Culturally Competent Multicultural Workforce

  • Dula Pacquiao


Globalization and the internationalization of the economy have contributed to changing patterns of supply and demand in healthcare workforce. Several studies have documented the value of a multicultural workforce in business, healthcare, and education. While diversity in the workforce needs to better represent the growing diversity in the population served, the need for cultural competence development of all health professionals is recommended by public and private stakeholders worldwide. Approaches for cultural competence training of diverse healthcare workforce that aim toward global citizenship and the attributes of global citizens are presented. Three case studies demonstrate application of this guideline in different parts of the world with recommendations for approaches at the individual, organizational, and community levels.

31.1 Introduction

The trend toward increasing diversity in world populations has been associated with globalization supported by advances in technology and internationalization of economy. Technology has allowed easier world travel and movement of people, reducing physical distances and heightening awareness of cultural diversity. As part of the global economy, people are now living and working in environments exposed to diversity, requiring more interactions with people from diverse backgrounds. The global economy has intensified competition for resources worldwide, moving human and material capital across regions and nations to maximize productivity and profitability. Organizations are becoming more diversified to remain competitive.

Today’s world gradually is becoming more global in its outlook, and as the marketplace becomes increasingly global in nature, the need for multiculturalism in the workplace will continue to grow. For many people, encounters with people from different racial and ethnic backgrounds as well as national origins occur most frequently in the workplace (Martin and Nakayama 2010). Workplaces are places where individuals from diverse cultures convene and collaborate. Recent immigrants comprise more than half of the total workforce in the USA (Okoro 2012). Diversity challenges are not limited to businesses and healthcare organizations but also involve academic institutions.

31.2 Definition of Multicultural Workforce

Understanding a multicultural workforce requires an expanded definition of cultural diversity to encompass differences between people in an organization including age, generation, national origin, race, ethnicity, class, gender, sexual orientation, religion, education, disability, language and communication, and life experience (Okoro 2012). Workforce diversity also includes differences in personality, cognitive style, tenure in the organization, organizational role, and work preferences. Diversity requires acknowledging, understanding, accepting, and valuing differences among people; it involves how people perceive themselves and how they perceive others, which affect their interactions (Mayhew 2017).

31.3 Drivers of Workforce Diversity in Healthcare

31.3.1 Global Healthcare Workforce Shortage

The World Health Organization estimated that the worldwide shortage of healthcare workers including doctors, midwives, nurses, and other healthcare workers rose from 4.3 million to 7.2 million in 2013. This shortage is predicted to increase to 12.9 million by 2035 (WHO 2013). The number of countries with health workforces well below the basic threshold of 23 skilled health professionals/10,000 people increased from 75 in 2006 to 83 in 2013. While the largest shortages are predicted in parts of Asia, sub-Saharan Africa will be most severely affected. Internal and international migration of health workers exacerbates regional and global shortages. The pattern of internal migration flows from rural to urban areas, while international migration flows from low- and mid-income countries to high-income countries in North America and Western Europe (Allutis et al. 2014). International migration may occur among neighboring countries in the same region or continent. This is motivated by several factors, including better wages and more opportunities for employment, educational advancement, and career mobility. Some health workers migrate to escape poverty, violence, and disease epidemics in their home country (Allutis et al. 2014; Kingma 2007).

Many countries in North America, Europe, the Middle East, and Oceania actively import health service labor to sustain their own healthcare system, while African countries (Zimbabwe, Nigeria, Ghana, Zambia, and South Africa) experience a net outflow of health workers. Seventy percent of health workers from African countries (approximately 65,000 physicians and 70,000 nurses) have migrated to high-income countries (Clemens and Petersen 2008). Nearly all European members of the Organization for Economic Cooperation and Development (OECD) increasingly rely on recruiting health workers from abroad to fill their shortages. In contrast to Estonia, Slovakia, and Poland that have little reliance on foreign medical doctors, Switzerland, Slovenia, Ireland, and the UK have very high reliance on foreign health workers especially medical doctors. A study of ten countries in the European Union (EU) found that one third of migrant doctors came from outside EU: 60% in France and Italy and 80% in Ireland and the UK (Dussault et al. 2009).

