Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 38 POLICY BRIEF Beyond Silos: A Call to Include Hospital Support Staff in Cultural Competency Training Ciara Sheehan¹, Estefanía Callejas De Luca¹, Hélène Marguerite Leon¹, Simon Boch¹ ¹Department of International Health, Governance and Leadership in European Public Health Master, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands. All authors contributed equally to this work. Corresponding Author: Ciara Sheehan Address: Duboisdomain 30, 6229 GT, Maastricht, The Netherlands Email: c.sheehan@student.maastrichtuniversity.nl mailto:c.sheehan@student.maastrichtuniversity.nl Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 39 Abstract Context: Patient populations are becoming more diverse. As a result, the “one-size fits all” approach to healthcare delivery is no longer sufficient. Today, quality of care is highly influenced by the cultural competency (CC) of healthcare providers (HCPs). HCPs, however, are not the only members of hospital staff who influence quality of care. Another group, hospital support staff (HSS), also play a critical role in the healthcare delivery process. Yet, HSS remain under-recognized and have been left out of hospital-led CC training. Aim: This policy brief offers a novel perspective, advocating for the inclusion of HSS in hospital-led CC training, as it has been acknowledged by previous research that increasing the CC of healthcare staff is an appropriate strategy to improve the quality of care for patients. Methods: To gain more insight, interviews and surveys were conducted (October 2022) among a group of HSS at the Ronald McDonald House (RDMH). These HSS include volunteers and managers who enable Family Centred Care (FCC) for Maastricht University Medical Centre (MUMC+). A non-systematic literature review on the topic of cultural competency development was also conducted. Results: To develop policy recommendations, options were first assessed using a pre-established framework for developing organisational CC by Castillo & Guo (10). In addition, a stakeholder analysis was completed. Together with the survey responses and interviews, this confirmed HSS, need and want to be culturally competent. These results feed into the development of policy recommendations. Recommendations:Thus, three policy recommendations are made: (1) formalise CC training at MUMC+; (2) include HSS in such a CC training; and (3) develop and monitor training with Participatory Action Research (PAR). Keywords: Cultural Competency, High-Quality Care, Hospital Support Staff. Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 40 Introduction and Context The Changing Landscape of Dutch Hospitals In recent years, the Netherlands has seen increasing ethnic diversity among its patient populations, due to migration patterns (1). For example, by 205030%-40% of the total population in the Netherlands is expected to have at least one non-Dutch parent (2). This demographic shift will have important implications for the Dutch health sectorin terms of how it can serve highly diverse patient populations (1). Language of people, belief system, and ethnic origins influence the experience of illness and level of adherence to healthcare advice (3). To keep pace with these transitions and ensure care remains of high-quality for all patient groups, Dutch hospitals are beginning to evolve as foundat Maastricht University Medical Centre (MUMC+). Feedback provided from MUMC+outlined that a DE&I group has recently been established to examine what DE&I policies can be developed in MUMC+. Among other initiatives, this group introduced training for healthcare professionals (HCPs) about patients’ cultural differences. Cultural Competency (CC) Training As recognised by previous research, increasing the cultural competency of healthcare professionals (HCPs) appears to be an appropriate strategy to improve the quality of care for today's multicultural populations(3) (Figure 1). "Cultural competence denotes the knowledge, skills, attitudes, and behaviours necessary for a professional to provide optimal healthcare services to people from a wide range of cultural and ethnic backgrounds" (3, p. 92). A lack of cultural competency amongst HCPscan result in negative impacts on quality of careand persisting health inequalities for patients of an ethnic minority (1). For example, a 2017 comparison of Dutch and ethnic-minority patients revealed that the latter experienced poorer levels of empathy from HCP’s and had shorter consultations (1). A Key Stakeholder is Missing Healthcare professionals are, however, not the only members of hospital staff who interact with patients and influence quality of care. Non-medical, or hospital support staff (HSS), ensure HCPs can deliver high quality care, both directly and indirectly Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 41 (e.g., by providing meals, transportation, and a hygienic environment) (4). Typically, HSS represent a third of the total hospital staff, including administrators, financial advisors, or cleaners (Table1). In the United States, 45% of people working in hospitals are non-clinical staff (including administrative and other support staff), while this proportion is around 30% in Switzerland, France and Iceland (5). Data on non-medical personnel in the Dutch health system, for example cleaning and administrative staff, is not available. In addition to their standard tasks, HSS may offer emotional support to patients and their families. Cleaning staff provide “mental, emotional, and spiritual, person-centred care” in the 10-20 minutes (per day) they spend with a particular patient (6, p. 6). Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 42 Policy Brief Aim Vance et al. (6) are among few authors that have elucidated the role of HSS in patient care. Therefore, the potential of HSS to maximise quality of care is overlooked. Broadly, this policy brief advocates for the recognition of HSS as key stakeholders in the hospital setting. Further, it argues that an immediate action towards this goal is the inclusion of HSS in hospital-led CC training. At the local level, this call is made to decision-makers in MUMC+. The recent establishment of a DE&I group at MUMC+ points to a desire by the organisation to engage in DE&I initiatives. CC competency training for all members of the healthcare workforce from HCP’s through to HSS is an option for MUMC+ to consider. Methods To gather the data from RMDH Maastricht,managers and volunteers of RMDH were interviewed and surveyed (October 2022). During the interview, key barriers and facilitators in providing FCC (under the umbrella of cultural competency) were discussed. An anonymous survey of the volunteers was conducted to assess four areas: (1) demographics; (2) perceived need for cultural competency and DE&I initiatives; (3) current barriers related to cultural competency that impact “hospitality”; (4) desire to improve cultural competency and DE&I practices. In total 22 responses were received (17 online and 5 on paper). To gain insight from MUMC+, feedback was received from an Ambassador of the MUMC+ DE&I group on current DE&I policies inplace in the organisation and plans for future programs, including CC training. A non-systematic literature review was conducted on the topic of developing CC and it’s benefits for the delivery of healthcare services. Evidence and Study Description 1. Why should HSS be included in DE&I Initiatives, such as CC Training In terms of the evidence gathered, RMDH Maastricht serves families from a large range of cultural and ethnic backgrounds, while the demographic of the volunteers is mainly white Dutch women over the age of fifty. While the survey data indicated that ethnic diversity of RMDH service-users is Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 43 varied, this has not been met with increasing diversity among RMDH staff. In terms of perceived need,responses from volunteers noted that personal awareness and communication were critical to make parents and families of a non-Dutch background feel more “at home”.To understand the motivation for participating in CC training, several DE&I initiatives related to developing cultural competencies were listed for the respondents’ consideration. Results suggest that the volunteers would be willing to participate in CC training programmes which develop understanding of cultural habits of oneself and others, how cultural practices and ideas affect health and understanding of quality of health services, andthe role of care providers in different cultures. On the basis oftheinterview data, there is a gap in demographics of the volunteers and service users. A potential benefit of CC training for the organisation would be an increase of inclusivity and hospitality which could improve services provided to the families. Also, a collaboration between RMDH and MUMC+onDE&I initiatives could also be of benefit for service users, as both organisations share similar barriers such as language and cultural differences. At MUMC+ there has been efforts made to date surrounding CC. For example, training has been provided to healthcare professionals in terms of cultural differences in patient populations. The DE&I group intend to continue provision of such training to enable staff to be informed of and appreciate cultural diversity. Finally, evidence suggests that improved cultural competency of healthcare staff can improve the quality of care provided to patients, as knowledge of cultural groups can be used appropriately to increase the quality of healthcare services provided (9). 2. How can HSS be included in DE&I initiatives such as cultural competency training? Castillo & Guo (10) have developed a framework for how healthcare organisations can develop cultural competence in an impactful way. The selected framework (Figure 3) is made up of three elements (9): (1) the Board of Directors and Chief Executive Officer (CEO) ensuring that Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 44 cultural competence is integrated into all organisational policies; (2) developing a strategic plan with anticipatory and long-term processes and objectives that emphasise the importance of cultural competence training; and (3) facilitating continuous monitoring and evaluating efforts in order to assess the level of cultural competence and whether objectives in developing cultural competence have been achieved. This framework will be employed to identify potential areas in MUMC+ where policies to develop cultural competence can be executed. These policies should ensure long- term change and provide opportunities for HSS to be recognised. As set out in the framework, the ultimate aim of adoption of such policies is to increase cultural competence, leading to improvements in quality of care. Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 45 Box 1. A Specific Case: The Ronald McDonald House Maastricht (RMDH) What is the Ronald McDonald House (RMDH)? Ronald McDonald Kinderfonds Nederland (RMKN) was established 35 years ago in the Netherlands and encompasses the Ronald McDonald Houses (n=12), Living Rooms (n=12), and Holiday Homes (n=3) (11). The RMDH Maastricht provides a “home away from home” for parents (and siblings) with a child in the NICU, PICU, or Children's Ward of the MUMC+ (11). RMKN has ensured sick children and their families can be close to each other, contributing to global, upward trends in Family Centred Care (FCC). Hereby, RMKN plays an essential role in promoting the physical and mental well-being of sick and care-intensive children and their families. For instance, an impact analysis in 2015 revealed that 97% of families indicated they were able to care for their sick child better by staying at the Ronald McDonald House (11). Moreover, RMKN has four core values, including: (1) Make families feel at home; (2) Provide a listening ear (3) Remain quality driven; and (4) Be reliable and transparent. To upload these values, RMKN must closely monitor developments in healthcare and society, such as patient diversification. Thus, a key focus of RMKN’s 2020-2023 “Multi-Year Strategy” is developing and implementing a “cultural program” with “cultural ambassadors'' (11). What is Family Centred Care (FCC)? How does it influence quality of care? HSS at RMDH play an integral role in the provision of Family Centred Care (FCC). The family-centred care approach requires a change in the role of the patient and his/her family (11). The patient and family represent an active component of care and the patient's potential Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 46 well-being depends on teamwork involving the patient, family, and healthcare workers (12).Thus, in this approach the patient is no longer a passive recipient of treatment and medicine. Further, the institute for FCC established some core concepts that are at the heart of this model, they are: dignity and respect, information sharing, participation and collaboration (13). Lastly, on an organisational level FCC offers means to improve quality of care and stimulates higher job satisfaction among HCPs (12). Policy Options The evidence gathered from literature, and interview and survey dataoutlines firstly the importance of developing cultural competency amongst the healthcare workforce and secondly, that non-medical personnel such as HSS are aware of the need and are motivated to participate in developing these skills. As DE&I practices have not yet been extended to include HSS, this research advocates for action to incorporate this group of the healthcare workforce in DE&I policies. Policy options to do so exist at four different levels corresponding to the Castillo & Guo (10) framework. These options are identified and described in Table 1. Table 1. Policy Options based on Castillo & Guo (10) framework. Tier Name Description of Options 1 Governance (Board of Directors and CEO) - At the governance level of both MUMC+ and RMKN (RMDH), DE&I should hold a prominent position in the “Annual Agenda”. - Commitment to DE&I could be exemplified by the funding and allocation of human resources to CC Training for all staff. Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 47 - This commitment could be further demonstrated by the Governance level requiring all HCPs and HSS, involved in FCC, to ascertain a CC Training certificate. 2 The Mission, Vision, Values Statement - In order for DE&I to hold a prominent position in the delivery of FCC, DE&I policies should be integrated into all organisational policies at the hospital and RMKN. - This would demonstrate a long-term commitment by the Governance level which will feed down into the culture of both organisations. 3 Strategic Plan - The development of a strategic plan at the hospital and RMKN should be developed to offer cultural competency training for HCP’s and HSS. - Such a plan should recognise the evidence that cultural competency training can improve quality of care. - Furthermore, including HSS in future Strategic Plans will acknowledge their role as “important players” in the delivery of high-quality care. 4 Monitor and Evaluation - Implementation of any DE&I policy, strategic plan, or initiative cannot be effective without progress monitoring (of pre-defined outcomes) and routine evaluation. - A key measure will be “Level of Engagement and Participation” of HCPs and HSS. Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 48 - Social media (e.g., Facebook and LinkedIn) could be implemented as channels through which the RMKN can easily reach their audience to deliver a message about CC. - Given CC Training is a “new” approach in the Netherlands, resistance is anticipated. To proactively address any resistance from key stakeholders, strategies such as Participatory Action Research (PAR) could be utilised. Stakeholders As outlined in Table 1, “stakeholder engagement” is necessary at every level (or tier) to develop organisational CC. Hence, stakeholders are considered the most influential part of this policy brief. The stakeholders necessary to implement and progress policy recommendations are visualised in Figure 4 and Figure 5 (based on their involvement in cultural competency). An important stakeholder group is the