Embracing Cultural Diversity in Health Care PDF

APRIL 2007 Healthy Work Environments Best Practice Guidelines Embracing Cultural Diversity in Health Care: Developing Cultural Competence Healthy Work Environments Best Practice Guidelines Greetings fr...

APRIL 2007 Healthy Work Environments Best Practice Guidelines Embracing Cultural Diversity in Health Care: Developing Cultural Competence Healthy Work Environments Best Practice Guidelines Greetings from Doris Grinspun, Executive Director Registered Nurses’ Association of Ontario It is with great pleasure that the Registered Nurses’ Association of Ontario releases “Embracing Cultural Diversity in Health Care: Developing Cultural Competence Guideline." This is one of a series of six Best Practice Guidelines (BPGs) on Healthy Work Environments (HWE), developed to date by the nursing community. The aim of these guidelines is to provide the best available evidence to support the creation of thriving work environments. Evidence-based HWE BPGs, when applied, will serve to support the excellence in service that nurses are committed to delivering in their day-to-day practice. RNAO is delighted to be able to provide this key resource to you. We offer our endless gratitude to the many individuals and organizations that are making our vision for HWE BPGs a reality. To the Government of Ontario and Health Canada for recognizing RNAO’s ability to lead this program and for providing generous funding. To Donna Tucker, program director from 2003 to 2005, and to Irmajean Bajnok – RNAO Director, Centre for Professional Nursing Excellence and the program’s lead since 2005, for providing wisdom and working intensely to advance the production of these HWE BPGs. To each and all HWE BPG leaders and in particular, for this BPG, Panel Chair Rani Srivastava and Panel Coordinator Dianna Craig, for providing superb stewardship, commitment and above all exquisite expertise. Thanks go also to the amazing panel members who generously contributed their time and knowledge. We could not have delivered such a quality resource without you! We thank in advance the entire nursing community, committed and passionate about excellence in nursing care and healthy work environments, who will now adopt these BPGs and implement them in their worksites. We ask that you evaluate their impact and tell us what works and what doesn’t, so that we continuously learn from you, and revise these guidelines informed by evidence and practice. Partnerships such as this one are destined to produce splendid results – learning communities – all eager to network and share expertise. The resulting synergy will be felt within the BPG movement, in the workplaces, and by those who receive nursing care. Creating healthy work environments is both a collective and an individual responsibility. Successful uptake of these guidelines requires the concerted effort of nurse administrators, nursing staff and advanced practice nurses, nurses in policy, education and research, and health care colleagues from other disciplines across the organization. It also requires full institutional support from CEO’s and their Boards. We ask that you share this guideline with all. There is much we can learn from each other. Together, we can ensure that health organizations including nurses and all other health care workers, build healthy work environments. This is central to ensuring quality patient care. Let’s make health care providers, their organizations and the people they serve the real winners of this important effort! Doris Grinspun, RN, MSN, PhD (c), OOnt. Registered Nurses’ Association of Ontario  Embracing Cultural Diversity in Health Care Disclaimer & Copyright Disclaimer These guidelines are not binding for nurses or the organizations that employ them. The use of these guidelines should be flexible based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work. Copyright This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. The Registered Nurses’ Association of Ontario (RNAO) will appreciate citation as to source. The suggested format for citation is indicated below: Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada: Registered Nurses’ Association of Ontario 1 Healthy Work Environments Best Practice Guidelines Development Panel Members Rani Srivastava, RN, MScN, PhD(c) Rob Calnan, RN, BScN, MEd Panel Chair Manager Deputy Chief of Nursing Practice Practice and Evaluation Centre for Addiction & Mental Health Canadian Nurse Practitioner Initiative Toronto, Ontario Canadian Nurse Association Ottawa, Ontario Saima Ahmad BScN Level Student (class 2006) Salma Debs-Ivall, RN, BScN, MScN McMaster University Corporate Associate Coordinator Diversity Officer, Nursing Students of Ontario Nursing Education Hamilton, Ontario Nursing Professional Practice Department The Ottawa Hospital Janet Anderson, RN, BScN, MEd Manager, Practice Terri Dixon RN, BN, MEd College of Nurses of Ontario Professor, Nursing Toronto, Ontario Collaborative Nursing Degree Program Ryerson University, Centennial College, Cynthia Baker, RN, PhD George Brown College Director, School of Nursing and Associate Dean George Brown College Site Faculty of Health Sciences, Queens University Toronto, Ontario Kingston, Ontario Lisa Dutcher, RN, BN, MN(c) Helen Barrow, RPN First Nations and Inuit Home Community (Registered Practical Nurse) Care Program Coordinator N.B. and P.E.I. Case Manager – Out Patient Mental Health Past President, Aboriginal Nurses Association North York General Fredericton, New Brunswick Toronto, Ontario Ginette Lazure, inf., MScinf., PhD Allison A. Brown, RN, BScN Professeure agrégée, Office Case Manager Directrice des programmes de premier cycle Central West Community Care Access Centre Responsable académique pour la formation Etobicoke, Ontario à l'international Faculté des sciences infirmières, Université Laval, Québec 2  Embracing Cultural Diversity in Health Care Ruth Lee, RN, BScN, MScN, PhD Chief of Nursing Practice, Professional Affairs McMaster University Medical Centre Hamilton Health Sciences Hamilton Ontario Joan Lesmond, RN, BScN, MSN, EdD Chief Nursing Executive Casey House Toronto, Ontario Shalimar Santos-Comia, RN, BScN, MHSc Director, Nursing Education and Informatics Sunnybrook Health Sciences Centre Toronto, Ontario Yasmin Vali, RN, MHSA Director, Community and Patient Relations Access and Equity Services The Scarborough Hospital Toronto, Ontario Michael J. Villeneuve, RN, BScN, MSc Scholar in Residence Canadian Nurses Association Ottawa, Ontario 3 Healthy Work Environments Best Practice Guidelines Responsibility for Development The Registered Nurses’ Association of Ontario (RNAO), with funding from the Ministry of Health and Long-Term Care and in partnership with Health Canada has embarked on a multi-year project of healthy work environments best practice guidelines development, pilot implementation, evaluation and dissemination that will result in guidelines developed by expert panels. This guideline was developed by an expert panel convened by the RNAO, conducting its work independent of any bias or influence from funding agencies. The panel was supported by members of the RNAO project teams as listed below. Project Team Irmajean Bajnok, RN, MSN, PhD Director, RNAO Centre for Professional Nursing Excellence Project Director (as of July 2005) Donna Tucker, RN, MScN Project Director (2003-2005) Dianna Craig, RN, BA, MEd Panel Coordinator (as of April 2005) Cian Knights, BA Project Assistant (2003-August 2005) Erica Kumar, BSc, GC, DipHlthProm Project Assistant (as of September 2005) Contact Information Registered Nurses’ Association of Ontario Healthy Work Environments Best Practice Guidelines Project 158 Pearl Street, Toronto, Ontario, M5H 1L3 Website: http://www.rnao.org 4  Embracing Cultural Diversity in Health Care Stakeholder Acknowledgement The Registered Nurses’ Association of Ontario wishes to acknowledge the following for their contribution in reviewing this nursing best practice guideline