Worldwide, nurses comprise the largest group of healthcare workers as well as the largest migrant group among all categories of healthcare workers. In the USA, the number of companies engaged in international nurse recruitment rose from about 40 in 1990 to 270 in 2009 (Eckenwiler 2009). About 8% of US Registered Nurses (RNs) are foreign-educated with the Philippines as the major source country accounting for more than 30% of US foreign-educated nurses. Nurse immigration to the USA has tripled since 1994 to about 15,000 annually (Aiken 2007). The USA employs the most international nurses, but foreign-educated nurses comprise only 4% of its nursing workforce, compared to the UK and Ireland (8%) and Canada (6%). The top six countries that export nurses are the Philippines, Canada, India, Nigeria, Russia, and Ukraine (Walker 2010).

High-income countries have resorted to foreign recruitment to address their workforce shortages instead of developing an adequate plan for sustainable workforce development within their own countries. International recruitment has created the phenomenon of “brain drain,” a shortage of highly educated and skilled health workers within the source countries, which has catastrophic effects on the quality of care, disease burden, and mortality in these countries (Allutis et al. 2014; Kingma 2007). The “brain drain” has worsened conditions in source countries that are likely to be low-income, resource poor, and plagued by shortages of manpower particularly highly skilled professionals and well-qualified educators; shortages are worse in rural areas.

31.3.2 Government Policies

The pattern of migration of Filipino internationally educated nurses (IENs) illustrates how the drivers of migration work. Filipino IENs comprise the largest group of migrants with the USA as the favored destination country. Filipino nurses emigrate because of high unemployment at home despite a glut of nurses because the local economy could not absorb the large numbers of graduates, creating tight competition and less opportunity for advancement. Low wages have prompted Filipino physicians to retrain as nurses for employment abroad.

According to Jurado (2013), both the US and Philippine governments have played a major role in creating the “push” and “pull” for nurse migration. The Philippines was colonized by the Americans in 1898 after the Spanish-American War that ended centuries of Spanish rule since 1521. Except for a brief period of Japanese occupation during World War II, the American occupation finally ended in 1946 when the Philippines gained its independence. During the occupation, Americans were confronted with health issues in the Philippines from epidemics of typhoid, cholera, smallpox, and tuberculosis. In addition to introducing mass public education, the Americans were instrumental in developing hospitals, public health programs, and training of doctors and nurses in the Philippines. The Americanization of Philippine nursing was paved by American teachers and textbooks and further training of nurses in the USA; these nurses subsequently assumed leadership positions in nursing education and service. The American influence in the country’s professional nursing and healthcare has remained strong with English as the medium of collegiate instruction (Pacquiao 2003). According to Masselink (2009) countries that were colonized may have been introduced to the colonizer’s language and educational systems, facilitating ease of migration to the colonizing country. Consequently, Filipino nurse graduates are preferred targets of foreign nurse recruitment. In fact, nursing shortages with corresponding opening of visa entry to the USA are the major influence in local nursing enrollment in the Philippines (Jurado and Pacquiao 2015). US immigration policies since after World War II have paved the way for thousands of Filipino IENs to enter the country legally by creating different entry visa categories (temporary and permanent status), extending their legal residence in the USA after expiration of their temporary work visas and allowing adjustment of their temporary status to permanent residents (Jurado 2013).

The Philippine government has encouraged labor emigration because Filipinos working in other countries send significant remittances that bolster the dollar revenues of the country critical to the payment of its foreign debt. Since the time of President Marcos, the government has encouraged overproduction of nurses for export. Large numbers of nurses are unemployed due to limited employment opportunities in healthcare. Healthcare jobs offer low wages, so many nurses seek employment outside of healthcare (Jurado 2013).

31.3.3 Increased Global Demand for Healthcare Services

Healthcare workforce shortages have been attributed to high demand for healthcare services because of the increasingly aging population, population growth, higher prevalence of chronic and noncommunicable diseases, and expansion of primary care services (WHO 2013). The UN’s Millennium Development Goals and Alma-Ata’s declaration of “healthcare for all” have given impetus to the global agenda to provide universal access to healthcare. Increased recognition of the social determinants of health has pushed the need for primary care services that promote health beyond disease-based care (ICN 2006). The shortage is also attributed to lack of workforce planning, inadequate funding for students entering the professions, inadequate numbers of faculty constraining enrollments, and growth of alternative work opportunities for women (AACN 2014; ICN 2006).

