Fluent Essays

Cultural Competence Training Program For African Immigrants 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 (even after the completion of this project). 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 … Running head: LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 1 Latinx Immigrants Cultural Awareness Toolkit in a Psychiatric Outpatient Clinic Roberto E. Gimenez Touro University In partial fulfilment of the requirements for the Doctor of Nursing Practice Jessica Grimm, DNP, RN Sandra Olguin, DNP, RN Neoves Diaz, DNP, RN 01/26/2021 LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 2 Latino Immigrants Cultural Awareness Toolkit in a Psychiatric outpatient clinic ......................... 4 Introduction ..................................................................................................................................... 5 Background ..................................................................................................................................... 5 Problem Statement .......................................................................................................................... 6 Purpose Statement ........................................................................................................................... 6 Project Question .............................................................................................................................. 7 Objectives ...................................................................................................................................... 7 Coverage and Justification………………………………………………………………………...7 Review of Synthesis……………………………………………………………………………….9 Literature Review………………………………………………………………………………….9 Review of Study Methods………………………………………………………………………..13 Significance of Evidence to Profession………………………………………………………….14 Historical Development of the Theory…………………………………………………………..15 Major Tenets………………………………………………………………..……………………16 Theory application of DNP……………………………………………………………………....18 Setting……………………………………………...…………………………………………….18 Population of Interest…………………………………………………………………………….20 Stakeholders……...………………………………………………………………………………21 Interventions...…...………………………………………………………………………………21 Tools...…………...………………………………………………………………………………23 Data Collection Procedures………………………………………………………………………26 Ethics/Human Subjects Protection…………….…………………………………………………27 Measurable Plan for Analysis……………………………………………………………………28 LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 3 Results……………………………………………………………………………………………29 Discussion findings………………………………………………………………………………30 Significance/Implications for Nursing…………………………………………………………...32 Limitations……………………………………………………………………………………….34 Dissemination……………………………………………………………………………………36 Sustainability……………………………………………………………………………………36 References………………………………………………………………………………………..38 Appendix A………………………………………………………………………………………45 Appendix B………………………………………………………………………………………46 Appendix C………………………………………………………………………………………50 Appendix D………………………………………………………………………………………52 Appendix E………………………………………………………………………………………62 Appendix F……………………………………………………………………………………….63 LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 4 Latino Immigrants Cultural Awareness Toolkit in a Psychiatric outpatient clinic Latino immigrants who seek mental health services need culturally competent care to improve their healthcare outcomes. Misunderstandings concerning the cultural needs of the Latino population are common among healthcare workers. As a result, health care providers are often unable to identify and understand the role that culture plays in the lives of most Latino people, including mental health (Luque et al., 2018). Many Latinos do not seek treatment for mental issues since they do not recognize their symptoms or do not know where to seek help (Adames, & Chavez-Dueñas, 2016). Current literature demonstrates that the lack of cultural competence in health workers has resulted in misdiagnosis as well as inadequate treatment of mental health issues for the Latino population (Adames, & Chavez-Dueñas, 2016). Latino immigrants, therefore, continue to receive poor quality care when it comes to their mental health needs. A systematic review determined that access to culturally competent care was essential to increasing health service utilization among the Latino population (Moore, 2017). Additionally, a study conducted by Govere & Govere (2016) demonstrated that cultural competence training of healthcare providers significantly improved patient satisfaction and outcomes. This evidence contributes to the conclusion that in order to increase health service utilization and improve healthcare outcomes for the Latinos, efforts should be made to provide adequate cultural competence training to healthcare providers in the United States. Currently, there are no cultural competence guidelines implemented at the mental health clinic where the DNP project will be taking place. As a result, the purpose of the DNP project is to implement a Latino immigrant cultural competence toolkit (LICCT) for healthcare workers at the project site to improve patient mental health outcomes at the outpatient clinic. LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 5 Background According to Flores (2017), the Latino population accounts for approximately 17.6 percent of the total U.S. population; in 1980, the Latino population represented just 6.5 percent of the total U.S. population (Flores, 2017). The number of Latinos is projected to grow to 107 million by 2025 (Flores, 2017) due to the ever-increasing rate of immigration of Latinos into the