RMKN; whose role is to create a sense of belonging and inclusion in all the Dutch RMDHs. The RMKN organises activities during the year where employees and volunteers are invited to attend. Events include charity runs, theatre performances, fundraisers, etc. Interviews with RMDH Maastricht management revealed, the current organisation of these events makes it difficult for volunteers and staff to engage. In fact, the events are organised only in the main cities (e.g., Amsterdam, Eindhoven), creating geographical barriers for volunteers. Arguably, more attention to these details could result in achieving higher participation as well as a stronger sense of belonging. Lastly, the stakeholder analysis confirmed HSS are key stakeholders in the hospital setting. Correspondingly, survey responses indicated HSS have a strong willingness to Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 49 take action on DE&I. However, resistance from HSS (reflected in some interview/survey responses of RMDH volunteers) as well as other staff members is anticipated. Thus, leaders (e.g., hospital management) need to be prepared to overcome this resistance and allow for participation and inclusion of all stakeholders. For example, one option is for RMDH to be included in the recently formed DE&I initiative group at MUMC+, thus allowing this under-represented group in the workforce to play a role in the development and implementation of DE&I policies. Figure 4. Stakeholders involved in our case study (created by Authors). Figure 5.Level of stakeholder interaction with patients (created by Authors) Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 50 Policy Recommendations Based on the research conducted and considering the policy options available throughout the tiers of the CC framework (10), the following recommendations are being made to facilitate the development of CC at RMDH Maastricht and MUMC+. Recommendation 1: Formalise Cultural Competency Training at Maastricht University Medical Centre (at TIER 3). A desire for progress of DE&I was reflected at the hospital level. A DE&I initiative group has recently (2022) been started by and for MUMC+ staff members. There have been substantive consultations with University Maastricht (academic institution) to inform this initiative. A DE&I initiative group organised a training for HCPs on cultural differences in patient populations. This training has not been formalised as an annual, mandatory Cultural Competency Training. A mission of MUMC+ is to guide staff from unconsciously incompetent to consciously competent, both for cultural diversity and for other forms of diversity. Thus, the DE&I group should commit to formalising this cultural training, as a CC training. In addition, as reflected by the intentions of the DE&I group, such training should become a point on the Annual Agenda of MUMC+. Recommendation 2: Include HSS in Cultural Competency (CC) training (at TIER 3). A review of literature found (globally) DE&I agendas and policies focus on front- facing clinical staff: neglecting a traditionally under-recognized group of HSS. However, surveys at RMDH revealed HSS are important players in the delivery of high-quality care, especially Family Centred Care (FCC). There exists a significant and visible gap between the demographics of volunteers/management staff of RMDH (e.g., white, Dutch women over the age of 50) and its guests (e.g., young Arabic, Polish, or Ukrainian parents). This gap extended to “spoken-language”; such that the languages spoken by volunteers (e.g., Dutch, English, French) did not align with those of non-Dutch RMDH families (e.g., Arabic, Polish, Ukrainian). Importantly, all survey responses indicated “language” was a significant barrier to creating a “welcome atmosphere” for Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 51 RMDH families. Other barriers included: guests’ bias towards females, the “stand-off” nature of guests, and a lack of understanding about cultural norms. RMDH management staff indicated this was also true for the MUMC+. However, the HCPs at the hospital make use of a translator available by telephone. Therefore, of possible DE&I priorities, the survey results illustrate CC training (to address language barriers and the increasing ethnic diversity among patients and their families) would have the greatest impact on the quality of FCC at MUMC+. Parallel, both the RMDH and MUMC+ are committed to developing DE&I policies, including policies aimed at increasing cultural awareness. RMDH staff knowledge, accept, and are motivated to participate in those DE&I initiatives. Recommendation 3: Develop and monitor CC training for HSS through Participatory Action Research (PAR) (at TIER 4). Given the central role HSS play in maximising quality of care, it is essential their participation in DE&I progress be facilitated and they be recognized as an important, valuable stakeholder (15). RMDH management staff believe that DE&I policies are necessary. Likewise, volunteers at RMDH demonstrated a keen desire to participate in DE&I initiatives related to cultural competency development. Namely, more than half of survey-respondents were interested in “A session on the advantages and disadvantages of one's own and other cultural habits”. Interestingly, while language was seen as a significant barrier to creating a “welcome atmosphere” few respondents wanted to participate in a “Polish or