. BACKGROUND: At handover, accountability must be transferred to ensure a consistent quality of patient care. Studies highlighted unstructured handovers as a major factor contributing to critical incidents. The design of handover training requires a systematic method for evaluating nurses' practices. DESIGN: An explorative case study, qualitative design that combined ethnography with discourse analysis. METHODS: A training programme based on these practices was administered to 50 nurses, and a protocol focused on CARE was implemented. The nurses' perceptions and practices were evaluated, and 80 handovers were recorded. RESULTS: Three areas likely to enhance the continuity of care emerged: 1) explicit transfer of responsibility by outgoing nurses; 2) responsible engagement of incoming nurses in the handover and 3) adherence to a systematic handover structure. CONCLUSION: The change in practice from monologic handovers with passive incoming nurses before training to interactive and collaborative handovers, where all nurses appeared to take an active role in clarifying patients' cases, after training was significant.

Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study.

BACKGROUND: Despite an increase in emphasis on psychosocial care in cancer nursing, time constraints and nurses' lack of knowledge in skilled communication continue to be challenges. AIMS: To examine how cancer care nurses view their communication with patients and how they deal with the psychosocial needs of patients in busy wards. DESIGN: A qualitative interview study. METHODS: Focus groups and individual interviews were conducted with eleven hospital-based cancer nurses in Hong Kong from July 2, 2017 to January 2, 2018. RESULTS: A qualitative thematic analysis of the data identified three themes: 1. Intentional and unintentional psychosocial care that is secondary in focus; 2. Managing an emotionally challenged environment; 3. Mentoring and learning. CONCLUSION: Oncology settings are time-constrained, emotionally charged environments for nurses, and providing psychosocial care for patients is a secondary concern. While proactive strategies can be used to avert patient complaints, being open and attending to the individual needs of patients is equally important to avoid blocking in nurse-patient communication. Despite emotional entanglement and tensions, the positive follow-up strategies used by nurses to manage the patients' emotions and provide psychosocial care reflect good practices. Leadership and support are needed to deal with the nurses' perception that their communication training has been ineffective and their ability to manage strong emotions deficient. Communication skills, honed by making continuous opportunities to communicate available, as well as an understanding of emotional labour, need to be integrated with mindfulness in the nurses' care of themselves and their patients. Notwithstanding the importance of experience in oncology care for junior nurses, it is necessary for both junior and senior nurses to learn about and reflect upon the different forms of emotional labour if value-based care is to be provided. In addition, it is essential for junior nurses to receive continuous coaching and mentoring, and to engage in reflective learning from each clinical encounter with oncology patients.

Communicative constructions of person-centred and non-person-centred caring in nurse-led consultations.

PURPOSE: Nursing is theorised to be a component of person-centred care. Communicative constructions of person-centred caring are a topic that needs to be studied in consultations. The study aimed to explore how person-centred caring and non-person- centred caring are verbally constructed in consultations between patients and nurse. METHOD: This study was qualitative using audio-recorded observations from consultations with advanced nurse practitioners in nurse-led chemotherapy clinics from four hospitals in the UK through purposive sampling. Discourse analysis was used to identify communicative patterns in 45 non-participant observations of nurse consultations. RESULTS: The dominant discourse was a non-person-centred oriented discourse framed by the biomedical model. It was also possible to identify fragments of an alternative discourse-a person-oriented discourse localising health problems within the patient's personal and sociocultural context. CONCLUSIONS: The prominent use of a non-person-oriented discourse focusing on the medical/technical aspects of a patient's assessment/evaluation in consultations may make it difficult for patients to raise questions and concerns from their daily lives during consultations. However, fragments of a person-oriented discourse show that it is possible for nurses to allow a person-centred approach to the consultation. The pedagogical implications have to do with raising nurses' awareness of the role of evaluative language in enhancing person-centred communication with patients in clinical interactions.

Health professional-patient communication practices in East Asia: An integrative review of an emerging field of research and practice in Hong Kong, South Korea, Japan, Taiwan, and Mainland China.

