Cross-Cultural Training in New Harbor Memorial Hospital

Introduction

Latinos played a crucial role in driving the US population growth during the past ten years. According to Krogstad (2020), the US population increased by more than 18.9 million, and 52% of the total increase was attributed to Hispanics. The US healthcare system needs to evolve considering these changes in demographics. Thus, cultural competence and cultural humility became the principal foundations of health care (Sharifi et al., 2017). Many hospitals in the US cannot provide culture-sensitive care to Latinos and other minorities, which often leads to unfavorable health outcomes (Sharifi et al., 2017). The problem of the inability to meet the needs of the rapidly growing Latino population can be solved by providing cross-cultural training (Jongen et al., 2018). The present paper provides a detailed explanation of how the program can be evaluated using a mixed-method approach.

Organization and Problem

The organization selected for the analysis is New Harbor Memorial Hospital. The hospital is a part of Christiana Care Health System, which ranks 22^nd in terms of hospital admissions in the US. Christiana Care Health System includes two hospitals with more than 1,100 patient beds, a home health care service, preventive medicine, rehabilitation services, a network of primary care physicians, and an extensive range of outpatient services. Thus, New Harbor Memorial Hospital is an advanced healthcare facility with no identified issues that threaten its financial well-being. However, the organization is facing the problem of the inability to meet the needs of the rapidly growing Latino population. In particular, the hospital is unable to provide culturally and linguistically competent services.

The identified problem suggests that two interventions need to be implemented. On the one hand, cross-cultural training intervention is required to improve the level of cultural competence of the medical personnel. Jongen et al. (2018) describe two central approaches to increasing the level of cultural competence. The first approach is called cultural competence training, which presupposes that the medical person is provided with the knowledge of the cultural peculiarities of different cultural groups (Jongen et al., 2018). The effectiveness of this approach is limited, as it divides people into several general groups, which fails to capture the peculiarities of the unique cultures of individuals (Jongen et al., 2018). The second approach is to provide general knowledge about how to provide culture-sensitive care in any cross-cultural situation (Jongen et al., 2018). This approach requires such training includes “eliciting patients’ explanatory models of health issues and their causes; strategies for negotiating shared understanding and facilitating participatory decision-making in creating treatment plans; and understanding health and illness in its biopsychosocial context” (Jongen et al., 2018, p. 2). This approach is associated with less bias, which implies that it would be best to address the identified problem.

Research Questions

The intervention will require an evaluation program to understand if it was successful. Every evaluation program needs well-worded research questions tied to the purpose of the research. In the case of the cross-cultural training program in New Harbor Memorial Hospital, the evaluation program will need to identify if the conducted cross-cultural training was effective. There were two measures of success identified: self-reported cross-cultural efficacy and minority patients’ satisfaction. Thus, the purpose of the evaluation program is to assess if the cross-cultural program conducted in New Harbor Memorial Hospital had a significant positive effect on the self-reported cross-cultural efficacy of the hospital staff and minority patient satisfaction.

The purpose statement can be transformed into two research questions. According to Mattick et al. (2018), “a good research question will send the researcher on a quest to identify or collect data that can be analyzed and interpreted” (p. 105). Additionally, Mattick et al. (2018) claim that research questions should be very specific so that they can be answered in a short time frame. Thus, program evaluation will be guided by research questions listed below:

• RQ1: Does the cross-cultural training program have a significant impact on minority patients’ satisfaction levels?
• RQ2: Does the cross-cultural training program have a significant impact on self-perceived cross-cultural efficacy?

These questions are very narrow yes/no questions that can be answered through careful data collection and analysis. Moreover, the questions are closely connected to the purpose of the evaluation, and they encourage the collection and analysis of data to answer them. Thus, the provided research questions appear to be appropriate for the evaluation program.

