Documente Academic
Documente Profesional
Documente Cultură
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and public sectors of healthcare. The 4 healthcare service levels, namely, direct healthcare services, advocacy (enabling) services,
population-based services, and infrastructurebuilding services (Office of State and Community Health, 1997), are interrelated and coordinated to advance the health of the entire
community (Fig 1).
Each healthcare service level and the interface among the service levels are essential to
advance community-based, comprehensive,
coordinated, family-centered healthcare for
CSHCN, and their families and communities.
The definitions of leadership competencies
associated with each of the 4 healthcare service levels w^ere revised and expanded upon
to identify specific clinical and leadership activities on behalf of the CSHCN population
(Brandt & Magyary, 1999). It is rare to find a
graduate healthcare program that emphasizes
the interface across all 4 healthcare service
levels. For example in nursing. Nurse Practitioner graduate programs typically emphasize direct healthcare and advocacy services;
in contrast. Community Health Nursing graduate programs typically emphasize aggregate
focused population-based and infrastructurebuilding services. The cross-fertilization of
strengths from each program enhances leadership development across the entire healthcare service spectrum that are interrelated
through private and public healthcare partnerships. The nursing training grant offered
students a unique opportunity to engage in
cross-fertilization-type activities. Nurse Practitioner students with Community Healthcare
students jointly engaged in training grant
activities designed to cultivate appreciation
for the entire spectrum of the 4 healthcare
service levels that are interrelated through
private-public partnerships.
Culturally competent leadership
An emerging challenge for the 21st century is the formulation of private and public
partnerships in delivering culturally relevant
and sensitive healthcare services to an increasingly diverse population. By the year 2010,
a dramatic increase w^ill occur in the numbers of racial and ethnic minority populations.
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DIRECT
HEALTHCARE
SERVICES
Examples:
Interdisciptinary
Basic Heatth Services,
and Health Services for CSHCN
ADVOCACY SERVICES
Examples:
Transportation, Translation, Outreach,
Respite Care, Heatth Education, Famity
Support Services, Purchase of Health Insurance,
Case Management, Coordination with Medicaid,
WIC, and Education
POPULATION-BASED SERVICES
Examples:
Newborn Screening, Lead Screening, Immunization,
Sudden Infant Death Syndrome Counseling, Orat Heatth,
Injury Prevention, Nutrition and Outreach/Public Education
INFRASTRUCTURE BUILDING SERVICES
Examples:
Needs Assessment, Evaluation, Planning, Policy tDevetopment,
Coordination, Quatity Assurance, Standards Development, Monitoring,
Training, Apptied Research, Systems of Care, and Information Systems
Figure 1. MCHB pyramid model encompasses 4 interrelated healthcare service levels. From "Background
and framework of Title v Block Grant Guidatice, the HSRA Performance Measurement Systems." by Office
of State and Community Health, 1997.
estimating to comprise 40% of the US population. And yet, typically in the United States,
professionals are not racially or culturally representative of the people they serve, or have
developed knowledge and experience using
culturally competent approaches (Committee
on Ways and Means, 1992; Smedley, Stith,
& Nelson, 2003). Racial and ethnic minority
populations including CSHCN typically have
more negative developmental and health outcomes in comparison to Caucasian populations (Smedley et al., 2003). This disparity in
health outcomes is due to a variety of reasons
such as lack of access to quality and culturally
sensitive healthcare (Committee on Quality of
Healthcare in America, 2001; Cross, Bazron,
Dennis, & Issacs, 1989; Smedley et al., 2003).
In acknowledgment of the importance of
culturally competent care, cultural competency was explicitly extracted as a separate
leadership dimension to be emphasized, de-
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building is more likely to be successful and effective if completed in the context of culturally sensitive interactions. An evolving body
of research substantiates that better health
outcomes occur if the family participates in
the decision-making process with culturally
sensitive professionals (Association of American Medical Colleges, 1999; Committee on
Quality of Healthcare in America, 2001). Families and communities included in healthcare planning and policy development enhance the cultural sensitivity and quality of
healthcare services (Barger, 1997; Bournes &
DasGupta, 1997).