In the USA, there are 6804 geographical areas, populations, and facilities with a shortage of primary medical practitioners, 5598 with a shortage of dental professionals, and 4730 with shortage of mental health professionals (HRSA 2017a). In addition, 4221 areas are designated as medically underserved areas or populations that have too few primary care providers, high infant mortality, high poverty, or high elderly population (HRSA 2017b). It is predicted that by 2025, there will be a shortage of 23,640 primary care physicians (general, family, and internal medicine) (HRSA 2016). Buerhaus et al. (2009) have predicted that the imbalance in the supply and demand for nurses will be worsened by the mass retirement of aging American nurses. The RN workforce is expected to grow from 2.71 million in 2012 to 3.24 million in 2022, representing an increase of 19%. In 2022, 525,000 nurses will be needed to replace those who will retire, bringing a total of 1.05 million job openings to meet the increased demand and replacement (AACN 2015).

Several studies have indicated that the insufficient nurse staffing contributes to higher stress levels among nurses, which has a negative impact on their job satisfaction and retention, as well as patient safety and survival (AACN 2015). Adequate nursing staffing was associated with decreased patient hospital stay, rehospitalization, infections, and mortality. Studies in 12 countries in Europe, USA, and Canada found fewer patient deaths in intensive care units that were staffed with higher percentages of nurses with baccalaureate degrees (Aiken et al. 2014). A consensus exists among consumers, nurses, physicians, and healthcare administrators regarding the significant impact of nurse staffing ratios on quality of care and patient outcomes (Aiken et al. 2012). The Institute of Medicine (2010) has called for increasing the numbers of baccalaureate and doctorally-prepared nurses to meet this need.

31.3.4 Population Diversity

The growing population diversity has highlighted the need for greater representation of racial and ethnic minorities among healthcare professionals. By mid-twenty-first century, it is predicted that the USA will cease to have a majority race. Ethnic and racial minorities will increase from 37% to nearly 50% of the total population as compared to white Americans who will decrease from 69.4% to 50.1%. Hispanics will experience 187% growth and African Americans 71%; Hispanics and African Americans will comprise 24.4% and 14.6% of the population in 2050, respectively (Colby and Ortman 2015; Okoro 2012).

Currently, over 33 million people speak Spanish in the USA, more than 10 million speak another European language, and more than 8 million speak an Asian language (Okoro 2012). However, today’s health professional workforce does not proportionally reflect all racial and ethnic groups; whites comprise more than 80% of the health professional workforce. While Asian Americans are well represented in health careers, the representation of African Americans, Hispanics, and Native Americans is much lower. When combined, these groups represent over 30% of the US population, yet these minorities are underrepresented among physicians, registered nurses, dentists, pharmacists, and allied health professionals (Valentine et al. 2016).

31.3.5 Existence of Health Inequities

There is mounting evidence of health disparities in access to health services and health outcomes across population groups within the same region and across different nations. Worldwide, there is overwhelming evidence demonstrating poorer health among those with lower socioeconomic status and groups who experience a history of systemic discrimination, marginalization, and disempowerment. These groups are likely to live in neighborhoods with meager resources and higher health risks as well as encounter prejudice and discrimination when accessing health services (see Chap.  1).

In the USA, racial and ethnic minorities comprise the majority of people living in areas designated as health professional shortage areas (Mitchell and Lassiter 2006). According to the American College of Physicians (2010), minorities have less access to healthcare than whites and receive poorer quality of care even when access-related factors such as insurance status and income are controlled. For example, 34% of Hispanics are uninsured as compared to 13% among whites, more minority women avoid doctors’ visits because of cost, and racial and ethnic minority Medicare beneficiaries with dementia are 30% less likely than whites to use anti-dementia medication. Compared to white Americans, African Americans are less likely to receive certain treatments, wait longer for kidney transplants, are more likely to die from cancer from all causes, and have higher infant mortality rates. Hispanic and African Americans are more likely to die from diabetes complications than white Americans (AACN 2014).

Countries with universal access to health services have focused on social determinants and social inequalities to address health inequity, defining the latter as avoidable and unfair differences (see Chap.  1). By contrast, the USA lacks a universal program for accessing healthcare services. Hence, efforts have focused on increasing representation of racial and ethnic minorities in health professions, training, and development of health practitioners and students in culturally competent care and changes in organizational infrastructure and health delivery. It should be noted that development of all healthcare practitioners and students in culturally competent care has been recommended by international and national stakeholders alike.