Variables

The dependent variables that will be measured to evaluate the program are self-reported cross-cultural efficacy and minority patients’ satisfaction. The two variables will be measured using a questionnaire designed specifically for the present project. The questionnaires will include several Likert scale questions, which will help to quantify the variables. There will be no independent variables; however, several control variables will be included in the analysis. Demographic variables, including gender, age, education level, and race, will serve as control variables for patient satisfaction. The control variables for cross-cultural self-efficacy will also include a position as a control variable.

Evaluation Design

One of the most frequently used research designs in evaluation programs is the pre-experimental design (Arora et al., 2019). This approach implies gathering pretest and posttest data utilizing statistical analysis to understand if the intervention had a statistically significant effect on the dependent variables. First, the satisfaction level of minority patients’ will be measured before and after the intervention. Second, the self-perceived level of cross-cultural efficacy will be measured before and after the intervention. Statistical analysis will be performed to understand if the cross-cultural intervention had a significant impact on the dependent variables. A statistically significant improvement with a large enough effect size will demonstrate the success of the cross-cultural program.

The proposed research design is associated with significant benefits, such as simplicity and low cost, which can be crucial for researchers with a small budget and limited experience. However, the research design is associated with significant drawbacks. For instance, the design does not control for many extraneous factors, which are associated with significant threats to validity, as it is difficult to dismiss a rival hypothesis (Evaluation Toolkit, n.d.). As for the reliability of the method, pre-experimental design is not associated with special threats. However, it would be crucial to use large samples of data to ensure the consistency of measurements.

While the primary evaluation method was selected to be a simple pretest-posttest analysis; however, a qualitative approach to evaluation can also be beneficial for the project. Utilizing a mixed-method approach to evaluation can help acquire more in-depth results than utilizing either a qualitative or quantitative approach. Researchers utilize mixed-method approaches to validate qualitative findings using quantitative methods, explore quantitative results, augment quantitative data using qualitative methods, develop survey instruments, or involve community-based stakeholders (Wisdom & Creswell, 2013). The primary benefits of the mixed-method approach include the ability to compare qualitative and quantitative data, reflect participants’ viewpoints, collect flexible data, and promote interaction (Shorten & Smith, 2017). Semi-structured interviews with different stakeholders can help to expand the understanding of the program’s impact.

One of the measures of the program’s success is the personnel’s cross-cultural self-efficacy. While self-efficacy will be measured using a survey before and after the program, five semi-structured interviews with the staff members are expected to expand the knowledge about the program’s impact. Four participants of the program and one of their managers will be interviewed to emphasize the benefits and flaws of the program and understand the transformations that the program helped to achieve. All the participants will be asked the created interview questions, and the provided answers will be recorded and carefully transcribed. Thematic analysis will be performed after the data is collected to identify valuable ideas. Interview transcript responses will be examined for codes based on related content. Each code will be evaluated for frequency across the interview sessions. These codes will then be categorized into main themes.

In summary, the evaluation will be conducted using a mixed-method approach, as it allows assessment of both qualitative and quantitative data. Such evaluation will allow to quantify the effect of the cross-cultural program on the dependent variable and explain the benefits and drawbacks of the program using the qualitative approach. The selected evaluation design is expected to provide valuable insights that will help to modify the program to improve the outcomes.

Sampling Design

The evaluation of the program will aim at measuring the impact of the program on two variables. The sampling method will differ for measuring the variables, as two different populations will be involved. First, the evaluation aimed at measuring if the program had a positive impact on satisfaction levels among Latino patients. For this purpose, simple random sampling will be used for both pretest and posttest measurements. According to Etikan and Bala (2017), the method is associated with the simplicity of use, low cost, and minimum bias. However, it may be difficult to use if the population is dispersed and it does not use knowledge about the population (Etikan & Bala, 2017). Since the population is not dispersed, as patients of one hospital are studied, a simple random sampling method is appropriate. The evaluation will require at least 50 measurements, while a sample of 100 responses is preferred to ensure the reliability of findings. The population under analysis will be non-White patients who visited New Harbor Memorial Hospital in the identified timeframe.

