How do you support a multicultural, multilingual workforce to drive down variability in care?

Robert Nieves, Vice President, Health Informatics, Elsevier, provides insight

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The international movement of healthcare professionals has led to the creation of a multicultural and multilingual workforce, particularly in regions such as GCC. This poses the question, “How do you support such a diverse clinical staff-base to standardise care, drive down variability and improve health outcomes?”

An increase in health resources

Rapid expansion in populations along with rises in per capita incomes and life expectancy have contributed to a swift increase in health resources across the GCC. New hospitals and medical centers are emerging, adopting the latest medical technology to attract their new patient population, with the goal of offering the highest standards of care.

New Demands

As a result, these centers often look to bring in foreign work forces to meet staffing demands. The international movement of healthcare professionals has led to the creation of diverse, multicultural and multilingual staff, offering benefits such as the influx of specialist skills. At the same time, unique challenges are introduced when attempting to inform and maintain best practice.

These are:

  • Variation in language proficiency and documentation standards, which leads to the loss of critical clinical information.
  • Variation in educational backgrounds, clinical experience, scopes of practice and knowledge retention leads to wide variation in how clinicians practice, directly impacting the quality of care and leading to poor adherence to institutional best practice standards.

Even positive outcomes in turn create challenges, such as:

  • New skills entering the institution from under-resourced specialties. This in turn drives up demand on training and development time for generalist or non-specialist trained staff to learn new practices.
  • Additionally, new staff may not be in situ long enough to be trained adequately over period of a weeks or months.

Consequently, institutions are exposed to the potential of costly never-events, omissions in care, errors of commission, operational and knowledge variability and missed opportunities to achieve high quality care and outcomes.

The Question: How do you support a multicultural, multi-lingual workforce to standardize care, drive down variability and improve health outcomes?

From what I have seen from my professional experience, the answer is twofold.

  • First, Clinical and IT leadership must think beyond rules, alerts and static reference links when thinking about Clinical Decision Support (CDS). CDS via static reference links answered some of the impediments from a pre-digital era by allowing for guidelines to be accessible for clinical staff at the point of care, but this is not enough. To truly meet the needs of a multilingual, multicultural workforce CDS must be designed and integrated into the everyday clinical workflow and make it a seamless process within the EHR, bringing the right information to the right user, in the right context, and at the right time.

Order Sets and Care Planning are CDS solutions which integrate into the institution’s EHR system. These solutions provide access to evidence based practice and are intentionally designed to provide consistent, reliable, and relevant information to clinicians within their workflow, bridging the knowledge gap and addressing inconsistent practices.

Digital CDS solutions bring together the knowledge to drive best practice and place it in the hands of doctors, nurses and allied health professionals when entering new health systems and institutions. In addition, these CDS solutions can rapidly upskill to effectively deliver the best for their patient within in a new environment.

  • Second, and of equal importance, is having a knowledge empowered workforce. Through access to CDS solutions, organizations can encourage critical thinking and informed decision-making among the clinical workforce. In addition, and equally important is the need to enhance both Individual and Integrated Staff Competency. The use of e-learning performance management tools based on evidence must also be considered as CDS and can be integrated into the clinical workflow of an EHR.

The value of CDS solutions to empower workforces and benefit outcomes is exemplified by looking at the benefit this technology can provide for the nursing staff – those who have most direct contact with patients. The benefit of working to empower the nursing staff was seen with a recent project with the Dr. Sulaiman Al Habib Medical Group. Fundamental to Elsevier’s successful implementation of our CDS solutions was the positive engagement we received with the nursing staff at Sehat Al Suwaidi Hospital.

Following a thorough on-boarding process, the nurses at Sehat Al Suwaidi Hospital now benefit from the reassurance that their working practices are underpinned by the latest, credible evidenced based information and guidance.

I would recommend ClinicalKey for Nursing to everyone. It makes us more knowledgeable, up-to-date and smarter. An amazing education tool for myself, my staff nurses and my student nurses, too.

Considerations for considering a country such as the Kingdom of Saudi Arabia

When considering a country such as the Kingdom of Saudi Arabia, where approximately 70 percent of the nursing staff have come from outside of the country, another major challenge is knowledge retention. Recruiting clinicians from outside has many benefits, but a major downside is the loss of that knowledge when those individuals leave.

To minimise this issue we must look at nurse recruitment from within the local workforce and work towards maintaining the knowledge and expertise locally. Unfortunately, cultural perceptions of nursing vary and in reality are not positive.

Although medicine and nursing share some problems, there are additional barriers that the nursing profession must confront. Nursing does not have the same status as medicine and is widely perceived as ‘‘unclean’’. In a study undertaken in 2002–2003 Saudi high school students showed very little interest in nursing compared with medicine, computer science and teaching. Nursing was associated with long and unsocial working hours, contact with the opposite sex and was seen as a profession that lacked respect in their society (Al-Omar, 2004).

There is a marked need to positively change this perception to increase the number of local individuals entering the nursing profession. To address these negative perceptions we must first empower nurses to practice to their full scope of accountabilities. Second, we must clearly articulate and define nursing by our professional scope of practice and not by the tasks performed. Third, we must ensure that we utilize care planning as the framework for the written reflection of our nursing process. This is how we demonstrate our contribution to the holistic care of the patient.

Creating a positive work culture and recognising the contribution that nursing provides to patient care and quality outcomes are ways institutions in this region can help to support and elevate the professionalism of nursing.


In summary, effective delivery of digital solutions can ensure due recognition and support is given to the workforce. Healthcare institutions can drive down operational and knowledge variability, prevent adverse events, and elevate the standard of care based on evidence and best practices. Doing so leads to improved health outcomes AND a healthy work culture which all organization strive (and sometimes struggle) to achieve.

Robert Nieves

Vice president of Healthcare Informatics, Elsevier

Robert is an expert in the field of interdisciplinary Health Informatics, with experience managing/directing enterprise implementations of Healthcare Information Technology EMR software solutions (Eclipsys, Epic, Cerner, Meditech, and McKesson). Nieves has extensive experience in gathering, analysing and defining business and functional requirements, including workflow analysis within an multidisciplinary/interdisciplinary environment; directing and management of change control processes and decision-making tools; leading data-modeling and process mapping initiatives; and designing/re engineering processes, workflows and technology solutions for healthcare systems.