Arabic language class”. To ensure CC training is targeted to HSS appropriately, PAR may be employed. Importantly, PAR will engage HSS and enable them to share interactions/relationships of daily life in the workplace. Furthermore, PAR challenges the interests of stakeholders, destabilising established habits, hierarchies, and power dynamics (16). Lastly, PAR may be used to motivate HSS to participate in future DE&I programs, as those programs can be appropriately targeted to them. PAR is a valuable methodology to approach HSS, understand Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 52 their perspectives, and encourage a “flexibility” within them. Ultimately, this may lead to organisational internal development. In addition, it is a low-level, cost-effective and holistic approach to monitoring and evaluation (16). Future Considerations 1. At RMKN Level: There is an awareness among RMDH management staff of the importance of DE&I. This arose after the annual RMKN Annual Meeting, which focused on DE&I at RMDHs. The Management Team indicated, however, while DE&I efforts have been made, they may not have the desired impact at a local level. For example, the organisation of DE&I events such as the theatre performance had very little interest expressed from Maastricht RMDH staff. In organising such events, more attention to the preferences of staff and volunteers at the local levels could result in increased engagement and participation by HSS. 2. Recruitment Practices: In terms of supporting the diversity that RMDH Maastricht wants to embody, the management staff discussed how changes could be made to recruitment practices. Management discussed placing recruitment posters in more diverse locations and adjusting the language of recruitment material. Also, they expressed that the requirement to speak Dutch to be a volunteer at the RMDH could be a point to reconsider. 2. Data Availability: Lastly, at present, no (quantitative) analysis of the demographic characteristics of RMDH staff and service- users is possible. This is because data on these characteristics is not collected by the MUMC+ or RMDH administration. Management staff reported volunteers are diverse in terms of ethnicity, gender, sexuality, and disability. Limitations In terms of limitations, data related to the demographics of HSS in the Dutch health care system and from RMDH of the demographics of both volunteers and service users was not readily available. While the survey data and interviews from RMDH did indicate a gap between cultural and ethnic background across both groups, there is no quantifiable data available as this is not collected by the organisation. The use of CC training as a tool was the only initiative examined to improve quality Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. A Call to Include Hospital Support Staff in Cultural Competency Training. SEEJPH 2022, posted: 8th December 2023. Posted: 09 April 2023 Page 53 of care for minority patient populations. There are many facets to delivering care that is of high quality and standards, especially for patients from ethnic and cultural minorities. Further study of the factors that impact their care, outside of the cultural competence of staff, is an important consideration for future research. Conclusion As demonstrated HSS can be highly involved stakeholders in the delivery of care to patients and their families, as exemplified by the services provided at RMDH Maastricht. Given the frequent and low- barrier nature of contact between HSS and patients, they are considered important players for the delivery of high-quality care, particularly FCC. Their under-recognition must be addressed urgently, as advocated for by this research. This can be achieved by incorporating HSS in policies that seek to improve quality of care (i.e., organisational CC). This policy brief found, up to now, hospital- led DE&I initiatives only include hospital staff. MUMC+ and RMDH Maastricht are aware of the need for DE&I policies and are taking the initial steps to progress organisational change. Therefore, synchronising the work of MUMC+’s DE&I initiative group with RMDH, would provide an opportunity for both organisations to maximise DE&I efforts. At the centre of harnessing this potential are multi-level stakeholders. Thus, particular attention should be paid to proactively addressing the stakeholders' resistance by encouraging greater participation activities promoting cultural competencies. Through the interviews and surveys conducted, the need, motivation and will to incorporate DE&I change efforts is present at both RMDH Maastricht and MUMC+. This research has provided three key recommendations which can be considered to further the development of cultural competency across both organisations; (1) formalise CC training at MUMC+; (2) include HSS in such a CC training; and (3) develop and monitor training with Participatory Action Research (PAR). Conflicts of interest There are no conflicts of interest to declare. Acknowledgments The authors wish to extend gratitude to the MUMC+ DE&I Initiative Group and the Management Staff and volunteers at RMDH Sheehan, C. Callejas De Luca, E. Leon, H. Boch, S. 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Wiley- Blackwell, 2009. ___________________________________________________________________________ © 2023 Sheehan et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://rmhc.org/