and providing valuable feedback: Rita K. Adeniran, MSN, RN, CMAC, BC Jeffrey D’Hondt, BA Hon, BSW, MSW, RSW Global Nurse Ambassador Policy Analyst Hospital of the University of Pennsylvania Ministry of Health and Long-Term Care Philadelphia, Pennsylania Toronto, Ontario Patricia Boucher, RN, BHSc(N), COHN(C), Cécile Diby, RN, BScN CRSP, CDMP Nursing Education Specialist Director Client and Consultant Services SCO Health Care Service Ontario Safety Association for Community Ottawa, Ontario and Health Care Toronto, Ontario Josephine B. Etowa, RN, RM, IBCLC, BScN, MN, PhD Gwendolyn Bourdon, RN, BScN, MEd Assistant Professor Education Manager Dalhousie University School of Nursing Runnymede Health Care Centre Halifax, Nova Scotia Toronto, Ontario Nancy Fram, RN, BScN, MEd Barbara Aileen Bowles, RN, BSN, PNC(C) VP Professional Affairs and Chief Nursing Executive Staff Nurse Hamilton Health Sciences Niagara Health Systems Hamilton, Ontario St. Catharines, Ontario Linda Gardner, BA Manjit Kaur Budwal, RN, BScN Diversity and Community Access Coordinator Practice Consultant Women's College Hospital College of Nurses of Ontario Toronto, Ontario Toronto, Ontario Rose Gass, RN, ENC(C), BA Econ, MHS(c) Margarita Cleghorne, RPN Director Emergency and Intensive Care (Registered Practical Nurse) Norfolk General Hospital Clinical Instructor Simcoe, Ontario Wescom Solutions Mississauga, Ontario Amy Go, MSW Executive Director Patrick Clifford, BA, BSW, BEd, MSW, RSW Yee Hong Centre for Geriatric Care Coordinator, Professional Practice Toronto, Ontario Southlake Regional Health Centre Newmarket, Ontario Julie Gregg, RN, BScN, MAd Ed Coordinator, Member Relations and Development College of Registered Nurses of Nova Scotia Halifax, Nova Scotia 5 Healthy Work Environments Best Practice Guidelines Pat Griffin, RN, PhD Catherine Kohm, RN, MEd Executive Director Director of Nursing Canadian Association of Schools of Nursing Baycrest Ottawa, Ontario Toronto, Ontario Rebecca Hagey, BS, BSc, MA, PhD, Cert. Brenda Lewis, RN, BScN Mediation Registration Consultant Associate Professor, Faculty of Nursing College of Nurses of Ontario University of Toronto Toronto, Ontario Toronto, Ontario Cheryl Lyons, RN, BScN Mary Jane Herlihey, BScN, RN Professional Practice Educator Clinical Education Consultant Joseph Brant Memorial Hospital ParaMed Home Health Care Burlington, Ontario Ottawa, Ontario Suzette Mahabeer, RN, BScN, MS(c) Christy Ip Staff Nurse Student St. Joseph's Health Care Centre for Equity in Health and Society Stoney Creek, Ontario Toronto, Ontario Patricia Malloy, MSN, RN Sandra Ireland, RN, BScN, MSc, PhD(student) Clinical Nurse Specialist/Nurse Practitioner Chief of Nursing Practice The Hospital for Sick Children Hamilton General Hospital Toronto, Ontario Hamilton, Ontario Mariana Markovic, RN, CPN(C), BScN Terri Irwin, RN, MN Professional Practice Specialist Practice Consultant Ontario Nurses’ Association College of Nurses of Ontario Toronto, Ontario Toronto, Ontario Debra McAuslan, RN, MScN Rachel Johnson Professional Practice Specialist Nursing Student London Health Sciences Centre McMaster University London, Ontario Hamilton, Ontario Toba Miller, RN, MScN, MHA, GNC(C) Carolyn Johnson, BScN, RN, MEd Advanced Practice Nurse Professional Practice Liaison Children's Health The Ottawa Hospital and Policy Development Ottawa, Ontario IWK Health Care Centre Halifax, Nova Scotia 6  Embracing Cultural Diversity in Health Care Norma Nicholson, RN, BA, MA(Ed) Judy Smith, RN, BScN, ENC(C) Service Manager Nurse Educator West Park Health Care Centre York Central Hospital Mississauga, Ontario Richmond Hill, Ontario Nancy Purdy, RN, PhD(c) Paulette Stewart, BScN, MN, PhD(c) Doctoral Student Clinical Nurse Specialist University of Western Ontario Mount Sinai Hospital London, Ontario Toronto, Ontario Cheryl Reid-Haughian, RN, MHScN, CCHN(C) Hilda Swirsky, RN, BScN, MEd Director, Professional Practice Clinical Nurse and Sessional Professor ParaMed Home Health Care Mount Sinai Hospital and George Brown College Ottawa, Ontario Toronto, Ontario Andrea Riekstins, RN, MN, ACNP Rosemarie Taylor, RN, EdD(c), MA, BSN Clinical Nurse Specialist/Nurse Practitioner Associate Director of Patient Care Services Hospital for Sick Children Jackson Health System Toronto, Ontario Miami, Florida Chantal Saint-Pierre, PhD Adele Vukic, RN, BN MN Directrice Module des Sciences de la Santé Assistant Professor Université du Québec Dalhousie University Gatineau, Québec Halifax, Nova Scotia Mary Saxe-Braithwaite, BScN, MScN MBA, CHE Olive Wahoush, RN, MSC, PhD Vice President Programs and Chief Nursing Officer Assistant Professor Providence Continuing Care Centre McMaster University Kingston, Ontario Hamilton, Ontario Lorraine Schubert, RN, BAAN, MEd Donna Walsh, RN, BScN Clinical Nurse Educator ISMP Canada Fellow North York General Hospital Institute for Safe Medication Practices Canada Toronto, Ontario Toronto, Ontario Rhonda Singer, RN, CHRD Cheryl Yost, RN, BScN, MEd President Director of Patient Care Services Progress Career Planning Institute Manitoulin Health Centre Toronto, Ontario Little Current, Ontario 7 Healthy Work Environments Best Practice Guidelines Table of Contents Background to the Health Work Environments Best Practice Guidelines Project............................... 10 Organizing Framework for the Healthy Work Environments Best Practice Guidelines Project................. 12 Background Context of the Guideline on Embracing Cultural Diversity in Health Care: Developing Cultural Competence................................................................................ 17 Development of the Guideline................................................................................... 19 Conceptual Framework for Embracing Cultural Diversity in Health Care: Developing Cultural Competence Guideline..................................................................... 21 Sources and Types of Evidence on Embracing Cultural Diversity in Health Care: Developing Cultural Competence Guideline..................................................................... 22 Key Message and Themes from the Systematic Literature Review.............................................. 25 Overall Goals and Objectives..................................................................................... 26 Purpose and Scope............................................................................................... 26 How to Use this Document....................................................................................... 27 Individual Context: Best Cultural Competence Practices......................................................... 28 Individual Recommendations........................................................................... 30 Evidence................................................................................................. 32 Organizational Context: Best Cultural Competence Practices for Employers and Unions....................... 35 Recommendations....................................................................................... 36 Evidence................................................................................................. 39 External Context: Best Cultural Competence Practices for Academia, Governments and Regulators, and Professional Association................................................................... 46 Individual Recommendations........................................................................... 47 Evidence................................................................................................. 50 Conclusion........................................................................................................ 56 Process for Reviewing and Updating the Healthy Work Environments Best Practice Guidelines.............. 57 References........................................................................................................ 