31.4 Advantages of a Multicultural Workforce

Multiculturalism in the workplace can create a sense of cultural awareness among workers as employees are exposed to different ideas and perspectives. Encounters with diverse perspectives can stimulate reflection on one’s own ways of thinking and doing. Diverse viewpoints can generate new and innovative solutions (Lewis 2017). As a result of exposure to cultural differences, curiosity can be stimulated and employees are motivated to learn more about other cultures. Knowledge of cultural differences can promote tolerance in the workplace and implementation of work approaches that are informed by this knowledge (Green et al. 2015). Exposure to different viewpoints and cultures can build tolerance of different perspectives, which in turn can foster improved collaboration and cooperation. Employees from diverse backgrounds thrive in an organizational climate of inclusion and openness (Mayhew 2017). The effectiveness of a diverse workforce depends on a climate of multiculturalism that permeates every aspect of the organization (Greenberg 2004).

Organizations can draw from a greater variety of abilities offered by diverse employees, such as, multilingual proficiencies, and work-related expertise and life experiences in other cultures. Companies may benefit from a workforce with a larger social network than just one ethnic group that can generate an interest in providing products and services in many ethnic communities. An organization providing goods and services that appeal to several ethnic groups is more likely to be successful with workers who can communicate with these groups.

Employees with diverse backgrounds can also improve global competitiveness of their organizations because they are familiar with their own country—the customs, traditions, and language of the people. They can act as cultural brokers and facilitate bridging with global customers (Bovee and Thill 2008). Workforce diversity has become a powerful tool for recruitment and retention of the best employees in order to sustain an organization’s competitive edge (Cadrain 2008). An effective multicultural workforce can increase an organization’s success, competitiveness, and adaptability in a global marketplace. A multicultural workforce offers a greater pool of talents, ideas, and work ethic that can enhance organizational effectiveness.

Healthcare organizations gain these same benefits from a diverse workforce. A review of studies in healthcare by the US Health Resources and Services Administration (HRSA 2006) revealed that patients are more likely to receive quality preventive care and treatment when they share race, ethnicity, language, and/or religious experiences with their providers. A diverse workforce and the diverse perspective it provides contribute many benefits, including enhanced communication, increased healthcare access, greater patient satisfaction, decreased health disparities, and improved problem-solving for complex problems and innovation. Given a choice, racial and ethnic minority patients are more likely to select health professionals of the same racial and ethnic background as themselves. Patients are more likely to report greater satisfaction with care and higher quality of care received when they share a common racial and ethnic background as well as language with their providers. Minority providers improve access to care in underserved areas more than nonminority providers; they are more likely to practice in underserved communities and care for large numbers of minority patients (HRSA 2006).

Diversity in health professional educational environments improves the quality of education and ability to treat patients from different sociocultural backgrounds by broadening students’ perspectives. Diversity improves learning outcomes, thinking and intellectual engagement, motivation, social and civic skills, and empathy and understanding of racial and cultural differences (AACN 2015).

31.5 Challenges of a Multicultural Workforce

As the workforce becomes increasingly global and culturally diverse, organizations are challenged to communicate more effectively interpersonally, interculturally, and in groups (Lauring 2011). Internal and external communication is essential for an organization to maintain its competitive edge and sustainable growth in a global market. Perceptual, cultural, and language barriers need to be overcome for diversity to succeed. Communication affects productivity and overall business performance, individually and in groups (Gupta 2008). Ineffective communication results in confusion, lack of teamwork, and low morale. Performance and productivity of human capital in the global market depends largely on the effectiveness of business communication and employees’ competence in interpersonal communication, intercultural sensitivity, and nonverbal communication (Nagourney 2008). By expanding avenues for communication and providing ongoing feedback, organizations can establish a culture that values diversity in their employees (Hannay and Fretwell 2011).

Another challenge is resistance from employees to accept and accommodate differences. Productive diverse teams require a robust organizational leadership commitment to allocate resources and create the infrastructure and management systems supportive of active participation and success of diverse employees (Kokemuller 2017). Organizational leaders have the daunting challenge of motivating and promoting harmony among diverse employees while facing challenges from the community and business competitors.

