Abstract
An innovative partnership with the Kaiser Permanente (KP) Institute for Culturally Competent Care (ICCC) has enabled the KP School of Anesthesia (KPSA) to become one of the first nurse anesthetist programs in the western United States to incorporate a formal cultural competence curriculum into its educational program. Housed administratively in the California State University system since 1981, KPSA is a fully accredited, 24-month program that educates registered nurses to become certified registered nurse anesthetists (CRNAs). The collaboration between the ICCC and KPSA represents a unique opportunity to enhance the care student nurse anesthetists provide in ten Southern California KP hospitals. In addition to serving KP patient populations, students travel to 12 affiliated hospitals in urban and rural areas. The partnership also benefits KP: Upon graduation, 80% to 90% of the student nurse anesthetists in each graduating class join the diverse KP workforce. This article describes the genesis, evolution, and potential impact of this ongoing collaboration to reduce health disparities.
The Need for Cultural Competency Curricula at the Kaiser Permanente School of Anesthesia
The patient population in the Kaiser Permanente (KP) Southern California Region comprises approximately 100 distinct cultural groups. The major ethnic communities in the area include African American, Armenian American, Central American, Chinese American, East Indian American, Filipino American, Mexican American, Jewish American, Japanese American, Korean American, and Vietnamese American. Aware of the diversity in the patient population in Southern California, the faculty at the KP School of Anesthesia (KPSA) concluded that principles of culturally competent care should be incorporated into the didactic curriculum to enhance students' opportunities to deliver high-quality care and establish effective cross-cultural communication with patients.
To reach this educational goal, KPSA enlisted the participation and support of KP's Institute for Culturally Competent Care (ICCC). ICCC provides consultation and develops tools, training, and educational resources for clinicians to develop and enhance their cultural competency in order to increase their patients' compliance with treatment and positively impact the health outcomes of patients during the clinical encounter.
The KPSA faculty envisioned cultural competency training as enhancing student nurse anesthetists' ability to provide holistic, high-quality anesthesia care and to exhibit awareness, knowledge, understanding, and respect regarding cultural differences and similarities during the perioperative period. The faculty decided that the scope of the training would frame “culture” as encompassing racial, ethnic, religious, and social issues, thereby modeling the definition proposed by the US Department of Health and Human Services Office of Minority Health.1
Three cornerstones guided the collaborative planning process undertaken by ICCC and KPSA. First, the changing demographic profile of the United States requires health care staff to have a basic understanding of conceptual issues regarding cross-cultural communication and basic knowledge of health beliefs and practices of culturally diverse populations. Second, cultural competence can enhance clinicians' opportunities to deliver high-quality care to patients from diverse cultural backgrounds. Finally, the collaboration represented a strategic opportunity to help decrease racial and ethnic health disparities.
… students have received didactic training sessions on culture and expressions of fear and pain, leading students to understand that these cultural differences exist not only among patients but also among health care providers.
Developing and Implementing Culturally Competent Curricula at KPSA
Theoretical and practical aspects of patient care are incorporated into every accredited nursing educational program in the US. From human anatomy and physiology to pharmacology and pathophysiology, a major goal of nurse anesthesia education is to provide students with a solid theoretical foundation. Of critical importance is integration of theoretical concepts into clinical practice, which has been the focus of nursing education. Distinct educational opportunities for cultural competency knowledge and skills acquisition have not traditionally been formally integrated into nursing education curricula.
The KPSA cultural competency curriculum consists of four modules and was developed from the 16-hour cultural competence training curriculum created for KP health care clinicians by ICCC. Through collaboration with the KP Distance Learning Program, the KPSA curriculum was customized for integration into the existing KPSA nurse anesthesia program. Because application to clinical practice is a key component in developing cultural skills, the four modules are interwoven throughout the nurse anesthesia curriculum. This methodology allows students ample time to apply and practice the module concepts during clinical rotations. At the conclusion of the four-module training sessions, student nurse anesthetists become formally certified in culturally competent care.
During the first semester of each academic year, the Institute staff deliver Module 1: Introduction to Diversity and Culturally Competent Care and Module 2: Cultural Awareness. Through facilitated class discussions and learning exercises, students learn how to recognize and deal with the biases and preconceptions they have formed throughout their childhood and adulthood experiences.
Building upon the first two modules, KP content experts present Module 3: Cultural Knowledge to the students in the second semester. This module focuses on cultural beliefs, health practices, and nuances of specific social and cultural groups and includes information on African Americans, Latinos, Asian and Pacific Islander populations, LGBT (lesbian, gay, bisexual, and transgender) populations, and persons with disabilities. ICCC's Provider Handbook Series on Culturally Competent Care2–6 serves as a major resource for the students: Each handbook is devoted to a specific sociocultural group. Students who complete Module 3 are assigned to select a patient whose culture differs from their own and to record clinical encounters that occur during the clinical rotations; this serves as preparation for the case presentation each student is expected to conduct at the conclusion of the nurse anesthesia program.
During the last semester, students participate in Module 4: Cultural Skills, a highly interactive module that focuses on cross-cultural communication. A major component of this module is the individual student case presentation and discussion with peers.
Successes and Challenges
An obvious challenge encountered when implementing the cultural competency curriculum has been students' uneasiness with discussing cultural values different from their own. Some resistance to change has been encountered in the form of some students questioning the need for cultural competency when their jobs involved “minimal interaction with patients” and “putting people to sleep for a living.” On the successful side, many students value the utility of the cultural knowledge and skills gained as well as appreciate the insight gained from identifying their own biases and preconceptions around diversity issues.
The KPSA cultural competence program continues to evolve. Since 2004, for example, students have received didactic training sessions on culture and expressions of fear and pain, leading students to understand that these cultural differences exist not only among patients but also among health care providers. In addition, more specificity has been added to the cultural competency training curriculum, such as how to work with interpreters.
The partnership between KPSA and ICCC reflects leadership in delivering health care that is both evidence-based and built on understanding the health beliefs and practices of our culturally diverse membership. Training programs such as the four-module training curriculum in culturally competent care can facilitate development of cultural awareness, knowledge, and skills for the lifelong journey toward cultural competence. Most importantly, the KPSA-ICCC partnership reaffirms KP's commitment to help reduce health disparities.
Acknowledgments
The Medical Editing Service of The Permanente Medical Group Physician Education and Development Department provided editorial assistance.
References
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