58 Numbered References................................................................................... 58 Alphabetized References................................................................................ 64 Throughout this document words marked with the symbol G can be found in the Glossary of Terms. 8  Embracing Cultural Diversity in Health Care Appendix A: Glossary of Terms................................................................................... 70 Appendix B: Summary of Key Models Related to Cultural Competence......................................... 73 Appendix C: Guideline Development Process.................................................................... 76 Appendix D: Process for Systematic Review of the Literature Completed by the Joanna Briggs Institute..... 77 Appendix E: Tools................................................................................................. 80 Appendix F: Implementation – Tips and Stratagies............................................................... 82 Appendix G: CLAS Standards..................................................................................... 83 Throughout this document words marked with the symbol G can be found in the Glossary of Terms. 9 Healthy Work Environments Best Practice Guidelines Background to the Healthy Work Environments Best Practice Guidelines Project In July of 2003 the Registered Nurses’ Association of Ontario (RNAO), with funding from the Ontario Ministry of Health and Long-Term Care, (MOHLTC) working in partnership with Health Canada, Office of Nursing Policy, commenced the development of evidence-based best practice guidelines in order to create healthy work environmentsG for nurses.G Just as in clinical decision-making, it is important that those focusing on creating healthy work environments make decisions based on the best evidence possible. The Healthy Work Environments Best Practice GuidelinesG Project is a response to priority needs identified by the Joint Provincial Nursing Committee (JPNC) and the Canadian Nursing Advisory Committee.1 The idea of developing and widely distributing a healthy work environment guide was first proposed in Ensuring the care will be there: Report on nursing recruitment and retention in Ontario 2 submitted to MOHLTC in 2000 and approved by JPNC. Health care systems are under mounting pressure to control costs and increase productivity while responding to increasing demands from growing and aging populations, advancing technology and more sophisticated consumerism. In Canada, health care reform is currently focused on the primary goals identified in the Federal/Provincial/Territorial First Ministers’ Agreement 2000,3 and the Health Accords of 20034 and 20045: the provision of timely access to health services on the basis of need; high quality, effective, patient/client-centered and safe health services; and a sustainable and affordable health care system. Nurses are a vital component in achieving these goals. A sufficient supply of nurses is central to sustain affordable access to safe, timely health care. Achievement of healthy work environments for nurses is critical to the safety, recruitment and retention of nurses. Numerous reports and articles have documented the challenges in recruiting and retaining a healthy nursing workforce.2, 6-10 Some have suggested that the basis for the current nursing shortage is the result of unhealthy work environments.11-14 Strategies that enhance the workplaces of nurses are required to repair the damage left from a decade of relentless restructuring and downsizing. There is a growing understanding of the relationship between nurses’ work environments, patient/client outcomes and organizational and system performance.15-17 A number of studies have shown strong links between nurse staffing and adverse patient/client outcomes.18-28 Evidence shows that healthy work environments yield financial benefits to organizations in terms of reductions in absenteeism, lost productivity, organizational health care costs,29 and costs arising from adverse patient/clientG outcomes.30 10  Embracing Cultural Diversity in Health Care Achievement of healthy work environments for nurses requires transformational change, with “interventions that target underlying workplace and organizational factors”.31 It is with this intention that we have developed these guidelines. We believe that full implementation will make a difference for nurses, their patients/clients and the organizations and communities in which they practice. It is anticipated that a focus on creating healthy work environments will benefit not only nurses but other members of the health care team. We also believe that best practice guidelines can be successfully implemented only where there are adequate planning processes, resources, organizational and administrative supports, and appropriate facilitation. The project will result in six Healthy Work Environments Best Practice Guidelines Collaborative Practice Among Nursing Teams Developing and Sustaining Effective Staffing and Workload Practices Developing and Sustaining Nursing Leadership Embracing Cultural Diversity in Health Care: Developing Cultural Competence Professionalism in Nursing Workplace Health, Safety and Well-being of the Nurse “ A healthy work environment is… …a practice setting that maximizes the health and well-being of nurses, quality patient/client outcomes, organizational performance and ” societal outcomes. 11 Healthy Work Environments Best Practice Guidelines Organizing Framework for the Healthy Work Environments Best Practice Guidelines Project Physical/Structural Policy Components l Policy Factors Externa tional Physical Fac aniza tors Org ork Demand F al W acto ysic rs Ph Professional/ Cogni Occupational Factors Nurse/Patient/Client tive/Psycho/ Components Organizational ctors tional Societal Outcomes ors Organ Fa Soc ct rse up a al Fa ial Nu Exte izat Occ Wo al ion ion du al/ ivi rnal rk De ma Ind on pat al nd ssi Soc So Fact cu ors fe cia Oc io- ro lP lF ct al/ Cu na a or ion o ltu s at i z ani ra ss Org fe lF to ro ac P Individual Work Context rs al ern Micro Level t Ex Organizational Context Cognitive/Psycho/ Meso Level Socio/Cultural External Context Components Macro Level Figure 1. Conceptual Model for Healthy Work Environments for Nurses – Components, Factors & Outcomesi-iii A healthy work environment for nurses is complex and multidimensional, comprised of numerous components and relationships among the components. A comprehensive model is needed to guide the development, implementation and evaluation of a systematic approach to enhancing the work environment of nurses. Healthy work environments for nurses are defined as practice settings that maximize the health and well-being of the nurse, quality patient/client outcomes, organizational performance and societal outcomes. 