There are costs involved in cultivating an effective multicultural workforce. Ongoing development of managers and future leaders among the diverse pool of employees can facilitate organizational adaptability to internal and external challenges. There are associated costs to global recruitment, training, and development of diverse employees. There are costs associated with litigation involving internal workforce diversity and community diversity. Managers need to adapt to changing responsibilities and social norms by ensuring that practices are aligned with regulatory and legal provisions, e.g., protection against sexual discrimination and harassment, Equal Employment Opportunity, etc. (Greenberg 2004).

A diverse workforce poses increased potential for discrimination because when people with obvious distinguishing traits are placed together, employees with prejudices could use them against others. Diversity management is so critical to preventing such risks. Organizations need to provide cultural awareness and sensitivity training to help create a culture of tolerance and acceptance of differences (Kokemuller 2017).

31.6 Strategies for Building Effective Multicultural Healthcare Workforce

31.6.1 Workforce Planning and Development

Public and private stakeholders worldwide have called for the need for all nations to develop a sustainable workforce. Measures are needed through global and multilateral agreement among countries to prevent unethical manpower outflows that endanger any country’s health. Multilateral agreements among governments should address ways to compensate for the loss of financial investment in the education of healthcare professionals and the negative consequences on population health and healthcare services in source countries. While migration of health professionals has benefited their families and countries through their remittances, these gains are hardly used for improviwng overall population health, healthcare infrastructure, and educational systems. Source countries are also accountable for their lack of policies promoting retention and engagement of health professionals in their own healthcare systems.

A significant strategy recommended is improving the supply of sufficient numbers of students entering and graduating from health professions schools, particularly for racial and ethnic minority students. Attracting racial and ethnic minorities should begin early by increasing awareness of communities of healthcare professions and by engaging minority healthcare professionals in recruiting potential students. Healthcare organizations, including professional associations and schools, should develop long-standing partnerships with primary and secondary schools, the media, and communities to promote interest in healthcare professions. Partnerships among stakeholders in the public and private sectors with health professionals can create sustainable programs and policies on recruitment and workforce development, such as the partnerships between the Institute of Medicine and Robert Wood Johnson Foundation and between Johnson and Johnson and nursing professional stakeholders (IOM 2010; Johnson and Johnson 2016).

To enhance admission of racial and ethnic minorities in medicine, the Sullivan Commission (2004), which is comprised of multiple healthcare stakeholders, recommended using quantitative and qualitative criteria for admission to medical schools to enhance the competitive edge of racial and minority students who may not do as well in traditional measures for admission. To improve the quality of pipeline schools in minority neighborhoods, several initiatives have evolved such as summer enrichment programs to improve students’ proficiency in science, math, communication, and critical thinking as well as awareness of college-level expectations. Cooperative after-school and summer internship programs between high schools and local organizations connect students with mentors in health professions and expose them to different healthcare settings. Professional schools have created an infrastructure to provide academic, financial, and psychological support for disadvantaged students.

31.6.2 Training and Development

Various chapters of this book (Chaps.  1 11) are focused in more detail on development of cultural competence among healthcare workers. This section highlights the process of fostering global citizenship outlook and skills critical to culturally competent practices of healthcare workers. Developing cultural knowledge and awareness must emphasize empathic understanding of the social and cultural contexts of people’s lives. Fostering the development of cultural curiosity in learners by communicating enthusiasm about knowing other cultures should be developed early in education. Much influence is exerted by teachers and mentors who are keenly interested in cultural phenomena and diversity. Curricular integration and selection of learning experiences should be carefully planned to prevent marginalization of certain groups by building unquestioned superiority of others. Empathic and compassionate understanding is enhanced by using different methods of learning using videos, case studies, home visits, travel-learn, etc. Listening to actual narratives by the people provokes empathy and compassion among listeners.

The method of instruction must move away from a listing of descriptions of people’s characteristics and ways of life toward an understanding of how social, environmental, and historical circumstances have shaped people’s life chances and current life situations. Stereotypes and monolithic generalizations of cultures should be avoided. Actual encounters, observations, and experiences in different social contexts are superior in promoting appreciation of the holistic context of people’s lives. Exposure of learners to diversity, disadvantaged communities, and diverse groups should be aimed at developing comparative knowledge of cultures and compassionate understanding of how and why certain people live differently. Teachers and mentors should facilitate discovery of hidden forces that contribute to how people behave and live. For example, learning health disparities must not be limited to morbidity and mortality but should promote understanding of why certain groups have fewer resources and have greater health liabilities than others; learners must be made aware that poor health is not merely caused by poor genes or unhealthy life choices.