The second question the evaluation aims at answering is if the project had a positive effect on the self-perceived cross-cultural efficacy of the hospital’s personnel. The population under analysis are New Harbor Memorial Hospital employees who received cross-cultural training. Since the population under analysis is very small, it was identified that census is the appropriate way to measure the outcome. Census helps to avoid bias associated with sampling completely; however, it may be difficult to conduct (Etikan & Bala, 2017). For instance, some employees may quit the job right after finishing the course, which will prevent them from participating in the evaluation. Thus, it was decided to include only those employees who were still working at the hospital during the evaluation process. Such an approach may be considered convenience sampling, which is appropriate in this case.

Purposeful sampling will be used for the qualitative part of the evaluation. Purposeful sampling is a technique that allows the researcher to select the participants based on their own judgment (Luciani et al., 2019). While the method is associated with a large probability of bias, it may be effective when a small group of people can serve as a source of primary information due to the nature of the study (Luciani et al., 2019). In the case of the proposed program evaluation method, interviewees will be selected from a small group of participants judging by who may be the most valuable source of information. The hospital manager will be asked to advise participants for the interview based on their experience, knowledge, and availability of time. Such an approach to sampling for interviews will allow the program to stay efficient. As mentioned in previous sections, five participants will be recruited for qualitative evaluation.

Data Needed for Evaluation

Primary Data

As mentioned in the previous sections, two outcomes will be measured, including the satisfaction level of Latino patients and self-reported cross-cultural self-efficacy. Appendix A provides a ten-item questionnaire designed to measure the satisfaction level of Latino Patients. The survey includes four demographic questions and six content questions. The survey is expected to be effective for evaluating the outcome of cross-cultural training, as it measures the level of satisfaction of patients with the provided services. The questionnaire includes demographic questions that identified the background characteristics essential for the research project (Allen, 2017). The content questions measure the level of satisfaction from different angles, including general satisfaction level with services, the satisfaction with the actions of the personnel, and the cultural and linguistical aspects of the patient communication. The data will be assessed using an independent sample t-test. According to Siedlecki & Bena (2021), independent-sample t-tests are used to determine the difference in means of a dependent variable in two independent groups, which is appropriate for the purpose of the present analysis. Patient satisfaction surveys will be offered to patients by nurses at discharge. The data will be entered into s spreadsheet by the program coordinator.

The second variable will also be measured using a survey (see Appendix B). The survey includes 11 questions, among which five are demographic questions, and six are content questions. The survey will help to quantify cross-cultural self-efficacy and calculate if there were significant differences between the scores before and after the intervention. A paired-sample t-test will be used for the analysis of survey results. Siedlecki & Bena (2021) state that a paired-sample t-test should be used to understand if the differences between two paired observations were significantly different from zero, which is appropriate for the evaluation. The questionnaire will be distributed among the participants using e-mail. Survey Monkey will be used to conduct the survey, store the responses, and analyze the data.

Secondary Data

The importance of using secondary data for research in different spheres is growing every day. There are two types of data used for research: primary and secondary. Primary data is the information gathered by the researchers for a specific study. Secondary data is the information that has already been gathered and made publicly available to anyone. According to Johnston (2017), research utilizing secondary data has become more prevalent due to technological advances, and high amounts of data have already been collected, compiled, and stored. When considering cross-cultural training for the New Harbor Memorial Hospital, there are several kinds of data that may be used for evaluation.

There are two kinds of primary data that will be gathered and analyzed for the project, including customer satisfaction and self-reported level of cultural competence. Thus, data concerning the satisfaction levels of patients around the country can be used to compare the level of patient satisfaction in the New Harbor Memorial Hospital with the average levels of satisfaction. Additionally, such secondary data can be used to compare the mean levels of satisfaction of White patients with the level of satisfaction of Latino patients. Another type of secondary data that can be used for analysis is the changes in demographics. Information about the number of people of different ethnicities in the US at different points in time can be helpful to establish the importance of the project, as it would presumably confirm that the Latino population in the US is growing. Additionally, demographical data about the specific area near the New Harbor Memorial Hospital would also be helpful to understand if the tendency was the same in the area. While the secondary data can be used for in-depth analysis, the evaluation design does not require the use of secondary data.