12  Embracing Cultural Diversity in Health Care The Comprehensive Conceptual Model for Healthy Work Environments for Nurses presents the healthy workplace as a product of the interdependence among individual (micro level), organizational (meso level) and external (macro level) system determinants as shown above in the three outer circles. At the core of the circles are the expected beneficiaries of healthy work environments for nurses – nurses, patients/clients, organizations and systems, and society as a whole, including healthier communities.iv The lines within the model are dotted to indicate the synergistic interactions among all levels and components of the model. The model suggests that the individual’s functioning is mediated and influenced by interactions between the individual and her/his environment. Thus, interventions to promote healthy work environments must be aimed at multiple levels and components of the system. Similarly, interventions must influence not only the factors within the system and the interactions among these factors but also influence the system itself.v,vi The assumptions underlying the model are as follows: healthy healthy work environments are essential for quality, safe patient/client care; the model is applicable to all practice settings and all domains of nursing; individual, organizational and external system level factors are the determinants of healthy work environments for nurses; factors at all three levels impact the health and well-being of nurses, quality patient/client outcomes, organizational and system performance, and societal outcomes either individually or through synergistic interactions; at each level, there are physical/structural policy components, cognitive/psycho/social/cultural components and professional/occupational components; and the professional/occupational factors are unique to each profession, while the remaining factors are generic for all professions/occupations. i Adapted from DeJoy, D.M. & Southern, D.J. (1993). An Integrative perspective on work-site health promotion. Journal of Medicine, 35(12): December, 1221-1230; modified by Laschinger, MacDonald & Shamian (2001); and further modified by Griffin, El-Jardali, Tucker, Grinspun, Bajnok, & Shamian (2003). ii Baumann, A., O’Brien-Pallas, L., Armstrong-Stassen, M., Blythe, J., Bourbonnais, R., Cameron, S., Irvine Doran D., et al. (2001, June). Commitment and care: The benefits of a healthy workplace for nurses, their patients, and the system. Ottawa, Canada: Canadian Health Services Research Foundation and The Change Foundation. iii O’Brien-Pallas, L., & Baumann, A. (1992). Quality of nursing worklife issues: A unifying framework. Canadian Journal of Nursing Administration, 5(2):12-16. iv Hancock, T. (2000). The evolution, The Healthy Communities vs. “Health”. Canadian Health Care Management, 100(2):21-23. v Green, L.W., Richard, L. and Potvin, L. (1996). Ecological foundation of health promotion. American Journal of Health Promotion, 10(4): March/April, 270-281. vi Grinspun, D. (2000). Taking care of the bottom line: shifting paradigms in hospital management. In Diana L. Gustafson (ed.), Care and Consequence: Health Care Reform and Its Impact on Canadian Women. Halifax, Nova Scotia, Canada. Fernwood Publishing. 13 Healthy Work Environments Best Practice Guidelines Physical/Structural Policy Components Physical/Structural Policy Components At the individual level, the Physical Work rnal Policy Factors Demand Factors include the requirements of the Exte work which necessitate physical capabilities and tional Physical Fa effort on the part of the individual.vii Included niza ct o ga Or rs among these factors are workload, changing o r k D e ma n d Fa al W cto schedules and shifts, heavy lifting, exposure to sic y rs Ph Nurse/ hazardous and infectious substances, and Patient/Client threats to personal safety. Organizational Societal At the organizational level, the Organizational Outcomes Physical Factors include the physical characteristics and the physical environment of the organization and also the organizational structures and processes created to respond to the physical demands of the work. Included among these factors are staffing practices, flexible, and self-scheduling, access to functioning lifting equipment, occupational Figure 1A health and safety polices, and security personnel. At the system or external level, the External Policy Factors include health care delivery models, funding, and legislative, trade, economic and political frameworks (e.g., migration policies, health system reform) external to the organization. vii Grinspun, D. (2002). The Social Construction of Nursing Caring. Unpublished Doctoral Dissertation Proposal. York University, North York, Ontario. 14  Embracing Cultural Diversity in Health Care Cognitive/Psycho/Socio/Cultural Components Cognitive/Psycho/Socio/Cultural Components At the individual level, the Cognitive and Psycho-social Work Demand Factors include the requirements of the work which necessitate cognitive, psychological and social capabilities and effort (e.g., clinical knowledge, effective coping skills, communication skills) on the part Nurse/ of the individual.vii Included among these factors Social Work D Patient/Client are clinical complexity, job security, team Organizat Organizational Cognit ema Societal relationships, emotional demands, role clarity, Externa Outcomes and role strain. i ve i on /Ps nd cho y l So At the organizational level, the Organizational al Fac / S ci o tors oc lF Social Factors are related to organizational -C u ia ac tor ltu s climate, culture, and values. Included among ra Fa l cto rs these factors are organizational stability, communication practices and structures, labour/management relations, and a culture of continuous learning and support. Figure 1B At the system level, the External Socio-cultural Factors include consumer trends, changing care preferences, changing roles of the family, diversity of the population and providers, and changing demographics – all of which influence how organizations and individuals operate. 15 Healthy Work Environments Best Practice Guidelines Professional/Occupational Components Professional/Occupational Components At the individual level, the Individual Nurse Factors include the personal attributes and/or acquired skills and knowledge of the nurse which determine how she/he responds to the physical, cognitive and psycho-social demands of work.vii Included among these factors are commitment ational Factors Nurse/ to patient/client care, the organization and the onal Factors Patient/Client profession; personal values and ethics; reflective Factors Organizational Societal practice; resilience, adaptability and self ccup rse Outcomes confidence; and family work/life balance. Nu pati al/O al vid u At the organizational level, the Organizational n ccu Indi s sio Professional/Occupational Factors are characteristic l/O fe ro lP na ona of the nature and role of the profession/occupation. io ati iz ss Organ ro fe alP Included among these factors are the scope of ern Ext practice, level of autonomy and control over practice, and intradisciplinary relationships. At the system or external level, the External Figure 1C Professional/Occupational Factors include policies and regulations at the provincial/territorial, national and international level which influence health and social policy and role socializations within and across disciplines and domains. 16  Embracing Cultural Diversity in Health Care Background Context of the Guideline on Embracing Cultural Diversities in Healthcare: Developing Cultural Competence The 21st century brings challenges to Canada that are similar in many ways to those faced by Canadians a hundred years ago. While the future promises a less robust rate of population growth than was the case in 1907, much like that era the bulk of our growth will come from immigration. We differ from our early 20th Century colleagues in that the vast majority of those new immigrants – some 80% – will arrive from non-European countries where most citizens are not white. They will be younger on average than most Canadians, and neither English nor French will be their first language. Why this looming shift matters to the nursing profession is plain. These future Canadian citizens will access our health care system and receive a range of health care services from a variety of health care professionals, many of whom will be nurses. In addition, some of these future Canadians will become the nurses of the next and future generations. They bring with them different cultural norms and traditions, different values and beliefs about health and about illness and its treatment, all of which will influence their views about health care delivery in general, and nursing in particular. While Canada has a long standing multicultural identity and a tradition of acceptance of diversity, reinforced for example by the Federal government’s 1971 Multiculturalism Policy, government intentions have not been sufficient to achieve equity and integration. Racism and cultural oppression have been realities for many minority groups