The Nmc Code of Practice

Modern concepts of health and illness must take into consideration the range of biological, social and spiritual factors, as well as significant macroeconomic determinants, such as the movement of people across countries and continents. Ethnic conflicts, wars, oppressive political regimes and natural phenomena are largely responsible for this mass migration. Some of the challenges for health care providers in host countries include adapting to the impact of new cultures and developing strategic ways of working transculturally and sharing of innovative practices. These innovations also strive to challenge discriminatory attitudes that are still perpetuated within the health and social care setting.  Therefore, health care providers must recognise that to survive, they need to reinforce efforts to maintain their clinical integrity and foster relationships with clients and colleagues from diverse ethnic, cultural and linguistic backgrounds.  Fundamentally, this will also impact on the role of the health professional and create a need for a re-evaluation of the key competences and behaviours required to adapt to these cultural changes.  The aim of this essay therefore is to examine the impact of culture on professional practice, both at the level of the practitioner as well as the level of the health care organisation.

The NMC Code of Practice (2015) places the need to place people at the centre of the care that practitioners give.  Section 1, subsection 3 states, “Avoid making assumptions and recognise diversity, and individual choice” (NMC 2015).  The Equality and Human Rights Commission have also developed a measurement framework for equality and human rights. This sets out six domains which are education, health, justice, living standards, participation and work. (EHRC 2017) The framework looks at a range of indicators used to measure progress in each domain.  The measurement also looks at inter-sectional disadvantage, and at-risk groups such as homeless people and carers.

The National Institute for Health and Care Excellence published an annual equality report 2016 to 2017 which sets out guidelines by producing evidence based best practice for health, public health and social care practitioners. These guidelines provide performance metrics for commissioners, practitioners and managers across the whole spectrum of health and social care. (NICE 2015). However, for the health care organisation, the problem with implementing these guidelines is that of subjectivity.  At best, measures of cultural competency and cultural responsiveness are based on the interactionist approaches that are difficult to measure scientifically.  It is therefore difficult to assess the extent that these standards have been achieved at the level of the organisation.  For example, a hospital department might discharge a patient and record on the patient’s notes.  There is no mechanism however on the records to indicate the level of satisfaction of the patient or their feelings about the standard of care that they have received.  Perhaps if the patient was asked to rate the service, their response might show a level of dissatisfaction which the care provider would otherwise not have been aware of.

Another effect on the organisation might be the lack of recognition of the varied roles of health care practitioners (Miller et al 2001). For example, if communication channels are limited to staff handovers at the end of their shifts, the changing nature of roles may mean that a nurse might have to do ward rounds across many wards outside their delegated ward.  This might then pose a challenge to the nurse who then must widen their knowledge of the patients who they may not necessarily have to communicate with on a day to day basis (Purnell & Paulanka 2003).  Other cultural indicators of cultural responsiveness at the organisational level might be internal communication processes that are set up, for example are there interpreters or welfare officers designated in house, are there team briefings where multi-disciplinary teams can conduct an ongoing self-assessment and evaluation of their evidence based practice.

Where organisational strategies have some scope in addressing the issue, this often depends however on the managerial style of the healthcare organisation.  A trust with a unitarist style for instance might lean towards managerial adversarialism where managerial prerogatives dominate. Initiatives usually take on a top bottom approach.  Cultural responsiveness can therefore be limited as employee initiatives are not always encouraged. On the other hand, a pluralist style of management may encourage more forms of involvement and participation which encourages input at all levels.  

The responsibility therefore should be at the practitioner level to evaluate these standards of cultural competent care by way of individual self-appraisal (Markey et al 2012). The Papadopoulos, Tilki and Taylor model identify four stages of developing cultural competence for the practitioner (Papadopoulos 2006). The first stage is cultural awareness which begins with an examination of an individual’s personal values and beliefs, which then informs decision making.  This can often lead to stereotyping.  For example, a nurse might naturally assume that a patient who comes into the ward dressed in their traditional attire might require an interpreter if not accompanied by family members.  This of course might not be the case.  Therefore, it is imperative for a practitioner to find out the ethnic origins of the users they are providing a care to avoid these biases. The second is cultural knowledge which also links to cultural responsiveness as it involves both the study and research of both cultural diversity and similarities. The third is cultural sensitivity which emphasises building interpersonal relationships and fostering patient centred care. The fourth model is the highest achievement which is cultural competency. This requires a complex synthesis of skills as well as other factors such as a practitioner’s previous background experience. These skills enable the practitioner to undertake daily routine procedures such as assessment of needs, clinical diagnosis and other caring tasks (See Table I).  Campinha-Bacote’s collection of cultural data for patient’s assessment of needs also provides a further insight on the core skills element needed by practitioners (See Table II).  Leininger (2002) also developed a Sunrise model, which includes domains such as ethnohistory, language and communication.  

Within the health and social setting, culture can create a set of values, beliefs and norms and practices which guides thinking, decision making and actions in a patterned way (Leininger 2002).  Cultural competence therefore is the capacity of health and social care practitioners to provide effective evidence based health care that consider peoples’ cultural beliefs, behaviours and needs. This is an essential element of challenging deep rooted social misinformation that provides the basis of discriminatory care. Furthermore, this must be an ongoing process and results from a synthesis of knowledge and skills that are acquired and built upon in the cause of a practitioner’s personal and professional life.