Critical reflection can be facilitated by open and respectful dialogue focusing on critiquing and challenging individual opinions. This is built upon the foundation that each one has value and a positive contribution to the collective wisdom and decision. Honest and genuine dialogue should be facilitated in order to challenge individual opinions and come up with equitable solutions. The potential impact of recommended solutions must be examined thoroughly to develop a full understanding of the consequences of each solution on individuals, families, organizations, and communities.

Teachers and mentors must model the learner’s role and the value of humility to facilitate growth and mutual respect among learners. This approach builds trust essential for openness and acceptance of differences. While standards for practice are essential to follow, these should not blindly dictate actions and decisions. Rather, the personal, social, environmental, and historical factors must be considered in determining the proper course of action. Peer mentors should be trained and made available to facilitate individual level and unit level cultural competence.

Development of intercultural communication is critical. Health workers deal with different levels and types of diversity in healthcare. Flexibility and adaptability are extremely important in interactions. The ability to understand others, work with human and material communication aids, and reach diverse groups hinges upon one’s knowledge of cultural differences, commitment to diversity and equity and available resources. Conflict management skills are essential in intercultural communication as most conflicts are associated with cultural differences. Training and actual practice in advocacy skills to identify, question, and challenge injustices in the workplace should be provided. Promoting trust and cooperation requires the ability to create bonds and attachments emphasizing similarities with others, recognizing and bridging differences, and building mutual capacity by linking with appropriate social networks. Conflict management is a significant skill to develop as many conflicts arise from sociocultural differences. Training should be provided in negotiation, cultural brokering, and helping others navigate the healthcare system. Multilevel and interprofessional communication skills should emphasize the skills of collaboration, role clarification, and leadership to resolve conflicts and enhance patient/family-centered communication (Arain et al. 2017).

31.6.3 Global Citizenship Values

A critical foundation of culturally competent practice is the development of a global outlook and global citizenship skills. Reysen and Katzarska-Miller (2013) define global citizenship as “awareness, caring, and embracing cultural diversity while promoting social justice and sustainability, coupled with a sense of responsibility to act” (p. 858). As global citizens, individuals have a keen awareness of global trends and issues, appreciate the interconnectedness among people, and position themselves within a larger global context (Cesario 2016). Global citizens are self-actualized in inherently synergistic values such as the desire for relatedness and compassion for others (Cooper 2016). Relatedness allows for the flourishing of the values of mutuality and care for others and rejection of oppressive or exploitative relationships.

31.6.4 Valuing Diversity

Global citizens have an empathic understanding of the feelings and experiences of others, including both people who experience oppression and the oppressors (Lemberger and Lemberger-Truelove 2016). Empathy and compassion draw humans together, building meaningful and transformative connections and social capital. Global citizens have actualized their “wants” that may be dysergistic in nature such as the quest for individual competence, success, and uniqueness toward more prosocial values of mutual trust and reciprocity. Dysergistic wants can be tempered by the principle of equifinality that accepts the multiple ways by which problems can be solved and the myriad ways by which individuals can achieve (Cooper 2016). Cultural heterogeneity provides a means whereby each person can actualize their authentic being as a unique and distinctive person by tapping into their unique traditions and wisdom to build on the wisdom of others. Cultural heterogeneity allows people to actualize their desires for competence and significance without undermining these in others.

31.6.5 Commitment to Social Justice

Social justice is grounded in the principles of human rights and equality, consistent with societal efforts to provide equitable treatment and a fair allocation of health resources to all citizens (Matwick and Woodgate 2017). Understanding, respecting, and valuing of existing diversity is the foundation that enables global citizens to challenge injustice and take action in personally meaningful ways (Jones 2016). True justice must activate the human potentialities in both the advocates and those who are advocated for (Freire 2000). Empathy allows a deeper appreciation of experiences and feelings of others, including both people who experience oppression and the oppressors. Compassion allows the practitioner to accept another person’s humanity, even when their position as an oppressor or oppressed person is not understandable. Empathy and compassion draw humans together. By helping people trust, recognize, and articulate their true feelings and experiences along with developing skills for dialogue and negotiation (Cooper et al. 2012), advocacy for social justice can be informed by the context in which injustice occurs and allow best practices for advocacy and empowerment to occur (Ratts et al. 2016).