Qualitative Data

The qualitative analysis of the program requires conducting five interviews. The interviews will be approximately 40 minutes long and will be conducted by the program coordinator on hospital grounds within a month after the program. The question will be semi-structured, which will help to stay focused on the questions and allow some flexibility. The interview questions are provided in Appendix C. Thematic analysis will be used to analyze the findings. The results of the qualitative analysis will be juxtaposed with the

Summary and Conclusion

The present paper provided a detailed description of evaluation procedures for a cross-cultural training program in New Harbor Memorial Hospital. The analysis demonstrated that a mixed-method approach to the analysis would be beneficial as the results of the qualitative evaluation can add to the understanding of quantitative analysis results. The success of the program will be measured by the changes in the satisfaction level of minority patients and the cross-cultural self-efficacy of personnel. The proposed design requires conducting five interviews and two surveys. No secondary data will be needed for the analysis.

References

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Creswell, J.W. (2012). Educational research: Planning, conducting, and evaluating quantitative and qualitative research (4th ed.). Pearson.

Etikan, I., & Bala, K. (2017). Sampling and sampling methods. Biometrics & Biostatistics International Journal, 5(6), 00149.

Evaluation Toolkit. (n.d.). Choose an evaluation design. Web.

Johnston, M. P. (2017). Secondary data analysis: A method of which the time has come. Qualitative and quantitative methods in libraries, 3(3), 619-626.

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Krogstad, J.M. (2020). Hispanics have accounted for more than half of the total U.S. population growth since 2010. Pew Research Center. Web.

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Appendix A: Patient Satisfaction Questionnaire

Demographic Questions

1. Your age:

1. 1. Below 18
   2. 18 to 24
   3. 25 to 34
   4. 35 to 44
   5. 45 to 54
   6. 55 and above

2. Your gender:

1. 1. Male
   2. Female

3. Your highest educational level:

1. 1. Less than a high school diploma
   2. Graduated high school or equivalent
   3. Associate degree
   4. Bachelor’s degree
   5. Post-graduate degree

4. Your race/ethnicity:

1. 1. White, Non-Hispanic
   2. Black/African American
   3. Hispanic
   4. Other

Content Questions

Instructions: For the following seven statements, please rate how much you agree with them. Use the following scale: (1) disagree; (2) disagree to a certain extent; (3) neither agree nor disagree (4) agree to a certain extent; (5) agree.

Appendix B: Cross-Cultural Self-Efficacy Questionnaire

Demographic Questions

1. Your age:

1. 1. Below 18
   2. 18 to 24
   3. 25 to 34
   4. 35 to 44
   5. 45 to 54
   6. 55 and above

2. Your gender:

1. 1. Male
   2. Female

3. Your highest educational level:

1. 1. Less than a high school diploma
   2. Graduated high school or equivalent
   3. Associate degree
   4. Bachelor’s degree
   5. Post-graduate degree

4. Your race/ethnicity:

1. 1. White, Non-Hispanic
   2. Black/African American
   3. Hispanic
   4. Other

5. Your department:

1. 1. Nurse
   2. Physician
   3. Specialized doctor
   4. Manager
   5. Other

Content Questions

Instructions: For the following seven statements, please rate how much you agree with them. Use the following scale: (1) disagree; (2) disagree to a certain extent; (3) neither agree nor disagree (4) agree to a certain extent; (5) agree.

Appendix C: Interview Questions

1. Please, describe the general situation concerning culture-sensitive care in New Harbor Memorial Hospital before the program.
2. How has the situation concerning culture-sensitive care in New Harbor Memorial Hospital changed after the program?
3. How did the program affect you personally?
4. How did the program affect minority patients of New Harbor Memorial Hospital?
5. What do you think are the major benefits of the program?
6. What do you think are the major drawbacks of the program?
7. How would you improve the program?