The past 2 decades have -witnessed a
strong evolving emphasis on collaboration
among families, communities, and professionals. Several significant laws and policies
emphasize collaborative partnership building
between families with CSHCN and systems of
healthcare as well as public education (Healy
et al., 1989; Shelton & Stepanetk, 1994). The
Washington State Health Care Policy Board
(1997) endorsed "partnership networks"
among families, communities, health providers, and health plans as the primary way to
promote access to high-quality, affordable.
MULTICULTURAL COMPETENCY
Congruency
Attitudes/Beliefs/Values/Knowledge/Skills
COLLABORATIVE
PROCESS
OR
PARTNERSHIP BUILDING
WITH
FAMILIES,
COMMUNITIES, AND PROFESSIONALS
COMPLEXITY
HUMAN DEVELOPMENT AND DIVERSITY
Person-centered Knowledge
Culture-centered Knowledge
SOCIAL -POLITICAL
RESPONSIBILITY AND ACTIVISM
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propensities such as temperament and cognitive and emotional disabilities interact with
environmental socialization processes within
the family and the broader community. This
complex developmental process has been referred to in the literature as a transactional
ecological developmental perspective.
Given the complexity of developmental
processes, consideration of both "culturecentered collective knowledge" and "personcentered individual knowledge" enhance
appreciation for the complexity of human
diversity. Sasao and Sue (1993) conceptualize
cultural complexity at 2 levels, the individual level and the larger collective level.
Taking into consideration these 2 levels of
complexity, cultural competency entails the
interface between 2 types of knowledge.
Culture-centered collective knowledge is
understanding how a child or a family, or
both, perceives itself as being similar to its
identified social-cultural unit. This type of
knowledge requires an understanding about
commonalties that characterize social-cultural
groups. Person-centered individual knowledge is understanding how a child or a family,
or both, perceives itself as being different
from its identified social-cultural unit. This
type of knowledge requires an understanding
about individual variations often referred to
as "w^ithin-group differences." Sometimes,
individuals may perceive themselves as being
positioned outside the group norms, thus
being a minority who may be marginalized
even within their own cultural group. In
addition, generational differences and levels
of acculturation often exist within socialcultural groups or even within a faniily that
holds multiple perspectives and values.
Two competency skills that incorporate
the notion of person-centered knowledge
and culture-centered knowledge is "scientific
mindedness" and "dynamic sizing," as proposed by Sue (1998). Scientific mindedness
requires professionals to explore and check
out a family's social-cultural identity rather
than making premature conclusions. Professionals need to invite family members to
share their various perspectives and values.
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uative data after the graduate program of studies. For the purpose of this article, examples
of formative and summative evaluation will be
presented to illustrate the translation of the
leadership and the culturally competent conceptual model to actual educational experiences and outcomes.
Formative evaluation during
graduate studies
Leadership portfolio
Each student documents their evolving
mastery of leadership and cultural competencies by completing on a quarterly basis the
training grant's Web-based Leadership Portfolio (Brandt & Magyary, 1999). The Leadership Portfolio template is based on the
training grant's conceptual pyramid model
of leadership service levels (infrastructurebuilding services, population-based services,
advocacy/enabling services, and direct healthcare services), with the addition of cultural
competencies. Each student describes their
leadership activity for the quarter, articulates
how the leadership activity interfaces with
the specific leadership and cultural competencies, and plan their ongoing developmental leadership goals for the future. Particular
emphasis is placed on the development of
leadership competencies that advance healthcare services for CSHCN, and their families
and communities. Leadership competencies
are advanced through nursing and interdisciplinary coursework, scholarly projects,
fieldwork, clinical leadership practicums,
community-based partnership-building activities, and clinical scholarly projects, theses,
and dissertations.
