REVISION 8

Cultural Competence Training Program For African Immigrants

Chidinma Ogundu

Touro University Nevada

DNP 763: DNP Project II

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

Dr. Calaiselvy Elumalai

Dr. Jessica Grimm

September 24, 2021

Cultural Competence Training Program For African Immigrants

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

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

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

Background

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

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

Problem Statement

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

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

PICOT Question

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

Literature Review

Search Methods

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

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

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

Review Synthesis

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

Review of Study Methods

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

Literature Themes

Effects of Cultural Incompetence

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

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

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

Language Barriers and Cultural Competence

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

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

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

The Impact of Cultural Competence Training On Health Care Workers

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

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

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

National Guidelines

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

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

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

Aims of the Quality Improvement Project

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

Objectives

The objectives of this project are:

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

2. To create an African Immigrant Cultural Competence Toolkit that will be used by care providers to assess and enhance cultural competence in the organization.

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

Conceptual Model: Madeleine Leininger's Cultural Care Theory

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

Historical Development of the Theory

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

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

The Major Tenets

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

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

Theory Application to the DNP Project

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

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

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

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

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

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

Setting

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

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

Population of Interest

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

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

Stakeholders

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

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

Interventions

The activities of the project will be conducted during the regular working hours. The project lead will be available to assist the medical providers any questions about the AICCT tool Communication with the staff will be through physical means and phone calls or emails as needed. The following is a weekly timeline of the implantation.

Week 1

In the first week, a pretest located in Appendix E will be administered. This will be done a day before an educational training. The educational training will then be conducted the next day using the PowerPoint presentation material in Appendix D. The educational training session will be brief and to the point and will touch on all issues that concern cultural competence when handling the African immigrant group. One detailed session will be enough although the progress will be monitored to identify any need for an additional training session. The session will also include training the participants on how to use the African Immigrant Cultural Competence Toolkit (Appendix B). It will also include training the staff on how to use the African Immigrant Resources Toolkit (Appendix C). After the session, both toolkits will be handed to the participants. Additionally, a post-test will be administered after the educational training session. The post test will be done using the material in Appendix E, a pass grade of 80% is required. The goal is to determine how the participants perform in the test before the training and after the training has taken place. A remediation class will also be conducted for participants with a grade less than 80 on the posttest.

Week 2 to 4

The resources toolkit will be handed to the patients as they visit the clinic. There will be continued education and support to the participants to ensure efficiency of the progress. Participants will make use of the toolkit handed to them, data collection and assessment of compliance will be done at the end of each week to ensure that any loopholes are identified and any additional support is identified as well. Participants will be re-trained if needed.

Week 5

In week 5, data compilation will be done and its analysis will follow. The success of the project will be measured by the rate at which the resources toolkit were handed out to African immigrants and the rate at which the providers utilized the African Immigrant Cultural Competence Toolkit while interacting with African immigrant patients. The approach for measuring these rates is outlined in the Chart Audit Tool (Appendix F).

Tools

The tools that will be used during this DNP project include the AICCT, AIRT, educational presentation, pretest/posttest questionnaire and chart audit tool. The following is an explanation of each tool.

This is a one-page guideline that acts as a reference point for the African immigrants cultural competence issues. The guideline has cultural issues, their descriptions, and the solutions. It is to be handed to the healthcare providers. The toolkit is developed by the project lead and will utilize project team consultation for validation. The tool was developed based on evidence-based research about the main cultural competence issues and solutions involved when handling the African immigrant population and the sources are listed in the references.

African Immigrant Resources Toolkit (Appendix C)

This is a one-page toolkit with information about the food assistance, legal services, housing services, employment, financial, and health resources and where they can be found. It is to be handed to the patients during their visits to the clinic. It is developed by the project lead and will utilize project team consultation for validation. The tool was developed based on evidence-based literature identifying these resources as primary needs of African immigrants. These resources are important because they play a huge role in the social determinants of health of the African immigrant population. These resources impact the environment and manner in which the African immigrants live and work, which in turn impacts their health outcomes.

