Culturally Sensitive Practice and Leadership

Culturally Sensitive Practice and Leadership Culturally Sensitive Practice and Leadership Discuss what it means to provide culturally sensitive services to clients, or culturally sensitive leadership practices to people within an organization. Using the MHHS Case Study identify an issue in the case that lacks a culturally sensitive approach. As either a health and human services provider or leader, how would you address this issue? Clearly identify the practices you would put in place. Your initial post should contain a minimum of 400 words. HHS497 Culturally Sensitive Practice and Leadership hhs497_discussion.docx health_workforce_cultural_competency_interventions_a_systematic_scoping_review.pdf recognizing_the_complexity_of_cultural_identifications.pdf mhhs_case_study.docx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS HHS497 Culturally Sensitive Practice and Leadership. DISCUSSION 1 Culturally Sensitive Practice and Leadership Prior to beginning work on this discussion forum, review the resources listed below: • • • • Recognizing the Complexity of Cultural Identifications Health Workforce Cultural Competency Interventions: A Systematic Scoping Review Cultural Competence (Links to an external site.) Cultural Competence (Links to an external site.) Discuss what it means to provide culturally sensitive services to clients, or culturally sensitive leadership practices to people within an organization. Using the MHHS Case Study identify an issue in the case that lacks a culturally sensitive approach. As either a health and human services provider or leader, how would you address this issue? Clearly identify the practices you would put in place. Your initial post should contain a minimum of 400 words. My career of choice is Guidance Counselor See attachments Jongen et al. BMC Health Services Research (2018) 18:232 RESEARCH ARTICLE Open Access Health workforce cultural competency interventions: a systematic scoping review Crystal Jongen1,2* , Janya McCalman1,2 and Roxanne Bainbridge1,2 Abstract Background: Addressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. Research evidence in this area is primarily focused on cultural competency training and its effects on practitioners’ knowledge, attitudes, skills and behaviour. While improvements in measures of healthcare practitioner cultural competency and other healthcare outcomes have been reported, there are concerns around evidence strength and quality. This scoping review reports on the intervention strategies, outcomes, and measures of included studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence. Methods: This systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce. Results: There was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes. Conclusion: Training and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. However, the effects of interventions beyond practitioner knowledge and attitudes remains unclear. Assessment of practitioner behavioural outcomes as well as measures of intervention impact on healthcare and health outcomes are needed to build a stronger evidence base. Keywords: Cultural competence, Indigenous, Ethnic minorities, Cultural competence training, Health workforce development * Correspondence: 1 School of Health, Medicine and Applied Sciences, Central Queensland University, Cnr Shields and Abbott Streets, Cairns, QLD 4870, Australia 2 Centre for Indigenous Health Equity Research, Central Queensland University, Cnr Shields and Abbott Streets, Cairns, QLD 4870, Australia © HHS497 Culturally Sensitive Practice and Leadership The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated. Jongen et al. BMC Health Services Research (2018) 18:232 Background While there is no doubt about the central role of culture in health and health care [1] the concepts of culture, cultural difference and cultural competence are complex and can be difficult to define [2]. Many varied definitions are used to describe cultural competence; one definition commonly used was provided by Cross, Bazron, Dennis and Isaacs (1989) [3]. Cross et al. define cultural competence as “a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or professions to work effectively in cross-cultural situations” (p. iv) [3]. This definition accounts for a range of intervention approaches which are used to improve the cultural competence of healthcare systems. One key approach to improving overall health care cultural competence is to develop the capacity of the health workforce to practice in a culturally competent manner. Health professionals play a key role in determining the nature of interactions and patient experiences when accessing health care. Cultural and linguistic differences between healthcare providers and health service users can results in significant miscommunication [4], as well as service user mistrust [5], decreased satisfaction and disempowerment [6]. In contrast, practitioners’ increased cultural competence has been linked to increased patient satisfaction [7, 8], treatment adherence [9] and information seeking and sharing [8]. It is perhaps due to the key role that health practitioners play in determining the health care experiences of patients that improving health workforce cultural competency is one of the oldest and most predominant of cultural competence strategies [10, 11]. The general focus of cultural competence workforce interventions has been on educating and training the health workforce in the requisite and relevant knowledge, attitudes, and skills needed to effectively respond to sociocultural issues arising in clinical encounters [11]. Cultural competence training can include: understanding the central role of culture in all lives and how it shapes behaviour; respect and acceptance of cultural differences; learning to effectively utilise culturally adapted and culturally specific practices; and, continuous development of ones awareness of personal cultural influences and prejudices or biases [12–15]. Cultural competence training has mostly focused on developing knowledge, attitudes, awareness and sensitivity of those working in healthcare. However, the literature reiterates the need to reach further than this, and focus on teaching the skills needed to translate knowledge and awareness