U.S. Despite the increasing size in the number of Latinos in the U.S., they are still significantly less represented in the healthcare workforce. According to Fisher (2018), less than 4% of healthcare providers in the U.S. speak Spanish, with Texas having the highest proportion at 9% followed by New Mexico and Florida with 8% and 6%, respectively. Additionally, statistics from the U.S. Census Bureau report show that 29.8% of Latinos are not fluent in the English language (Office of Minority Health, 2020). Due to this language barrier, most health providers do not understand how to effectively deal with diversity, which raises problems for the Latinx immigrant population. Latinx not only face language and other external barriers to obtaining mental treatment, but also their cultural perceptions of mental health care prevent them from getting help. (Cabassa, Lester, & Zayas, 2007). Moreover, their culture has various aspects concerning mental health that many health care providers fail to understand appropriately and hence cannot provide quality care. For example, primary mental health care providers fail to recognize specific cultural-bound syndromes that are characteristic of Latinos such as fright, an evil eye, and nerves, among others; symptoms that are unique to this ethnic group include uncontrollable screaming, crying, trembling, physical and verbal aggression, seizure-like episodes, as well as suicidal gestures (Caplan, 2019). To cater to the mental health care needs of this minority group, there is a need LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 6 for health care providers to understand such syndromes and symptoms for purposes of providing care that considers their cultural perspectives and beliefs (Camacho, 2015). Problem Statement Racial and ethnic minorities in the U.S. are generally less satisfied with the health care services that they receive (Adames, & Chavez-Dueñas, 2016). Although there has been policy and research emphasis on delivering culturally competent mental health care, there is little evidence concerning what frontline mental health care providers consider to be culturally appropriate care (Adames, & Chavez-Dueñas 2016). Existing research also suggests that various challenges hinder them from delivering culturally appropriate health care in their everyday practices. It is essential for healthcare providers to have a proper understanding of the cultural needs of Latino immigrants surrounding mental health issues. Mental health care providers should also be sensitized concerning specific aspects of both Latinos' learning style as well as their illness perception, along with other perspectives such as authority and physical contact issues (De Freitas, Crone, DeLeon, & Ajayi, 2018). To achieve this cultural competency among mental health care providers, it is essential to provide education and training concerning the perspective of Latinos on mental issues (Cabassa, Lester, & Zayas, 2007). Mental health providers at this DNP project site, a mental health clinic in urban Florida, do not yet have training on providing culturally competent care for Latinos. Purpose statement This project aims to provide a Latinx immigrant cultural competence toolkit (LICCT) for healthcare workers in an outpatient mental health clinic. When mental healthcare providers are able to approach care with cultural competence, they can gain the trust of their patients to LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 7 encourage them to speak freely about their symptoms that can then be used in diagnosis and treatment. This project aims to eliminate cultural barriers that hinder Latino immigrants from receiving appropriate mental health care, such as lack of diversity in the mental health workforce, language barriers, and ineffective communication (Boykin, Schoenhofer, & Valentine, 2014). This will be achieved through training of health care providers on cultural norms and expectations of care of Latinos. Latino immigrants will also be provided with a toolkit of resources to assist them with their mental healthcare. Project Question This project shall incorporate the PICOT question method as the guide for answering the project questions. The project question is: Does the implementation of a cultural competence toolkit aimed at Latino immigrants improve culturally competent care and increase resource referral for this population? Objectives In the timeframe of this DNP project, the following objectives will be met: 1. To administer an educational seminar for the multi-disciplinary team in the health facility, consisting of one psychiatrist and two Mental health Nurse practitioners, to train them on culturally competence practice guidelines and the LICCT. 2. To develop a LICCT and implement it at the mental health clinic project site. 3. To increase the resource referral of Latino immigrants during mental health visits at the project site. Coverage and Justification Limits for the review of literature were set to achieve the desired results. The selection benchmark used for this review include those examining Latino communities, study design of LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 8 systematic reviews or qualitative and quantitative studies, peer reviewed reports, and involving the mental health setting. The PICOT question was used as the primary search method to obtain sources. The question was: Does the implementation of a cultural competence toolkit aimed at Latino immigrants improve culturally competent care and increase resource referral for this population? Govere and Govere (2016) conducted a general review on of literature to evaluate