Jun 13 2014
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Neonatal Nurse Practitioner Advocates for Culturally and Linguistically Appropriate Services

Yolanda Ogbolu, Ph.D., CRNP, is an assistant professor of family and community health and deputy director at the Office of Global Health at the University of Maryland-Baltimore. She is a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2013-2016).

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Human Capital Blog: Congratulations on your recent Outstanding Faculty Award from the University of Maryland-Baltimore! What does it mean for you and for your career?

Yolanda Ogbolu: It was an honor to be recognized by the University of Maryland-Baltimore (UMB) and by my colleagues in the school of nursing who nominated me for this award. It specifically identifies a faculty member on campus who has demonstrated achievements in the area of diversity and inclusiveness. It is presented in the annual Dr. Martin Luther King, Jr., and Black History Month celebration.

Having my colleagues share and honor my passion for addressing health inequities using the social determinants of health model locally and globally was particularly rewarding, as I reflected on the work of Dr. King and others before me. At the same time, I acknowledge that most of my work benefitted from my passion for collaboration. Therefore, I wholeheartedly shared the award with many people who have assisted me along this path. Receiving the award has strengthened my career and enthusiasm for actively engaging in efforts that move forward the ideals of social justice and health equity in a way that transforms practice and patient outcomes in my local and global communities.

HCB: The award recognizes 20 years of clinical and research work to narrow health disparities for newborns and others. One of your goals is to improve the provision of culturally competent care. Why has this become a priority for you?

Ogbolu: My interest in improving the provision of culturally and linguistically appropriate services (CLAS) for families stems from my clinical and policy experiences. As a legislative intern in the Maryland General Assembly in 2009, I assisted in developing a cultural competency bill with Del. Shirley Nathan Pulliam.

In my testimony, I detailed my role over 20 years as a neonatal nurse practitioner. In the Neonatal Intensive Care Unit, my daily assignment was to manage the care of 20 critically ill newborns and their families. Due to the growing diversity in Maryland, often nearly 50 percent of the families spoke a language other than English. Throughout that time, I had difficulty explaining complex or negative health outcomes, such as intraventricular hemorrhage and death of a premature infant, via a phone translator. And the lack of linguistically appropriate documents were frequent challenges that I hoped could be addressed.

I used my opportunity as a legislative intern to address these challenges by helping to pass a law requiring cultural competency training for health providers. Over the years that followed, I noticed that translation of these types of policies and standards were sluggishly being put into clinical practice.

For example, the national standards for CLAS were developed nearly a decade ago, yet many health care organizations have failed to adopt the basic standards. If we are to achieve equity in health care service delivery in a multicultural society, these policies and standards must become evident and routine in health care. Recognizing the need for more active approaches to dissemination, my current research seeks to use dissemination and implementation science to better understand how policies and standards related to cultural competency are spread throughout health care organizations. The study will also identify and document best practices related to the provision of culturally and linguistically appropriate care. These findings could be utilized to increase uptake, spread standards, and, ultimately, improve the care patients receive.

HCB: What kind of problems arise for babies and their families when nurses and physicians do not provide culturally or linguistically competent care?

Ogbolu: Multiple challenges may arise due to the lack of provision of culturally and linguistically appropriate services when caring for babies and their families, yet very few are documented in the literature. Problems include communication challenges leading to medication errors, infant formula mixed incorrectly, and failure of families to follow-up on important tests and appointments. Delayed diagnosis can also occur if the provider is unable to obtain a detailed, informative, and appropriate family and past medical history.

Most importantly, the lack of culturally and linguistically appropriate services leads to failure to fully engage parents and families in every aspect of the care for their newborns. Most of these challenges are preventable; but if they are not prevented they have the potential to lead to significant, adverse health outcomes, including death, and to worsen health disparities.

Standards and policies related to the provision of culturally and linguistically appropriate services are designed to prevent these outcomes, thereby protecting our most vulnerable populations, including newborns. Advancing adoption of the CLAS policies, standards, and services can assist by preventing the unnecessary, negative health outcomes that can occur due to failed communication and inconsideration of an individual’s cultural needs.

HCB: You have called CLAS a “social justice and economic imperative for health care organizations.” Can you elaborate?

Ogbolu: From a social justice perspective, there is a moral imperative to respond to the growing diversity in America, improve health disparities, reduce patient errors due to communication challenges, and improve patient-reported experiences with care. Some organizations view the provision of patient-centered and culturally competent care as a corporate social responsibility and have high value for social justice within their missions.

However, for other organizations, social justice alone is insufficient as a rationale for providing culturally and linguistically appropriate services. We need to clearly identify and articulate the economic benefits of adopting CLAS to encourage institutions to adopt them. To start, the provision of CLAS minimizes lost revenue due to failed adherence to regulatory and legislative mandates. They also reduce litigation from malpractice suits related to patient errors and failed communication.

Additionally, case studies of health care organizations show increased revenue from serving more diverse patients in their local communities. I believe this is an area that needs to be further investigated so that organizations can better understand the importance of CLAS from both the business and the social justice perspectives.

HCB: Can you put the problem in context for us? In your experience, do most health care providers have the training to deliver culturally and linguistically competent care? If not, in what ways should training be improved?

Ogbolu: All health care providers receive training to deliver culturally and linguistically appropriate care as part of their pre-service education. In fact, nearly every discipline has its own set of cultural competencies that must be delivered in the educational curricula. Some institutions offer a required course on the subject, while others integrate the training into other courses or offer training as an elective, which may not allow students sufficient time to delve into it.

At UMB, students rapidly fill an elective, stand-alone course that I teach, indicating that students are enthusiastic about the training when offered the opportunity to participate.  After basic educational programs, providers continue their training through annual continuing education, which is offered by most health care organizations and professional regulatory bodies. These annual provider trainings are often mandated and offer opportunities for long-term learning.

But improvements in training for health care providers are needed. Practitioners today enter the field with improved knowledge from their pre-service education, yet many providers who have been in practice for longer periods have not had the same opportunities to receive training in the provision of culturally and linguistically appropriate care.

Further, annual cultural competency training, in some instances, has become more of a ritual than a true mechanism to transform practice. Innovative teaching and training strategies that translate and implement the training into actual practice settings are needed to ensure that equitable and culturally competent care becomes part of routine clinical practice. Reviewing actual patient cases regularly and engaging members of the community to tell their own stories may be an important first step. Simulation and patient actors are additional measures we employ at UMB to train nurses using real-life applications.

Importantly, all employees in the health care setting, not only direct health providers, need training so that patients can receive appropriate care from the receptionist at the front desk to the health provider in the home care environment. Recently, the Maryland Office of Minority Health and Health Disparities (MHHD), along with the University of Maryland, developed the Cultural Competency and Health Literacy Primer: A Guide for Teaching Health Professionals and Students.” The free resource guide provides more than 200 tools through Web links to sample course curricula, self-guided learning resources, case studies, and clinical application resources.

Tags: Cultural competence, Disparities, Human Capital, Nurse Faculty Scholars, Nurses, Nursing, Social determinants of health