Resource Materials:
Sixth National Conference on Quality Health Care for Culturally Diverse Populations
September 21-24, 2008 Minneapolis, MN
Submitted by:
Rani H. Srivastava RN, MScN, PhD
Deputy Chief, Nursing Practice
Centre for Addiction and Mental Health
Toronto, ON, M2N-1V3
Rani_Srivastava@camh.net
Ph: (416) 535-8501 x 2006
The attached package of materials reflects components of a cultural competence program that is
under development at Centre for Addiction and Mental Health in Toronto, On, Canada. The
program acknowledges the need to address cultural competence at the individual as well as the
organizational level and focuses on synthesizing evidence and best practices in cultural competence
and its integration in clinical care. We would be happy to share more details regarding any of the
initiatives. This program arose out of the preliminary analysis of research on “The Influence of
Organizational Factors on Clinical Cultural Competence” that will form the basis of the
conference presentation.
Selected References:
College of Nurses of Ontario. (2005). Practice Guideline: Culturally Sensitive Care. Toronto, ON: Author.
http://www.cno.org/docs/prac/41040_CulturallySens.pdf
Registered Nurses Association of Ontario (2007). Embracing Diversity: Developing Cultural Competence.
Toronto, ON: http://www.rnao.org/Storage/29/2336_BPG_Embracing_Cultural_Diversity.pdf
Srivastava, R. (2008). The ABC(and DE) of Cultural Competence in Clinical Care. Journal of Ethnicity and
Inequalities in Health and Social Care. 1(1) 27-33.
Srivastava, R. (2008). The Influence of Organizational Factors on Clinical Cultural Competence. Unpublished
PhD dissertation, Institute of Medical Sciences, University of Toronto. Toronto, ON, Canada
Srivastava, R. (2007). The Healthcare Professional’s Guide to Clinical Cultural Competence. Toronto, ON:
Mosby.
Influence of Organizational Factors on Clinical Cultural Competence
Rani Hajela Srivastava, PhD, Institute of Medical Sciences, University of Toronto, 2008
Abstract
This qualitative research used a case study method to study clinical cultural competence at
one hospital located in a large city in Canada. The study explored the overarching central question:
how does the organizational and practice environment influence the understanding and enactment
of clinical cultural competence in an organization embarking on a deliberate process of
organizational and practice change? Interviews with clinicians, administrators and organizational
diversity consultants (N=40), along with field notes and a review of selected documents were used
to: a) examine clinical cultural competence from the clinicians’ perspective; and b) describe key
factors and processes within the practice environment that support or limit the provision of such
care. The research was situated within a theoretical framework for practice development proposed
by Kitson, Harvey & McCormack (1998) that identifies practice development to be a function of
three key variables: evidence, context and facilitation. The philosophical stance of critical realism was
used to analyze the findings.
Results indicate that despite a significant organizational commitment to diversity, cultural
competence in clinical care was largely limited to awareness and lacking in application in practice.
Cultural competence was described in terms of adding a layer of cultural understanding to clinical
care; however, this was accompanied by a feeling of inadequacy with respect to cultural issues. This
study further revealed an overlap and a need to differentiate between cultural competence and
client-centered care. The overall organizational approach was one of mandated change and included
the development of various initiatives such as diversity policy and mandatory training for all staff.
However, these initiatives were experienced both positively and negatively; indicating a need to
examine not just what resources exists in an organization, but also how they are experienced.
Although leadership was evident in the form of organizational commitment, it was not translated
into care. The findings suggest a reconsideration of two of the most frequently recommended
strategies -- diversity training and enhancing workforce diversity. In addition, the findings also
suggest enhancements to practice development framework to address complex phenomenon such as
clinical cultural competence. These are further discussed in the dissertation report.
Culturally Responsive Therapeutic Relationships
Final Report: Change Foundation Grant # 05053
Rani Srivastava, RN, MSc, PhD (c)
Deputy Chief of Nursing, Centre for Addiction and Mental Health
Project Summary
The Culturally Responsive Therapeutic Relationships Initiative (CRTR) (formerly the Clinical Cultural
Competence Capacity Building project) is a nursing practice initiative aimed at fostering the development
of therapeutic relationships that are culturally competent, that understand and incorporate cultural issues.
The CRTR initiative is a collaborative venture between the Centre for Addiction & Mental Health
(CAMH), the Lawrence Bloomberg Faculty of Nursing, University of Toronto and the Pacific Institute
for Research and Evaluation (PIRE).
