Nursing leaders emphasize cross-cultural engagement and communication when building international team
Even before they greeted their first patients in March 2022, the nursing team at Cleveland Clinic London was a study in diversity, representing a wide array of nationalities and cultures.
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Although the nursing staff admits this diversity made for some fabulous potluck lunches, it also presented a major challenge: How could the hospital respectfully meld more than 350 diverse individuals representing more than 70 nationalities into a unified team?
“Just from the nursing perspective, there were so many variables to consider,” says Sheila Miller, DNP, MBA, RN, Cleveland Clinic London’s Chief Nursing Officer. “But we knew that in an international city like London, there would be a real strength in being able to understand and appreciate each other. Ultimately, this would help us connect with our patients and see their perspectives,” she explains.
Although the diversity of backgrounds, experiences and ideas has resulted in a remarkably rich and adaptable nursing team, she explains, it initially left her wondering how the team would ever find common ground.
“Education, expectations and the role that nurses play in the healthcare system vary widely from country to country. Even basic practices can vary, so the question becomes: Whose practices do we follow?”
Two nonnegotiable standards helped shape the answer. “First, we established very clear expectations about respecting and valuing each individual for their unique strengths,” says Miller. “And second, we approached the idea of team building with awareness and intentionality. We knew that we would need to work together to identify and seek substantiating evidence for best practices from among our backgrounds and pull together the threads required to deliver world-class nursing care.”
Clinical Nurse Educator Khaled Hussein, DNP, MSN, RN, played a key role in that process. Born in Abu Dhabi and educated at the American University of Beirut in Lebanon and Case Western Reserve University in Cleveland, Khaled joined Cleveland Clinic London in October 2021.
Before relocating to the UK, he served as a nursing education specialist in the ICU at Cleveland Clinic Abu Dhabi for seven years, an experience that introduced him to the benefits and challenges of workplace diversity.
“Honestly, it was a little shocking when I started at Cleveland Clinic London,” he says. “All humans have the same anatomy and physiology, so you’d think we would all practice nursing the same way. But I quickly learned that — surprise, surprise! — things are done a little differently in every country. In the beginning, we all loved to say, ‘Back home, we used to do it this way!’”
Khaled quickly realized that getting everybody on the same page would take some planning. “In order to do that, I needed to understand the background of each person, the curriculum they had studied and the clinical reasoning behind their practices,” he explains. “I discovered a lot of similarities, but there were a lot of differences as well.”
The implication was clear, he says. “Before we even opened the doors, we had to make sure that all the nurses underwent the same onboarding process — all of us, together, getting the same training.”
He says practice simulations were especially helpful and provided an opportunity for the new nurses to share what they had learned in their previous work settings. Once everyone had an opportunity to be heard, the time was right to discuss the rationale behind Cleveland Clinic’s policies, procedures and protocols.
Even beyond direct patient care, issues arose that required shared knowledge. For instance, the use of Epic, the electronic health records system used in all Cleveland Clinic locations, was unknown to many of the London caregivers. “The majority of the nurses from the UK had never used it before, so the American nurses stepped up to share their knowledge of how to use it,” he says.
That’s one of the strengths to be found in diversity, Khaled adds.“Sharing with each other helped us come together as a team.”
Cleveland Clinic’s shared governance model, which empowers nurses to be an active part of the decision-making process, was also new to many caregivers, he explains. “Instead of the old mandate ‘this is how you’re going to do it,’ shared governance allows team members to own their individual challenges and create their own solutions. Better yet, it helps the staff feel more valued and engaged, which improves the quality of care.”
Nurse Manager Tabiso Mahlambo, BSN, RN, counts herself among the nurses won over by Cleveland Clinic’s nonhierarchical management approach.
Born in South Africa, raised in Zimbabwe and trained in the UK, Mahlambo began her nursing career in 2005 in a National Health Service Hospital in London. From there, she moved to a private healthcare organization, where she served as nurse manager for the orthopaedic and neurosciences departments. Mahlambo joined Cleveland Clinic London in June 2021, where her role has included onboarding and training the new nursing team.
“Every caregiver believes that their practice is the best practice, of course, and thinks the way they learned to do things is the right way,” she adds. “Our job was to pull the rug out from under everybody’s feet and say, ‘Now, we need to standardize our own new way of working.’”
An imbalance between the number of skilled nurses in the orthopaedics and neurosciences departments provided Mahlambo with a chance to take the lead in some creative problem-solving. Recruiting more nurses would have meant going over the budget, so she saw an opportunity to merge the two departments to create one team.
Her solution was to cross-train her staff so that every caregiver could manage any patient who came into either department. She laughs, explaining that the strategy required some convincing. “The orthopaedics nurses initially felt they could not possibly look after the neuro patients — and vice versa,” says Mahlambo.
In an effort to boost the team’s confidence and knowledge, the nursing leaders issued training challenges. “For example, we might ask the neuro team to research how to manage a hip replacement or ask the ortho team to research what a craniotomy involves,” she says. “Then we would invite the nurses to come back and present what they had learned to the whole group.”
Mahlambo says the hospital’s advanced practice providers were eager to provide the team with education, guidance and support — a dynamic that improved caregiver relationships and instilled confidence in nurses. “By the time we opened the facility to patients, our caregivers were prepared to look after everyone who came through the doors,” she says.
Mahlambo also introduced a “buddy system” in which a nurse with an orthopaedic background was partnered with a nurse with a neurology background. She says the process allowed colleagues to support one another while troubleshooting any gaps in education or experience. “It has made us an exceptionally strong team,” she adds.
Forging a united front doesn’t happen only during work hours, adds Khaled, explaining that old-fashioned fun also served as a valuable bonding agent. During downtime, the team organized a variety of social activities, including soccer matches, dances and a 10K run.
Shared meals also played a unifying role. “There was a lot of food,” he says. “For instance, one day we arranged to have each caregiver bring in food from their own country, and as they presented it, we were also learning about the culture they came from. It really helped us understand each other’s backgrounds and even informed our understanding of our international patients.”
The hospital’s diversity and inclusion group continues to support organized caregiver events, including Pride celebrations and cultural festivals, notes Miller. The result is what she calls a “dynamic” work environment fueled by staff members who are proud of both their individual identities and being part of a truly global nursing team.
In the end, Khaled insists that the key to London’s success has been clear communication. “In the beginning, it was natural for our nurses to get frustrated from time to time,” he says. “For years, many had performed their jobs the same way, but then they were suddenly out of their comfort zones and were expected to do things differently. So as a leader, I found that visibility was critical. Unity was made possible by talking to the staff, really listening to their opinions and identifying strategies that would resolve their very natural concerns.”
Mahlambo says she has also reaped the rewards of that approach. “The first thing I noticed when I joined Cleveland Clinic London was the positivity of my colleagues and their willingness to help,” she explains. “At first, I assumed people were just being polite, but I soon realized that my teammates really cared — and their concern was genuine.”
In sum, she says, a team of former strangers has now become a family.