into tangible practitioner behaviours which can be consistently applied and assessed in healthcare encounters and settings [3, 10, 15, 16]. Different approaches to cultural competence training have been adopted over the years. Historically, there has been a greater focus on categorical approaches that involve Page 2 of 15 teaching health providers information about particular cultural, ethnic or racial groups. Such approaches describe common health beliefs, attitudes and behaviours of particular groups and offer prescriptive advice about what to do and what not to do in clinical encounters [11]. Nevertheless, it has been acknowledged that categorical approaches are insufficient and problematic for numerous reasons. To begin with, the categorical approach is critiqued for misrepresenting and oversimplifying the concept of culture as fixed and static [17] rather than a fluid and dynamic phenomenon in a process of constant change and adaptation [16, 18, 19]. HHS497 Culturally Sensitive Practice and Leadership# Furthermore, the significant cultural, religious, ethnic and national diversity present in many countries means that it is not feasible to be familiar with all cultural perspectives practitioners may encounter [11, 18, 20]. Categorical approaches to cultural competence training may lead to stereotyping which can in fact increase cultural misunderstanding [11, 17, 20]. Such approaches have also been criticised for giving little attention to intra-group variability [19] and for failing to account for the ways in which acculturation and socioeconomic status effect different individuals ways of expressing and experiencing their culture [11]. Another key approach to cultural competence education and training which addresses some of the concerns identified with categorical approaches is the cross-cultural approach. A cross-cultural approach to cultural competence education and training is focused on teaching general knowledge, attitudes and skills relevant to navigating any cross-cultural situation [11, 18]. Some of these skills and attitudes were outlined by pioneers in cross-cultural medicine such as Berlin and Fowkes [21], Kleinman [22] and Leininger [23], and include: eliciting patients’ explanatory models of health issues and their causes; strategies for negotiating shared understanding and facilitating participatory decision-making in creating treatment plans; and understanding health and illness in its biopsychosocial context [18, 20]. As well as being applicable in clinical encounters with patients from varied cultural and ethnic backgrounds, such approaches have the advantage of being focused on specific skills that can be applied in healthcare encounters. Cultural competence interventions have come to be considered a key strategy towards addressing racial and ethnic healthcare and health disparities that exist across Canada, Australia, New Zealand, the United States (hereto referred to as the CANZUS nations) [24]. For example, the release of Unequal Treatment in 2002 by the United States (U.S.) Institute of Medicine revealed the critical disparities in the quality of health care received by ethnic and racial minorities [25] and established cultural competence training for healthcare professionals as an important step in addressing these pervasive disparities [18, 26]. As a result, factors besides cultural differences and cultural barriers came to be included in the discourse and scope of cultural Jongen et al. BMC Health Services Research (2018) 18:232 competence. These factors include patient mistrust of health practitioners and systems because of historical and contemporary experiences of discrimination and provider bias towards minority groups [20]. Cultural competence training can include developing an awareness of issues of gender, sexuality, and those such as racism, health practitioner and system bias and mistrust [18, 20]. Critical reflection on practitioner perspectives is also advocated. This includes critically reflecting on and acknowledging the limitations of “medico-centric” frameworks and the effects of dynamics of power and privilege associated with professional status [20]. Positive outcomes have been reported from cultural competency interventions targeting the health workforce, particularly for practitioner outcomes. In their literature review on educational interventions to improve the cultural competence of health care providers, Beach et al. [27] found excellent evidence of improved practitioner knowledge and good evidence of improved practitioner attitudes and skills . However, there is less evidence generally for the impacts of cultural competence education and training interventions on the patient healthcare and health impacts so crucial for determining broader intervention effectiveness. For example, in their review Beach et al. [27] found some evidence for effects of cultural competence education interventions on patient satisfaction. However, poor evidence was found for patient adherence and no health outcomes were reported. Lie et al. [28] reviewed cultural competency workforce interventions that included measures of health outcomes. HHS497 Culturally Sensitive Practice and Leadership Although seven studies were found, the studies were of low to moderate methodological quality and showed limited evidence of a positive relationship between cultural competency training initiatives and improved health outcomes. This paper was developed as part of a broader review of cultural competency interventions in health care for Indigenous peoples and other minority ethnic/cultural groups in the CANZUS Nations [24], the findings of which have been published in our book [2]. The aim of the larger review was to assess the intervention strategies and measures used to increase cultural competence in health care in the CANZUS nations, along with the outcomes reported for these interventions. These countries were selected due to the commonalities in population health and colonial history that exist across these four settler countries [29, 30]. Several reviews have addressed common issues across the CANZUS nations, reporting particularly on Indigenous health issues [31, 32]. The larger review looks at various cultural competence interventions across multiple healthcare system levels or components. This