Objectives and Activities: The primary purpose of this initiative was to strengthen nursing
practice/quality of care by assisting nurses to develop confidence and competence in providing client
centred, culturally competent care. The CRTR had three main goals:
1. Develop and implement a model of education that facilitates knowledge transfer from awareness of
culture and therapeutic relationships to competencies in practice
2. Prepare up to 30 nurses and student nurses with integrated theoretical knowledge of culturally
responsive therapeutic relationships to provide leadership in CRTR
3. Contribute to nursing knowledge by building on resources such as the Registered Nurses of Ontario
(RNAO) Best Practice Guidelines (BPG) and the College of Nurses of Ontario (CNO) Guidelines
for Providing Culturally Sensitive Care in order to:
a. make recommendations for integration and revision of guidelines
b. develop competencies for CRTR
This project utilized a learning/practice framework with a group of nurses at CAMH and a group of
nursing students at the Faculty of Nursing, University of Toronto. Twenty (20) registered nurses at the
CAMH and 10 second-entry nursing students signed up for the initiative. Sixteen (16) nurses and 7
nursing students participated until the end of the initiative. The CRTR initiative used four approaches:
the development of integrated competencies, systematic education that provided content while promoting reflection,
clinical application and supervision, and web-based journaling to document and manage practice change. The
Nursing Best Practice Guideline: Establishing Therapeutic Relationships (Registered Nurses Association
of Ontario, 2002), the Practice Guideline: Culturally Sensitive Care and Practice Standard: Therapeutic
Nurse-Client Relationship (College of Nurses of Ontario, 2004a), the need for reflective practice based
on self awareness and self knowledge, as well as previous work done in the organization on cultural
competency were used to guide the curricular content.
In order to obtain baseline information, prior to the initiative, the project team developed and
administered a survey to determine the demographics and the competency levels of nurses and students.
CRTR participants also completed this survey at the beginning of the initiative. Although the survey was
not hypothesis testing, it was assumed that years of nursing experience, level of education, and more
importantly, participation in the CRTR initiative, as well as social and cultural identity would noticeably
influence cultural awareness and, possibly CRTR competency levels. The 15-competency based questions
focussed on self-appraisal of culturally sensitive care and therapeutic relationships. They included, but
were not limited to, eliciting client’s explanatory models of illness; recognizing difference as well as
power and privilege; collaborating with clients in their plan of care; eliciting additional help, adjusting
communication styles; and establishing therapeutic relationships (see Appendix 1).
Outcomes and Evaluation Results: The baseline survey was completed by 150 (about 33% of all
CAMH nurses, 18 of which were also part of the CRTR initiative. Thirty-one (31) student nurses
(response rate of about 21%) completed the survey, 10 of which were part of the CRTR initiative.
Individuals rated themselves fairly high on the competencies. One of the several possible explanations
for the high ratings is that possibly individuals may have responded to what they expected of themselves
as competent learners and practitioners as opposed to what they did in practice. Alternatively, high
CRTR competencies ratings could reflect the notion of “you do not know what you do not know.”
Based on the survey results, there was an observable link between marginalized cultural and social
identity and perceived competency but more strikingly, there was also a link between marginalized
cultural and social identity and interest/passion for clinical cultural competence. Hence, one might
presume that many of the nurses, through their own experiences of marginalization, intuitively
understood issues of cultural and social identity and the impact of these on care and health outcomes.
Possibly, while intuitively aware, many of the participants were searching for a way to be able to name,
understand, explore, and integrate their personal experiences into their clinical practice – a
transformation we have certainly observed for many nurses over the period of the CRTR initiative.
The overall project consistently received positive evaluations from participants. The overall objectives of
the CRTR initiative, other than the development of reliable competencies, were successfully met.
Participants expressed appreciation for the opportunity to have a ‘safe space’/learning environment to
reflect on their experiences with one another. Both nurses and students consistently gave high ratings for
the education sessions. Analysis of journaling data demonstrated that involvement in this project
broadened participants’ understandings of culture and improved their ability to identify, respect, and to
integrate cultural needs in care as well as taking on a advocacy role, and, in general, the participants
identified that participation enriched their knowledge and contributed to improving their practice in
culturally responsive therapeutic relationships. Participants validated the importance of reflective practice
and many indicated that while journaling was very challenging for them, they found the activity
beneficial.
Recommendations for further work: The learning/practice framework and curriculum are effective in
assisting nurses to develop culturally responsive therapeutic relationships (CRTR). Self-awareness and
reflection are critical elements of the development process. Future work should focus on competency
development and use the work done by the project team in this area as a starting point. As well, future
work should focus on client and care outcomes that result from nurses’ development of CRTR.
Lessons Learned: The acquisition of CRTR skills is a complex and timely process. The
practice/learning model and the longitudinal nature of the project facilitated the development of these
skills as demonstrated in the shift from the discussion of general concepts in the project’s introductory
phase to deeper more detailed discussions of complex CRTR issues during the project’s consolidating
phase. CRTR skill/competency development requires the investment of unstructured supports, for
example, participants’ timely access to support persons in between education sessions to provide
consultation, link to resources, and answer questions. The participants were particularly open to cultural
diversity and interested in gaining more knowledge about it. This predisposition may have facilitated
positive changes throughout the project, thereby reinforcing the knowledge translation process, which
could have resulted in more solid outcomes in terms of CRTR skill development.
Contact Information: Rani Srivastava, , Centre for Addiction and Mental Health
Phone: 416-535-8501 ext. 2006; E-mail: rani_srivastava@camh.net.