Educational Presentation (Appendix D)

This is a power point presentation educational material that will be used for the training session. It is developed by the project lead and will utilize the project site and team for consultation and validation before seeking approval. The material is based on evidence-based literature regarding the cultural competence of African immigrants in healthcare. The material addresses the meaning of cultural competence for African immigrants, its importance, and expected impacts. The material also addresses the main challenges faced by African immigrants in healthcare and their solutions. It addresses the objectives of this project and the interventions for achieving these objectives.

Pre and Post Test Questionnaire (Appendix E)

This is a tool used to assess the healthcare professionals’ level of cultural competence regarding the African immigrant group (see Appendix E). It is developed by the project lead and will require expert and project team consultation for validation. The tool is developed based on the objectives of the project and the educational material used in the educational training session. The tool contains 10 questions and each of the question addresses specific content while testing a specific level of cognitive skill. The test is in a multiple-choice question format. Three experts will rate the relevance of each item on the test using the Expert Rating Form (see Appendix F). This data will then be used to calculate the validity of the tool.

Chart Audit Tool (Appendix F)

This is a tool for auditing the rate that the handout of resources was provided to African immigrant patients and the rate at which the providers utilized the African immigrant toolkit when interacting with the patient. Guidelines on how these rates will be calculated are provided in the tool (see Appendix F). The tool is developed by the project lead and will require experts and project team consultation for validation.

Because of the sensitivity of data in health care, the data collection procedures will follow strict guidelines in order to protect patients' privacy and confidentiality. These data collection procedures will also aim to ensure that only data required for this project is collected and no unauthorized parties have access to this information. Anonymity of the data will also be upheld for preserving identities, locations, and addresses as private (Martinez et al., 2018). As mentioned above, the first data collection segment will be the pre-survey about the cultural competence of the participants. This will be administered a day before the educational presentation and will be stored in digital form to prevent manipulation of data. On the following day, the educational training on cultural competence via a PowerPoint presentation will be conducted by the project lead. This educational training will include information regarding the purpose, goals, expected outcomes, and the flow of activities of the project. A post -survey will be administered after the session and the data will be collected. The surveys will have a label with the names of each participant, but they will be recorded using unidentified initials for privacy and confidentiality (Martinez et al., 2018). Comment by Elumalai, Calaiselvy - SRDH: Add: The Health Insurance Portability and Accountability Act (HIPAA) rules will be maintained during the extraction of information from the chart audit. Comment by Elumalai, Calaiselvy - SRDH: You also should tie this back to your objectives. Plan for data collection aligns with project aims and objectives in full.

At the end of the educational training session, the participants will receive both the resources toolkits that they will hand to patients visiting the clinic and the developed cultural competence toolkit that will act as a guideline as they attend to the patients. The intervention will then begin and there will be data collection at the end of every week. The data collected will include information regarding whether the African immigrant patients visiting the clinic have been given the resource toolkit and whether the participants are using the cultural competence guideline tool handed to them. This data will help to understand which additional support is needed and how issues arising during the intervention can be addressed. Finally, upon the completion of the project implementation, data analysis will be conducted using the audit tool (appendix F). Comment by Elumalai, Calaiselvy - SRDH: You are not allowed to interact with patients as a DNP student. Who validates the providers’ utilization of the toolkit? Comment by Elumalai, Calaiselvy - SRDH: Are you planning to consult a statistician to ensure appropriate statistical testing is utilized?

Ethics/Human Subjects Protection

After reviewing Touro University DNP Project Determination document, it was determined that the project is a Quality Improvement project and not a research project. Therefore, this means that there is no need for an Institutional Review Board committee, as it meets the minimum requirements for a quality improvement project. However, the DNP project will uphold the highest standards of ethical practice, inclusive of issues regarding confidentiality and privacy as required by the code of ethics. As described above, each phase of the DNP project implementation will be carried out in a way that addresses key confidentiality and privacy issues to ensure compliance by the required standards. Some techniques that will be used include the removal and destruction of data identifiers for keeping the information anonymous (Kamya, 2017).

All the participants will be informed about the benefits and risks of their participation in the DNP project. Some of these benefits include providing data which can help in improving the health care experience of African immigrants and helping to determine effectiveness of some solutions developed to address the challenges faced by African immigrant patients. The information got from participants during the activities can be helpful in creating a sustainable plan for an improvement of the healthcare experience of African immigrants later on. Thirties issues are, however, addressed in the project document and various approaches of mitigating them shall be implemented as described earlier on. The recruitment will be mandatory for all the health care professionals attending to the health care needs of African immigrants. The participants will not be compensated and will be informed at the beginning of the project. Comment by Elumalai, Calaiselvy - SRDH: What was done to ensure these individuals participate? What are the benefits?