Cotntnunity-catnpus partnerships
As students think about their leadership
goals and evaluate their advancement in leadership competencies through completion of
the Leadership Portfolio, innovative interdisciplinary collaboration with families and
communities is also emphasized. Eaculty encourage and mentor student participation
in interdisciplinary types of higher education and community partnership projects as
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SUMMATIVE EVALUATION
POSTGRADUATION
with leadership functions. The newly created nursing roles are implemented within the
context of interdisciplinary collaborative partnerships with families and communities to
advance healthcare for children/adolescents
with special healthcare needs, and their families and communities.
The majority of master's prepared graduates have found employment as certified
nurse practitioners or clinical nurse specialists w^ho integrate advance practice with leadership responsibilities. The nurse practitioner
students have obtained advanced practice
certification at the national level as pediatric
nurse practitioner or psychiatric nurse practitioners. AU of the employed graduates are
providing services and leadership activities
on behalf of chUdren/adolescents with special healthcare needs that include physical,
developmental, neurobiological, and/or
psychological conditions often coupled with
environmental risk/protective factors. Eightyseven percent of the employed graduates
provide services to populations who are
"medically underserved"as defined by a shortage of health professionals and/or healthcare
services directed to both private and public
agencies with families who are underinsured,
homeless, residents of public housing, and/or
recipients of welfare. These populations were
also characterized by a large percentage of
ethnic minorities. Graduates tended to be
employed by inpatient hospitals, outpatient hospital clinics, community clinics,
government-related health facilities, public
health departments, home care facilities,
and child developmental centers. The geographic location of employment included
rural, inner-city urban, urban, and suburban
areas.
The 4 MCH core leadership functions were
incorporated into graduates' job responsibilities with a designated average percentage
of time devoted to infrastructure building
(21%), population-based services (17%), enabling/advocacy services (14%), and direct
healthcare services (48%). Culturally competency at each of the 4 levels of services was
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The MCH pyramid model on healthcare service levels coupled with a cultural competency conceptual framework proved to be
useful in training nursing leaders with an emphasis on leadership activities that interface
the private and public sector within the evolving healthcare system. Culturally competent
leadership development through collaborative campus-community partnership building
was emphasized across the entire healthcare
service spectrum (direct healthcare, advocacy, population-based programs, and infrastructure building). The interdisciplinary educational process enriched the nursing training
grant's emphasis on famUy-centered comprehensive and well-coordinated healthcare services involving teams of different disciplines
and ethnically diverse teams of healthcare
providers. Ultimately, interdisciplinary collaboration w^Ul result in a well-coordinated and
comprehensive delivery of healthcare that
better serves CSHCN, and their families and
communities.
REFERENCES
Arons, B. S., Katz-Leavy, J., Wittig, A. C, & Holden, E. W.
(2002). Too young for ADHD: The potential role of
systems care. Developmental and Behavioral Pediatrics, 23(1S), S57-S63.
Association of American Medical Colleges. (1999). Contemporary issues in medicine: Communication in
medicine. Washington, DC: Author.
Barger, S. E. (1997). Building healthier communities in
a managed care environment: Opportunities for advanced practice nurses. Advanced Practice Nursing
Quarterly, 2(4), 9-14.
Blancquaert, I. R., Zvagulis, I., Gray-Donald, K., & Pless, I.
B. (1992). Referral patterns for children with chronic
diseases. Pediatrics, 50(1), 71-74.
Bournes, D. A., & DasGupta, T. L. (1997). Professional
practice leader: A transformational role that addresses
human diversity. Nursing Administration, 21(4), 6168.
Brandt, P, & Magyary, D. (1999). Leadership portfolio:
Nursing graduate leadership enhancement for culturally competent care (Children and Adolescents
With Special Health Care Needs, Families and Communities Training Grant, Number 6 T80 MC 00002-37).
Retrieved 2000 from http://www.son.washington.
edu/departments/pch/cshcn/index.htm
Cartland, J. D. C, & Yudkowsky, B. (1992). Barriers to pediatric referral in managed care systems. Pediatrics,
89(2), 183-188.
Children's Defense Fund. (2001). The state of America's
children: Yearbook 2001. Washington, DC. Author.
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