paper is distinguished from this larger review in that it provides a detailed and evidence-based review of the findings specific to health Page 3 of 15 workforce interventions, a discreet and unique approach to increasing cultural competence in health care. In this article, we contribute to the existing literature base by providing a systematic scoping review of studies on workforce cultural competency education and training interventions from 2006 to 2015. Its purpose is to inform the implementation and evaluation of future interventions to improve the cultural competence of health professionals. In particular, this review aims to: Examine the definitions of culture, cultural difference and cultural competence adopted by the included studies; Examine the intervention strategies utilised by studies; Report on the measurement approaches taken to evaluate interventions; Examine the reported outcomes of included studies. Methods As this review was completed as part of a larger systematic review, details on the inclusion/exclusion criteria, search strategy, identification, screening and inclusion of publications, as well as data extraction and analysis processes used in the broader systematic review have been reported elsewhere [2, 33, 34]. To summarise briefly, the review included peer-reviewed and grey literature published in English from January 1st 2006 to December 31st 2015. Included publications were those which evaluated an intervention designed to improve cultural competence in healthcare for Indigenous or other racial or ethnic minority groups in Australia, Canada, New Zealand or the United States (see Additional file 1 for an overview of the search strategy). Our comprehensive, six step search strategy and blinded screening process resulted in 64 studies for inclusion in the review (see Fig. 1 for PRISMA search strategy flow chart). Data was extracted for all included studies (see Additional file 2) and the quality of included studies were assessed using the Effective Public Health Practice Project (EPHPP) [35] and Critical Appraisal Skills Programme (CASP) quality assessment tools [36]. The 64 studies found were organised according to the healthcare level or component being addressed. The authors identified four primary cultural competence intervention categories including: health workforce development (n = 16, 25%); student education and training (n = 16, 25%) [37]; programs and services (n = 22, 34%) [33], and; health organisations and systems (n = 10, 16%) [34] (see Fig. 2). The 16 evaluated interventions that aimed to increase cultural competency through health workforce development are reported in this paper. Jongen et al. BMC Health Services Research (2018) 18:232 Page 4 of 15 Fig. 1 PRISMA search strategy flow chart Results Definitions of culture, cultural difference and cultural competence Across all included studies, none provided a definition of culture and only three provided a definition of cultural competence [38–40]. Although sharing some commonalities, all three definitions of cultural competence were distinct.HHS497 Culturally Sensitive Practice and Leadership There were also dissimilarities in the primary cultural differences discussed across studies which justified the need for cultural competence. Some included studies discussed cultural differences as distinctions in understandings of health that exist among different population groups, for example the holistic understandings of health held by Indigenous people and how this differs from mainstream approaches to health [41, 42]. Other studies discussed communication issues related to language discordance and cultural differences and how these affect clinical encounters, particularly for Hispanic populations in the United States [43–45]. Intervention strategies Fig. 2 Cultural competence interventions by targeted healthcare level Across the included studies, diverse intervention strategies were used to address cultural competence at the workforce level. The two primary workforce strategies were cultural competency training interventions and professional development interventions aimed at improving the cultural competence of health services and practitioners. There was a significant variation in focus, content, mode Jongen et al. BMC Health Services Research (2018) 18:232 of delivery and duration of interventions within these two primary strategies. There was also heterogeneity in the outcomes reported across the studies. The most common outcomes were for practitioner related cultural competence, along with some healthcare process and health outcomes. See Table 1 for a detailed summary of intervention strategies and outcomes of included studies. Page 5 of 15 frequency and duration of cultural competency training interventions that an analysis of outcome effects related to course duration cannot be provided. Study quality When assessing for study quality, ten of the 16 studies were found to be weak (63%), four moderate (25%) [38, 41, 47, 50] and two strong [43, 49]. Cultural competence training Eleven of the 16 studies reviewed (69%) provided cultural competence training to the health workforce as the primary intervention. The different approaches to cultural competence training and education discussed previously were reflected in the reviewed studies. Five reported interventions employed a cross-cultural approach focused on teaching broadly applicable knowledge and skills for cultural competence [40, 46–49]. Six interventions utilised a categorical approach, teaching practitioners about certain characteristics, beliefs and behaviours of relevant populations [38, 43–45, 50, 51]. Three studies using categorical approaches focused on Indigenous Australians [38, 50, 51], and three were specific to Latin American peoples [43–45]. Two cultural competency training interventions also included some degree of Spanish language training [43, 45]. See Table 2 for summaries of cultural competence workforce training approaches. Intervention outcomes After cultural competence training, the next most common intervention type was professional development. Professional development interventions used both training and mentoring/supervision to increase the cultural competence of the health workforce. 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