living in Canada, especially the First Nations’ peoples,G with longstanding impacts of poverty, poor health, loss of identity and marginalization.G This realty, a part of all aspects of Canadian society, is clearly evident in our health care work environment. Nurses from visible and non-visible minority groupsG, working across Canada in different health care environments, speak of their experiences of discriminationG and racismG and the challenges of working effectively in such environments. The challenge of diversity, which has been with us for generations, must clearly be addressed for the future such that it is no longer acceptable to engage in practices or tolerate attitudes that limit the potential of many fellow Canadians. This becomes especially important in health care where we face serious recruitment and retention challenges in nursing and other health care professions. This best practice guideline for nurses on cultural diversity provides bold recommendations about actions that can be taken to embrace diversity in the health care work force as part of creating a healthy work environment and a healthy work team. 17 Healthy Work Environments Best Practice Guidelines Cultural diversity in its broadest sense, must be addressed in order to create a truly integrated health care workforce that embraces all types of diversity. Minorities, whether they be Canadians of colour, First Nations’ peoples, physically challenged, homosexual, etc., have made clear that there are ways and times they have felt unwelcome in nursing, in health care and in the workplace. They talk about treatment in the workplace that feels uncomfortable – either due to outward hostility or subtle discrimination. And although the health care workforce is becoming more diverse, this diversity may not always be reflected in senior leadership and middle management levels. What can we do to prepare ourselves to integrate a new and changing workforce? How can we be innovative, welcoming, and responsive, protecting patient safety and integrating new ideas while at the same time maintaining and enhancing the best of what we have? How, indeed, can we create practice settings that embrace and advance the careers of the diverse groups of nurses who are already in the workforce? This best practice guideline includes recommendations related to individuals, organizations and the external system. It is a critical tool that can be used by leaders to better understand and plan work environments that optimize the performance, productivity and satisfaction of every team member. As employers and organizations strive to create meaningful and healthy work places that maximize worker potential, programs that focus on diversity, culture, team work and common values are no longer seen as superfluous offerings targeted to the minority. Such programs promote the full realization of each team member’s potential as the most fundamental underpinning of a healthy and vibrant work environment. Although there are numerous challenges in taking the agenda of embracing diversity forward, inaction is not an option. Attention to this aspect of the work environment is essential for quality health care based on retention of a productive and satisfied team of health care professionals, as well as successful ongoing recruitment. The guideline lays the foundation from which nursing leaders and others can develop a work environment that acknowledges and truly embraces diversity with positive outcomes for patients, nurses and the organization. 18  Embracing Cultural Diversity in Health Care Development of the Guideline While developing this guideline, the expert panel gave careful attention to its title. Diversity is a broad term and can refer to any number of distinct qualities, traits or characteristics – including, but not limited to skin colour, gender, age, race and ethnic identification, citizenship, sexual orientation, and physical and cognitive abilities. For the purposes of this guideline, the definition proposed by Friday was adopted.34 The panel concluded that while embracing diversity is an ideology, cultural competenceG is a skill and is reflected in behaviours. Embracing cultural diversityG in the workplace means a commitment to culturally competent practices that eliminate discrimination and disparity, affirm differences, and actively engage in strategies that draw on the strength of the differences. Cultural competence (see model, Appendix B) ranges on a continuum from eliminating the negative end of destructiveness (racism and abuse) to a positive end, where cultural diversity is valued and has the potential to create innovative, transformative opportunities that maximize health, economic and social benefits. Cultural competence35 in the workplace can be described as a congruent set of workforce behaviours, management practices and institutional policies within a practice setting resulting in an organizational environment that is respectful and inclusive of cultural and other forms of diversity.35 The underlying values for cultural competence are inclusivityG, respect, valuing differences, equity and commitment. These values have been embedded in all recommendations. In reviewing the evidence related to this guideline, including expert opinion and stakeholder feedback, it became clear that there were divergent views and passionate opinions related to a number of issues. The guideline panel of experts concluded that it was important raise these issues and confront present inequities, disparities and gaps in order to challenge the systems and structures that created the current realities. These issues have been grouped under four themes: (1) terminology; (2) out-reach to under- represented groups (targeted recruitment); (3) collecting data in order to identify under-represented groups (measuring diversity); and (4) recruitment and retention of internationally educated nurses. Because these issues have no easy resolution, they have been identified as “thorny issues” and discussion of each has been incorporated into different sections of the guideline. “ Diversity refers to any attribute that happens to be salient to an individual that makes him/her perceive that he/she is Key Values for Cultural Competence 1. Inclusivity ” different from another individual. 2. Respect 3. Valuing differences 4. Equity Friday34 5. Commitment 19 Healthy Work Environments Best Practice Guidelines This guideline provides recommendations that health care professionals in all roles can use to embed work environments with a culture that moves all team members to understand diversity and accept and embrace the differences it brings to work settings. Consistent with the conceptual framework for the Healthy Work Environment Best Practice Guideline programme, the recommendations in this guideline fall into three categories: 1. Individual Recommendations: target the professional behaviors of the individual practitioner and are grouped into those addressing self-awareness, communication and learning new behaviours. 2. Organizational Recommendations: target employers of nurses, unions, and groups of employees (such as in settings where staff are not unionized but may work together on workplace issues). These recommendations are grouped into two sections: recruitment and retention. The retention section is further categorized into recommendations targeting employee orientation and continuing education, workplace policies and practices, and the retention of internationally educated nurses. Note that these recommendations target all settings that employ nurses, including health care organizations and other clinical settings, education settings (e.g., colleges and universities employing nurses as professors), public health and community settings, and professional organizations. 