Measurable Plan for Analysis

There are various assumptions applicable in the analysis phase, which include the assumption that there is normal distribution of score, each observation is mutually exclusive, and the sample used is a representation of the entire population. The data collected before and after the interventions will use the SPSS statistics software for analyzing and running statistical tests. Based on the reviewed literature, Fisher's Exacts Test proves to be one of the most effective statistical tests for projects and research on cultural competence. Therefore, the test will also be applied in this project, with some reasons being its effectiveness when small sample sizes are used and its ability to perform exact calculations rather than approximations (Henderson et al., 2018).

Since the test is used in analyzing the correlation between data classified in two categories, it will be used in this project to determine the significance of the association between two variables. The variables in this case will be the implementation of a cultural competence program as compared with no implementation. The chart audit tool will evaluate the data in the surveys based on the guidelines provided in the tool as seen in appendix F. All data will be collected using unidentifiable code names and will be registered in a code book. A presentation of the results and discussion of findings will then follow. Comment by Elumalai, Calaiselvy - SRDH: Please address: Discussion of assumptions to be addressed and specific process for analysis included such as tools/software to be used or need for a statistician. Comment by Elumalai, Calaiselvy - SRDH: You still need to provide us the details on the chart audit tool process.

References

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

Allen, K. M., Jackson, I., & Knight, M. G. (2012). Complicating culturally relevant pedagogy: Unpacking African immigrants' cultural identities. International Journal of Multicultural Education, 14(2).

Allison, K. W., Echemendia, R. J., Crawford, I., & Robinson, W. L. (2016). Predicting cultural competence: Implications for practice and training. Professional Psychology: Research and Practice, 27(4), 386.

Asare, M., & Sharma, M. (2012). ROLE OF HEALTH BELIEF MODEL ON SEXUAL COMMUNICATION AMONG AFRICAN IMMIGRANTS. American Journal of Health Studies, 27(2).

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

Chat Audit Tool.

Guidelines for the Chart Audit Toolkit

1. How to measure the rate that the handout of resources was provided to African immigrant patients.

· This process will involve speaking to random patients during their visit to the clinic and asking them whether they are part of the African immigrant population because there is a study at the clinic involving the population.

· If the answer is yes, the patient will be asked whether he/she received a resources toolkit from the healthcare provider who attended to him or her.

· This will be carried out for 15 patients who fit the above criteria.

· Thereafter, the number of patients who admitted to receiving the toolkit will be divided by the total number of patients asked and the result will be multiplied by 100 to convert it into a percentage (rate).

· The formula is (x/N)*100% where x = number of patients who admitted to receiving the toolkit

· N= total number of patients asked

2. How to measure the rate at which the providers utilized the African immigrant toolkit when interacting with the patient.

· The healthcare providers will establish whether the patient they are attending to is part of the African immigrant population. This will help to identify the need for the resources toolkit or the African immigrant toolkit guideline during their interaction with the patient.

· If a patient is part of the African immigrant population, the healthcare provider will hand them a resources handout either during or at the end of the interaction.

· Every participant will record how many African immigrant patients they attended to during the week and the number of instances they utilized the African immigrant toolkit. For example, a healthcare provider may have attended to 4 African immigrant patients during the week and utilized the African immigrant toolkit in 2 of those occasions.

· This data will be collected weekly and a percentage will be calculated. For instance in the example above, the provider will have utilized the African immigrant toolkit 50% of the time.

· Calculation= (X/N)* 100% where N= total number of African immigrant patients attended to

· Y= number of times the African immigrant toolkit was utilized.

· The cumulative percentage results will be added together and then divided by the total number of healthcare providers.

Example: Let’s say healthcare provider A has used the African immigrant toolkit 50% of the time, provider B 100% of the time, and provider C 30 % of the time.

Rate = (A+B+C)

3

In this case, (50+100+30) = 60%

3

Therefore, the rate at which the providers utilized the African immigrant toolkit when interacting with the patient in this case is 60%.