31.6.6 Recruitment and Retention

The best recruitment strategy is generated from the positive testimonial from employees and consumers of care. Racial and ethnic groups tend to gravitate toward members of their own group and seek care from organizations that value their culture and understand their language and communication. Job promotion and recognition of minority employees are positive advertisements for recruitment of diverse workforce and consumers. As organizational leaders, they can serve as mentors and role models for their group. Capitalizing on the cultural identity and community affiliation of diverse employees can establish the link between the community and the organization. By engaging diverse staff, consumers, and communities, the organization can benefit from their input in recruiting potential employees, develop interest in health professions in their community, and improve its services. Partnering with local schools (secondary and collegiate) by offering cooperative work experiences, internships, and clinical affiliations can generate long-term interest and commitment in students to work in the organization.

A diverse workforce flourishes in an organizational climate that values expressions of diversity and using diversity to develop innovative practices that others can support. Organizational leaders should develop the structure and management systems supportive of diversity. Further discussion of leadership strategies to promote this organizational climate is presented in Chap.  10.

Organizational investment in continuing education of employees for advanced degrees nurtures loyalty and commitment of employees to stay in the organization. Management systems built on fairness, respect, and appreciation of diversity contribute to a sense of value and belonging among diverse staff. Organizational leaders, mentors, and preceptors should have training in advocacy for these values. Orientation of new staff should include not only the technical aspects of their work but also the culture of the organization and the community in which it is nested. Concrete explanations with demonstrations of policies and protocols of care will minimize confusion and misinterpretation for multicultural staff. Soliciting feedback of diverse employees in a non-threatening way will enhance their security and sense of belonging as well as increase their participation in unit decisions.

Staff retention is enhanced by how employees fit within the organization. Organizational norms and cultural nuances are best learned through bicultural mentors who can nurture multicultural perspectives within the context of the organization and the community. Training and modeling of professional behaviors (communication, conflict management, decision-making, etc.) for diverse employees require a concerted effort by all staff. This is particularly important for nurses who were socialized in a hierarchical culture and gender-differentiated behaviors. Training should include both oral and written expression particularly for those who are nonnative speakers of the mainstream language of the culture.

Advocacy for diverse staff with aggressive patients and abusive co-workers should be fostered as well as assist their development of self-advocacy skills. Many cultures across the globe do not value assertiveness and confrontation; hence healthcare professionals from these cultures need to learn the cognitive, expressive, and emotional components of this interactive style. Effective communication enhances achievement of desired outcomes and ability to influence others. Understanding cultural differences among all staff and administrators promotes development of empathy and compassion for others. In this environment, mutual trust, reciprocity, and engagement with others thrive.


The value of workforce diversity has been documented in studies in businesses, healthcare, and education. In healthcare, language and racial/ethnic concordance between health providers and patients have positive impact on patient’s health behaviors, satisfaction with care, and access to care. However, the approach to increase the proportional representation of diverse patients among healthcare professionals is challenged by market forces, globalization, and increasing movement of populations across the world. Therefore, training and development of all health professionals and students in culturally competent care must be instituted while continuing efforts to recruit and graduate large numbers of diverse health professionals.

Culturally competent practice in a diverse world with long-standing disparities in healthcare access and outcomes that impact more negatively the disadvantaged and diverse minorities should be grounded in the values of global citizenship. The model presented in Chap.  1 emphasizes the need for healthcare professionals grounded with a compassionate understanding of social inequities that impact health. It requires commitment to the principles of social justice, equity, and human rights protection. Cultural competence can assist in transforming vulnerable groups when it is grounded in these principles. Culturally competent healthcare professionals have a common grounding in a global citizenry emphasizing a collective outlook that respects and treats others as part of oneself and a common humanity. Global citizenship is built on empathy and compassion for others that can foster common bonds and social connectedness for a common good—promote well-being and health of everyone. Cultural competence development must be centered on building inherent prosocial tendencies to be connected with others in a climate of mutual trust and respect that transcends cultural differences.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Dula Pacquiao
    • 1
    • 2
  1. 1.School of NursingRutgers UniversityNewarkUSA
  2. 2.School of NursingUniversity of Hawaii, HiloHiloUSA

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