3. External System Recommendations: target education and curriculum, governments, accrediting bodies, regulators, and professional associations that support nurses. Recommendations for academia are further sub-divided into those addressing students and faculty, and curriculum. Each of the above sections is introduced with a background statement and includes recommendations and the related supporting evidence. Terms and phrases marked with the symbol “G” are defined in the Glossary Appendix A. Thorny Issue: Terminology Terminology in this guideline is a thorny issue since the choice of terminology used to distinguish groups of persons can be personal and contentious, especially when the groups represent differences in race, gender, sexual orientation, culture or other characteristics. Throughout the development of this guideline the panel endeavoured to maintain neutral and non-judgmental terminology wherever possible. Terms such as “minority”, “visible minority”, “non-visible minority” and “language minority” are used in some areas; when doing so the panel refers solely to their proportionate numbers within the larger Canadian population, and infers no value on the term to imply less importance or less power. In some of the recommendations the term “under-represented groups” is used, again, to refer solely to the disproportionate representation of some Canadians in those settings in comparison to the traditional majority. 20  Embracing Cultural Diversity in Health Care Conceptual Framework for Embracing Cultural Diversity in Health Care: Developing Cultural Competence Guideline The conceptual Model for Healthy Work Environments for Nurses was used in organizing the recommendations, based on the early literature review. However, the expert panel conceptualized a companion framework to guide the subsequent systematic literature review and analysis. The major precept of the framework is that outcomes, whether related to individuals, patients, groups or organizations, are influenced by four variables: OUTCOMES Figure A 1. External characteristics such as globalization of society and the Individual, Patient, Group,Organizatinal market place, the international workforce, multiculturalism policies, human rights legislation and the overarching nursing shortages. INDIVIDUAL CHARACTERISTICS 2. Organizational characteristics such as the diversity climate in the workplace. 3. Group characteristics, such as diversity within the group, GROUP CHARACTERISTICS Diversity within group the culture of inclusion within the group, communication skills, Culture of Inclusion Communication/Knowledge Exchange and knowledge exchange between the members of the group. 4. Individual characteristics such as cultural background, beliefs, values, and ethnicity. ORGANIZATIONAL CHARACTERISTICS Diversity Climate These variables are linked together and to outcomes by the “linking themes” noted in the Figure A and B. External Characteristics Figure B EXTERNAL CHARACTERISTICS Globalization of society and marketplace Organizational Characteristics International workforce Multicultural policy Group Characteristics Human rights Legislation Nursing Shortage Individual Characteristics Outcomes Linking themes [ ] 1. Accountability mechanisms to embrace and sustain diversity 2. Culturally competent practices 3. Benchmarks and indicators 4. Guidelines and standards 21 Healthy Work Environments Best Practice Guidelines Sources and Types of Evidence on Embracing Cultural Diversity in Health Care: Developing Cultural Competence Evidence-based decision-making has become the generally accepted standard for health care practices and policies. However, it must be acknowledged that the term itself is open to multiple interpretations and perspectives. The World Health Organization defines evidence as “findings from research and other knowledge that may serve as a useful basis for decision making in public health and health care.”36 “ Evidence is inherently uncertain, dynamic, complex, contestable, and rarely complete. Canadian Health Services Research Foundation36 ” While the desire to extend the guidance offered by evidence-based clinical practice to health services management is admirable, it has been argued that honouring or valuing research evidence over organizational and political evidence can be problematic. In a report on conceptualizing and combining evidence for health systems guidance, the Canadian Health Services Research Foundation (CHSRF) notes that evidence can be either colloquial or scientific. Colloquial evidence can be described as the “expertise, views, and realities of stakeholders”36 and includes evidence about resources, expert and professional opinion, political judgment, values, as well as the particular pragmatics of the situation. Day-to-day health care decisions are predominantly guided by colloquial evidence. Different types of evidence can be combined by the process of deliberation. A deliberative process is an integration of the technical (or research) analysis and stakeholder deliberation (expert panel consensus) and is desirable when the issues at stake are debatable. The process has clear objectives: is inclusive and transparent; challenges science; promotes dialogue between parties; and promotes a consensus about the potential decision. A deliberative process is different than a consultative process and reflects participation of the stakeholders. The intended outcome is balanced consensus, which “respects both scientific integrity, on the one hand and its implementability in a specific health system context on the other. Balanced consensus is obtained by careful consideration of all relevant evidence, and involving a good range of those best qualified to assess it and those most likely to be affected by it.”36 “ Colloquial evidence can complement or substitute for missing scientific evidence on context Canadian Health Services Research Foundation36 ” 22  Embracing Cultural Diversity in Health Care Perhaps for all these reasons, Davies37 inserts a note of caution into talk of “best” practices, a term laden with subjectivity, and argues that a more realistic hope is to discover and share “promising” practices. With respect to governments, he warns that “evidence-based government is no substitute for thinking-based government.” That same warning holds true for health care decision-making. Development of healthy work environments needs to reflect promising practices that are continuously evolving based on critical thinking and analysis of the specific environment. Even during the time this guideline was being prepared, the accepted wisdom about evidence had begun to shift from “evidence-based” decision-making to “evidence-informed” decision-making.36 This change recognizes some of the very real challenges of defining evidence and then deciding what is the “right” evidence in a given situation. It also acknowledges that the kind of evidence traditionally accorded the highest value – i.e. the results of rigorous, randomized controlled trials – does not represent the only, or best way of understanding a particular phenomena. Furthermore, many phenomena, including diversity and cultural competence, could not be studied using a randomized trial methodology. Evidence-based practice can be described as a problem solving approach to clinical practice that integrates the conscientious use of best evidence with a clinician’s expertise as well as patient preferences and values to make decisions about the type of care that is provided.38 In other words the context and fit is critical to evaluating and utilizing evidence in practice. The context of diversity varies across the province (for example urban or rural) and across the nation. This must be considered in determining applicability of the evidence and recommendations to particular areas of practice. These guidelines are a result of the systematic review conducted by the Joanna Briggs Institute (JBI), qualitative data review, extensive dialogue and debate within the expert panel, and feedback from a team of external reviewers. Due to a paucity of research on diversity, cultural competence and healthy work environments, logical inferences have been