the effect of cultural proficiency education of physicians on patient satisfaction. They concluded that culturally competent practitioners had a significant positive impact on patient satisfaction (Govere and Govere, 2016). Similarly, Jongen, McCalman, and Bainbridge (2018) undertook a systemic review, and established that culturally proficient training of the health workforce was the main strategy of reducing healthcare disparities among ethnic minorities. The search terms used to guide the selection of secondary sources include Latino, immigrants, minority communities, culturally sensitive healthcare, mental health clinic, and LICCT. The search results generated over 500 results. Initially, 100 journal articles and academic books were found to have potentially relevant titles and abstracts. Out of those results, 20 duplications in multiple databases were eliminated. Further specifications were used with Boolean phrases such as ‘cultural competence among Latino immigrants and mental health,’ ‘mental health and Latino immigrants,’ ‘cultural themes in mental health among Latino,’ and ‘culturally competent healthcare service among the Latino group.’ Eventually, the search yielded ten peer-reviewed journals and academic books that covered the PICOT question, which had been published in the past five years. A full-text screening followed the screening of titles and abstracts. LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 9 Review of Synthesis The theme development process was based on an analytic examination of the previous studies related to various aspects of social phenomena through literature reviews and analysis of transcriptions. Online data bases use included, Cochrane library, Agency for Healthcare Research and Quality (AHRQ), PubMed, and Cumulative Index of Nursing and Allied Health Library (CINAHL). The emerging themes from the review of literature included lack of knowledge among professionals on the different cultural practices among minority communities, lack of knowledge about traditional remedies, poor representation of minority communities in the healthcare workforce, poor cultural competence education, and diagnostic errors emerging from miscommunication. The themes provided insight into the implications for knowledge, practice, policymaking, and research on mental health among minorities. Literature Review The primary objective of the review of literature was to examine the cultural proficiency of physicians among minority communities with a specific focus on the Latino group. In this regard, the project leads used themes that emerged to identify the current state of cultural healthcare perceptions among professionals, patients, and the community members, identify the factors and challenges that influence the cultural competence, relationship, and communication among caregivers and patients, and provide recommendations on how to improve care for cultural competence. The search terms that guided the selection of articles include minority representation in the nursing profession, cultural competency training, barriers to cultural training, and miscommunication in healthcare. An online search produced a total of 800 results. Out of which 200 were journal articles and published books. The search generated 8 articles LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 10 when it was further narrowed to peer-reviewed sources published from 2010. The articles were then used to conduct the literature review. Cultural Knowledge Among Healthcare Workers The increasing population of minorities in America has triggered the need for an ethnically proficient workforce. However, most healthcare institutions in America are not culturally competent to provide services to minority communities due to sociocultural bottlenecks, namely clinical impediments organizational challenges, and structural constraints (Oriana, Schilgen, & Mosko, 2019). Organizational challenges impede the accessibility of care and include things such as the representation of the minority population in the workforce (Oriana et al., 2019). Structural constraints result from the red tape in healthcare systems. Clinical impediments occur in the patient-healthcare professional interactions. Healthcare institutions must invest in cultural competence strategies to mitigate the glaring disparities evidenced in health outcomes. Barrera & Longoria (2018) performed a systemic literature review to assess some of the cultural obstacles that Latinx face when seeking mental health treatment. The researcher established that cultural sensitivity enhance communication between the physician and the patient (Barrera & Longoria, 2018). Similarly, Larson, Mathews, Torres, and Lea (2017), in their qualitative study, sought to evaluate the relationship practitioners and elderly Latinx in rural areas. They found that healthcare providers need to require cultural sensitivity education to meet the needs of their patients (Larson et al., 2017). Therefore, healthcare stakeholders should promote culturally sensitive training to promote patient outcomes. Poor Representation in the Healthcare Workforce Poor representation of minorities in the healthcare workforce is also a challenge to providing culturally sensitive care. Even though minority communities constitute 37% of the LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 11 American population, minority nurses only take up 16.8% of the total nursing population (Loftin, Newman, Dumas, Gilden, & Bond, 2012). Minority representation in the workforce significantly influences service delivery across all settings because nurses care for all patients regardless of