OBJECTIVE: To provide an integrative review of literature on health communication in East Asia and detail culturally-specific influences. METHODS: Using PRISMA model, search of PubMed, PsychInfo, Web of Knowledge, ERIC and CINAHL databases were conducted for studies between January 2000 and March 2017, using the terms 'clinician/health professional-patient', 'nurse/doctor-patient, 'communication' and 'Asia'. RESULTS: 38 studies were included: Mainland China, Hong Kong, Japan, South Korea, and Taiwan. The existing body of research on clinician patient communication in East Asia can be classified: 1) understanding the roles and expectations of the nurse, clinician, patient, and family in clinician-patient consultations: a) nurse-patient communication; b) doctor-patient communication; c) the role of family member; and 2) factors affecting quality of care: d) cultural attitudes towards death and terminal illnesses; e) communication preferences affecting trust, decision-making and patient satisfaction; f) the extent to which patient centred care is being implemented in practice; and g) communication practices in multilingual/multi-disciplinary environments. CONCLUSION: The review detailed the complexity and heterogeneity of clinician-patient communication across East Asia. The studies reviewed indicate that research in East Asia is starting to move beyond a preference for Western-based communication practices. PRACTICE IMPLICATIONS: There is a need to consider local culture in understanding and interpreting medical encounters in East Asia. The paper highlights the need for a specific culturally-appropriate model of health communication in East Asia which may significantly improve relationships between clinicians and patients.

Pre-departure preparation and co-curricular activities for Students' intercultural exchange: A mixed-methods study.

BACKGROUND: Nurses are required to be culturally competent to provide quality care to an increasingly diverse and ageing population. International exchange programmes were developed to support the traditional nursing curriculum. These programmes have often overlooked the importance of pre-departure preparation and co-curricular activities to the development of intercultural competency. OBJECTIVES: To explore the influence of pre-departure and co-curricular activities on the intercultural learning experiences of both exchange and host students in a short-term international summer programme. DESIGN: A mixed-methods study. SETTING: Students were recruited from international and mainland exchange partners, with host students as ambassadors. The international summer programme involved a week of online pre-departure activities and two weeks of face-to-face meetings. PARTICIPANTS: A convenience sample of 62 students from diverse cultural backgrounds was recruited on a voluntary basis. The participants were aged between 19 and 27. METHODS: Data were collected from students' pre- and post-visit questionnaires, discussions within the workshops, their online discussion threads, and focus group discussions. RESULTS: The quantitative findings suggested that students' cultural intelligence improved significantly after the exchange programme. Qualitatively, three themes emerged as: 1) Students' motivation to engage in intercultural learning; 2) Barriers to intercultural communication; 3) Enablers of intercultural communication. CONCLUSION: Pre-departure preparation enabled students to discuss their common goals and expectations, while exploring differences, asked for practical living information, and used the basic intercultural concepts in their discussion on the care of elderly. This virtual encounter has lay the foundation for students' subsequent discussions about the why and how the differences that inform their own practices and about global ageing and poverty issues during their co-curricular activities. While the pre-departure preparation could serve as a stimulus, the value of this programme for intercultural learning also rests with the importance of debriefing to further students' reflective and experiential learning.

Taken-for-granted assumptions about the clinical experience of newly graduated registered nurses from their pre-registration paid employment: A narrative inquiry.

Paid employment within clinical setting, such as externships for undergraduate student, are used locally and globally to better prepare and retain new graduates for actual practice and facilitate their transition into becoming registered nurses. However, the influence of paid employment on the post-registration experience of such nurses remains unclear. Through the use of narrative inquiry, this study explores how the experience of pre-registration paid employment shapes the post-registration experience of newly graduated registered nurses. Repeated individual interviews were conducted with 18 new graduates, and focus group interviews were conducted with 11 preceptors and 10 stakeholders recruited from 8 public hospitals in Hong Kong. The data were subjected to narrative and paradigmatic analyses. Taken-for-granted assumptions about the knowledge and performance of graduates who worked in the same unit for their undergraduate paid work experience were uncovered. These assumptions affected the quantity and quality of support and time that other senior nurses provided to these graduates for their further development into competent nurses and patient advocates, which could have implications for patient safety. It is our hope that this narrative inquiry will heighten awareness of taken-for-granted assumptions, so as to help graduates transition to their new role and provide quality patient care.