drawn from the literature from cultural competence in clinical practice where appropriate. The expert panel was composed of individuals within the nursing profession representing diversity in ideology related to the concepts of culture and diversity as well as diversity with respect to role and domain within the profession (education, policy, practice, administration and research, across clinical specialties), geography, and cultural identities including age, gender, education, race, ethnicity, sexual orientation and First Nations’ people status. An outline of the process used in the development of this guideline is presented in Appendix C. Sources of Evidence Many sources of evidence are available. Klein36 discusses three types of evidence: research, organizational, and political. The latter two are aimed at organizational capacity and implementation. Current practice in creating best practice guidelines involves identifying the strength of the supporting evidence.39 Prevailing systems of evidence grading assess systematic reviews of randomized controlled trials (RCT) as the “gold standard” for evidence with other methods ranked lower.40 However, not all questions of interest are amenable to the methods of RCT particularly where the subjects cannot be randomized or variables of interest are pre-existing or difficult to isolate. As well, not all questions are focused on cause and effect relationships. Therefore there is no single leveling system that fits all types of questions and evidence. While a systematic review or meta analysis of all relevant randomized controlled trials is the most desired type of 23 Healthy Work Environments Best Practice Guidelines evidence for research questions concerned with a causal relationship, they are among the least desired when the research question requires understanding of experiences. The highest level of evidence in this situation is the evidence obtained from systematic reviews of descriptive and qualitative studies.41 For this reason these guidelines do not include a rating system. The literature on embracing diversity in health care consists largely of descriptive, qualitative studies, opinions, experience-based, and narrative reports based on program evaluations. The panel also relied on documents and reports from programs in the United States, Australia, UK, and Canada as well as first hand experiences of panel members in implementing cultural competence or diversity related initiatives in education, practice, and policy settings. “ Evidence is information that comes closest to the facts of a matter. The form it takes depends on context. The findings of high-quality, methodologically appropriate research are the most accurate evidence. Because research is often incomplete and sometimes contradictory or unavailable, other kinds of information are necessary supplements to, or stand-ins, for research. The evidence base for a decision is the multiple forms of evidence combined to balance rigour with expedience – ” while privileging the former over the latter. 42 24  Embracing Cultural Diversity in Health Care Key Messages and Themes from the Systematic Literature Review Key messages that emerged from themes identified from the systematic literature review conducted by the Joanna Briggs Institute40 for this Best Practice Guideline are: 1. Practitioner Skill Set Cultural competence is a mandatory skill set for all health care providers. Health care professionals need to attain appropriate skills in order to embrace diversity and practice competently with diverse groups. 2. Workforce Diversity Recruiting and retaining staff to achieve diversity in the workforce can benefit not only the health care professional in the delivery of culturally competent careG but also minority groups in the care they access and receive. Organizations should implement processes to assist with ensuring workforce diversity exists in all roles, at all levels, and is maintained. Diversity in the workforce was suggested to positively impact on culturally diverse groups.40 3. Systems and Supports Embedding cultural competence processes and practices within organizational structures and curricula will promote the development of cultural competence. Cultural competence was shown to be an ongoing process that was required to be embedded into organizational processes. A need was identified to establish a defined set of protocols and guidelines to support cultural competency and that these practices should be based on the best available evidence. 4. Decision Support Systems and Practice Improvement Utilizing indicators related to an organization’s diversity climate is critical to measuring success and determining accountability for embracing diversity. There was an identified need to measure success of specific strategies with ongoing monitoring of indicators that are reported and utilized to make decisions for subsequent actions and approaches. 5. Education and Training Undergraduate and graduate education and lifelong learning within practice settings must embed the principles of cultural competence throughout the learning process. There was an identified need for health care professionals to receive education and training in cultural competency to prepare them to care for and address the needs of culturally diverse groups. It was identified that education and training should exist in initial curricula and continue through staff development processes offered by organizations. 6. Collaboration Organizations that promote collaboration and work collaboratively with each other will improve services for culturally diverse populationsG and contribute to a work environment that embraces diversity. Collaboration between health care providers and other agencies was indicated to improve care to culturally diverse patient groups. An increase in collaboration between health care providers and culturally diverse groups and their communities could also improve services and workforce productivity and satisfaction. 25 Healthy Work Environments Best Practice Guidelines Overall Goals and Objectives The focus of the Healthy Workplace Environment Best Practices Guidelines (HWE BPG) project is on creating healthy work environments for nurses which will impact on patients and organizations. Therefore, the Embracing Cultural Diversity in Health Care: Developing Cultural Competence BPG does not focus directly on cultural competence as it relates to patients, but rather on cultural competence as it relates to the workplace and workforce. Overall Goal and Objectives To promote a healthy work environment for nurses by identifying best practices for embracing diversity within health care organizations. The goal is achieved through these objectives: 1. Identify culturally competent practices that enhance outcomes for nurses, organizations and systems. 2. Identify organizational values, relationships, structures and processes required for developing and sustaining culturally competent practices. Purpose and Scope This guideline addresses: Knowledge, competencies and behaviours that exist in culturally competent workplaces Indicators and features of culturally competent practice settings Organizational values, relationships, structures and processes that support development of culturally competent practices Learning and development required to develop, support, and sustain culturally competent practices Behaviours and practices that reflect cultural awareness and serve as facilitators to embracing diversity in the workplace The recommendations in this guideline address: Culturally competent practices in the workplace Individual competencies, management practices and institutional policies that reflect culturally competent practices Transformational strategies for embracing diversity at the level of the individual, group, organization, and health care system Educational requirements and strategies to ensure a culturally competent workforce Policy changes to support and sustain culturally competent practices Future research opportunities Target group: The guideline is relevant to all domains and settings where nurses practice. 