their background. Loftin et al. (2012) conducted an integrative review to identify the challenges that nursing students face. They concluded that the most common challenge that nursing students experience in the course of their education was financial support (Loftin et al. (2012). Most students work to pay for education and support their families (Loftin et al., 2012). The ever- increasing college expenses and inadequate information on where nursing students can receive financial help in the form of scholarships or grants worsens their situation. A recent study survey indicates that 3 out of 4 Hispanic college students have difficulties completing their coursework because they are more likely to sign up for part-time classes, which allow them to work and support their families (Healthypeople.gov, 2020). Thus, financial support to minority students will increase their completion rate. Besides, mental illness was another challenge hinder minority student from completing their nursing education. DeFreitas, Crone, Deleon, & Ajayi (2018) conducted a survey to determine perceived mental health stigma among African American and Latino students. The researchers discovered that ethnic minority students were less likely to seek mental health treatment because of fear of being stigmatized (DeFreitas, 2018). Thus, to improve the representation of ethnic minorities in the health workforce, financial support and mental health services are required for nursing students. Cultural Competence Education Cultural competence education is vital in promoting healthcare equality. Jongen, McCalman, & Bainbridge (2018) performed a systemic scoping review to determine the role of LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 12 cultural proficiency training in effecting healthcare interventions. They discovered that the development and training of healthcare personnel were the most effective means of achieving a culturally sensitive healthcare system. Likewise, Sanchez, Killian, Eghaneyan, Cabassa, and Trivedi (2019) employed a pretest-posttest research technique to evaluate the impact of culturally competent depression education on practitioners understanding of mental health among Hispanic patients. They discovered that education and cultural training reduces stigma and improves patient engagement (Sanchez, 2019). Most studies treat patient satisfaction among minority communities as a secondary issue or tend to have extensive coverage of impacts of cultural competence (Govere & Govere, 2016). Due to the broad coverage of cultural competence in healthcare, managers do not have the information they need to understand how their current cultural knowledge base affects service delivery. Successful cultural competence education involves developing partnerships between communities and healthcare providers (Bhatt & Bathija, 2018). The approach guarantees that policies and organizational management will be reflective of the problems on the ground and representative of the community, respectively. Among the Latinos in North America, patients were generally satisfied with the healthcare services because they are the majority in that region due to the availability of provider-targeted cultural competence in the organizational, clinical, and systemic levels. Cultural competence is directly associated with an increase in patient satisfaction among minority communities. Miscommunication Culture defines the rules of communication. According to the Center for Disease Control (CDC) (2019), misunderstanding and miscommunication may result when people use ethnic jargon and dialects, which may lead to increase patients’ risk of misdiagnosis and dissatisfaction. A systemic research in Northern Australia to determine the cultural impediments to healthcare LATINX IMMIGRANTS CULTURAL AWARENESS TOOLKIT 13 found that language barriers often lead to miscommunication since the aboriginals speak over 100 dialects (Li., 2012). Consequently, lack of speech-language pathologists (SLP) in the region makes patients vulnerable to misdiagnosis due to miscommunication. Moreover, Amirehsani et al. (2018) conducted qualitative research on the healthcare experience Latinx adults residing in North Carolina. They established Amirehsani et al. (2018) that the patients experienced language barriers since most practitioners are not bilingual, and there are few trained interpreters, which often lead to misunderstands and medical errors. Therefore, healthcare institutions need to invest in reducing the cultural disparities that impede healthcare delivery. Review of Study Methods The emerging themes from the literature review revealed that Latinos are at an increased risk of poor mental healthcare services due to cultural incompetence. Misunderstandings on the cultural practices and beliefs of the Latino population are prevalent among physicians, which complicates patients’ ability to receive care and workers’ knowledge on how to tailor interventions to suit their needs. Steinberg, Zickafoose, DeCamp, Valenzuela-Araujo, and Kieffer (2016) performed and secondary data analysis to assess the experience of Latina mothers, who have limited English Proficiency, seeking pediatric care. Steinberg et al. (2016) found that many mothers complain of being misconstrued and stigmatized due to language barriers. Others did not want to attend follow-up visits because they were afraid of being a burden as they would require interpreters (Steinberg et al., 2016). Such misapprehensions on the patients’ cultural background or language negatively affect how Latinx receive care. Another theme in the studies was the common understanding of cultural …