26  Embracing Cultural Diversity in Health Care How to Use this Document The guideline provides a comprehensive approach to embracing cultural diversity through developing cultural competence. It is not intended to be read and applied all at once, but rather, to be reviewed and with reflection over time, applied as appropriate for yourself, your situation or your organization. We suggest the following approach: 1. Read the recommendations. 2. Decide on an area of focus: Identify an area for yourself, your situation, or your organization that you believe needs attention to strengthen cultural competence. 3. Critically reflect on your own assumptions regarding diversity and views of differences 4. Develop a tentative plan: Having selected a small number of recommendations and behaviours for attention, turn to the table of strategies and consider the suggestions offered. Develop a plan to address your area of focus. (See Appendix F) 5. Discuss the plan with others: Take time to solicit imput from people whom it might affect, or whose engagement will be critical to success and from trusted advisors, who will provide feedback on the appropriateness of your ideas. Remember to seek out perspectives that will be different from yours. 6. Identify resources for development: Consider the resources within your organization. If you need more information, you may wish to refer to some of the references cited or to explore some of the models identified in Appendix B, tools suggested in Appendix F, and/or ideas for implementation in Appendix F. 7. Get started: It is important to get started and make adjustments as you go, if necessary. The development of cultural competence is a life-long quest that offers many opportunities for personal and professional growth and enrichment; enjoy the journey! 27 Healthy Work Environments Best Practice Guidelines Individual Context: Best Cultural Competence Practices Introduction The concept of cultural competence is based upon a respect for others and a search to find greater meaning in how we can live and work together with ease and understanding. “ Whether or not an employer has embraced cultural competency, change must begin with each individual. Each of us must serve as culturally competent role models and share our skills and knowledge with others. We must engage others in discussions and challenge questionable ” behaviours or institutional practices. French43 Broadly defined, culture is made up of learned and transmitted beliefs, as well as information and values that shape attitudes and generate meaning among members of a social group.44 An individual’s culture is influenced by many factors, such as race, gender, religion, place of birth, ethnicity, socio-economic status, sexual orientation and life experience. The extent to which particular factors influence a person varies. Although the definition of culture is broad and includes values and beliefs, for the purposes of this guideline, the demographics of cultureG that are important to monitor include, but are not limited to, age, gender, ethnocultural identification, first language and sexual orientation. Cultural competence is a continuous process of effectively developing the ability to work within the cultural context of community, family and individuals from a diverse cultural and ethnic background.45 Caring is often called the key attribute of being a nurse and is not limited to interactions with clients. Developing collegial and collaborative relationships with each other is an expression of caring. Developing cultural competence means that the health professional becomes aware of one’s own cultural attributes and biases, and their impact on others. Understanding one’s own worldview and that of the “other,” avoids stereotypingG and the misapplication of scientific knowledge. It is unrealistic to expect any one individual to have consummate knowledge of all cultures and it is unreasonable to expect that all members of any one group will behave the same way in any situation. However, it is possible to obtain a broad understanding of how cultures can affect beliefs and behaviours including beliefs and behaviours that relate to how care is provided. It is an incorporation of respect, acceptance and a willingness to be open and learn from new ways of being and interacting with one another, rather than following a menu of cultural competence activities as outlined in a policy manual. 28  Embracing Cultural Diversity in Health Care As Canada becomes more diverse, so must its health care system. Men and women from all cultures need to be recruited and welcomed into a profession that is committed to the care of others. Through our actions and interactions we can support and learn from these diverse groups to create an environment that capitalizes on diversity and furthers the profession and the broader health care system. In striving towards developing quality professional practice environments, welcoming cultural diversity and enveloping cultural competence provides not only a rich environment in which to work and care for diverse populations, but also provides hospitals and other work places a competitive edge as they seek to recruit and retain staff. “ To care for someone, I must know who I am. To care for someone, I must know who the other is. To care for someone, I must be able to bridge the ” gap between myself and the other Jean Watson, cited by J. Anderson46 29 Healthy Work Environments Best Practice Guidelines Individual Recommendations For each individual, embracing diversity means development of the following competencies and behaviours. Tools to assist in developing these skills are suggested in Appendix E. RECOMMENDATION 1. Self Awareness – To learn to embrace diversity in individuals: 1. Perform self-reflection of one’s own values/beliefs, incorporating feedback from peers. 2. Express an awareness of one’s own views of differences among people (e.g. different opinions, different world views, different races, different values, different views of society). 3. State and continually explore, through reflection and feedback, how one’s own biases, personal values, and beliefs, affect others. 4. Identify cultural differences among clients and colleagues in the practice setting. 5. Acknowledge one’s own feelings and behaviours toward working with clients, families and colleagues who have different cultural backgrounds, health behaviours, belief systems, and work practices. 6. Explore one’s strategies for resolving conflicts that arise between self and colleagues and/or clients from diverse groups. 7. Identify and seek guidance, support, knowledge and skills from role models who demonstrate cultural proficiency.G 8. Recognize and address inequitable, discriminatory, and/or racist behaviours or institutional practices when they occur. 9. Acknowledge the presence or absence of individuals from diverse cultural backgrounds at all levels in the workplace, reflecting the cultural makeup of the clients or community being served. 10. Reflect and act on ways to be inclusive in all aspects of one's practice. 2. Communication – To develop communication skills that promote culturally diverse settings: 1. Are aware of different communication styles and the influence of culture on communication. 2. Are aware of one’s preferred communication style, its strengths and limitations, and how it affects colleagues and recipients of care. 3. Seek feedback from clients and colleagues, and participate in communication validation exercises (e.g. role-playing exercises, case studies). 4. Use a range of communication skills to effectively communicate with clients and colleagues (e.g. empathetic listening, reflecting, non-judgmental open-ended questioning). 5. Seek and participate in learning opportunities that include a focus on communication and diversity. 30  Embracing Cultural Diversity