· cultural competence train-the-trainer manual - 2011 acknowledgements the new immigrant support...

Train-The-

Trainer Manual

2011

Cultural Competence

Funded by

Cultural Competence Train-the-Trainer Manual - 2011

Acknowledgements

The New Immigrant Support Network (NISN) is grateful for the funding provided by Citizenshipand Immigration Canada (CIC). The resources developed and provided in this manual would nothave been possible without this funding and without the knowledge, experience and support ofmany individuals, both within and outside The Hospital for Sick Children (SickKids).

The following individuals have contributed to the creation of this manual and/or the resources itcontains.

Section Contributors:

Karima KarmaliLinda GrobovskyJennifer LevySean MartinKarla Wentzel

Cultural Competence Workshop Content and Guides:

Jane CameronTrinette CanningMichele DurrantKaren FlemingBukola KolawoleFrancis MacapagalAlison McLennanRani SrivastavaBetty WillsLaura Zahavich

Research and Evaluation Tools:

Fatima FazalullashaAtyeh HamedaniJahanara KhatunLaura Mandelbaum

Your comments, questions and feedback on the manual and other resources are greatlyappreciated and can be directed to Sean Martin, Inter-professional Education Specialist, NISN,The Hospital for Sick Children.

Email: [email protected]: 416-813-8209 Phone: 416 813-7654 ext. 28320

Mail: The Hospital for Sick ChildrenNew Immigrant Support NetworkRoom 635525 University AvenueToronto, Ontario M5G 2L3


Table of ContentsIntroduction 1

Section 1 Strategies to Advance Cultural Competence

Section 1.1 Advancing Cultural Competence: The SickKids Approach 31.1.1 Background 31.1.2 The Case for Cultural Competence 41.1.3 The Approach 41.1.4 Considerations for the Development and Implementation of a Strategy

to Advance Cultural Competence 51.1.5 References 6

Section 1.2 Building a Cultural Competence Champion Program 91.2.1 Introduction 91.2.2 Champions of Cultural Competence 101.2.3 Key Lessons Learned 101.2.4 References 11

Appendices 12

Section 2 Evaluation 192.1 Program Goals 192.2 Needs Assessment 202.3 Workshop Evaluations 212.4 Commitment to Change Activity 212.5 Other Indicators 222.6 References 22

Appendices 23

Section 3 Cultural Competence Curriculum

Section 3.1 Teaching Methodologies 373.1.1 Introduction 373.1.2 Transformative Learning 373.1.3 Narrative Pedagogy 413.1.4 Adapted ABCDE Cultural Competence Framework 423.1.5 Summary 443.1.6 References 44

Section 3.2 Educational Content 473.2.1 Introduction 473.2.2 Knowledge 483.2.3 Attitudes 503.2.4 Skills 503.2.5 Session Curriculum Overview 513.2.6 Summary 523.2.7 References 53

Section 3.3 Facilitation Strategies 563.3.1 Introduction 563.3.2 Learning Environment 573.3.3 Group Norms 583.3.4 Sensitive Comments 593.3.5 Summary 613.3.6 References 61

Section 4 Session Guides

Section 5 Additional Resources


Introduction

The Hospital for Sick Children (SickKids) has been fortunate to have received funding fromCitizenship and Immigration Canada to develop cultural competence programming to addresshealth disparities experienced by newcomers to Canada. To ensure that the resourcesdeveloped through this funding have a broad impact, SickKids would like to share them withother organizations interested in addressing health disparities, promoting cultural competenceand health equity, and enhancing the quality of care and service delivered to newcomers.

Purpose

The information presented in this Cultural Competence Train-the-Trainer Manual is intended fororganizations interested in implementing cultural competence programming. Specifically,educators and others can use the manual as a resource to implement educational programmingaimed at enhancing the knowledge and skill of healthcare providers and other health care staffin providing culturally competent care and service.

The manual is designed to orient the educator to specific considerations in the development,implementation and evaluation of a cultural competence education program. The resources inthis manual were developed specifically for SickKids but can be adapted to meet the uniqueneeds of any community or social service health care organization.

Manual Overview

Section 1 provides an overview of the approach adopted by SickKids to advance culturalcompetence. It includes strategies on how organizations can advance cultural competenceincluding using a champions program to build capacity and promote culturally competentpractice.

Section 2 provides an overview of the evaluation strategy developed to examine theeffectiveness of cultural competence programming and includes specific evaluation tools.

Section 3 provides information on teaching methodologies and workshop facilitation strategies,as well as an overview of the approach used in developing educational content.

Section 4 contains the workshop content and guides for workshop facilitators.

Section 5 provides additional resources for planning and delivering cultural competenceeducation.

Train-the-Trainer

Manual

2011

Section 1Strategies to Advance Cultural

Competence

Section 1.1Advancing Cultural Competence:The SickKids Approach

Section 1.2Clinical Cultural Competence:Building a Champion Program

Cultural Competence Train-the-Trainer Manual Section 1 2


1.1 Advancing Cultural Competence:The SickKids Approach

something far more rigorous, and even moreintellectual than that. It implies a readiness to study

and to learn across cultural barriers; an ability to

His Highness the Aga Khan

1.1.1 Background

The Hospital for Sick Children (SickKids) is an academic health science centre devoted to thetertiary and quaternary care of children. Situated in the heart of downtown Toronto, SickKidsserves a diverse patient population and is strongly committed to health equity, quality care andservice excellence.

and rhythms of a community. It continually interacts with the social, political, and economicrealities, and 2). Keys to developing a successfulcultural competence program for an organization include setting the context for change, havinga strong foundational knowledge of culture and cultural competence, and leveraging existingtools, policies and individuals to develop and sustain culturally competent care.

In April 2009, Citizenship and Immigration Canada announced funding to support SickKids inestablishing the New Immigrant Support Network (NISN). The goal of the NISN is to improveaccess to quality health care and health information for immigrant children and families throughthe provision of culturally competent care. This goal was to be accomplished through two keyprojects: 1) The Translation Project and 2) The Cultural Competence Education Project.Fundamental to this work is a strong focus on evaluation, research, sustainability anddissemination.

1.1.1.1 Translation ProjectFor many families and for new immigrants in particular, language is often a significant barrierthat can impede access to quality health care. Research on language barriers in health careindicates that this barrier can have a negativeconsent to treatment, can increase the risk of adverse events, and can result in misdiagnosisand poorer adherence to treatment recommendations (Flores, 2005).

The availability of interpreter services and translated patient education and other materials canhelp bridge the communication gap between the healthcare professional and the patient andfamily and can facilitate the provision of culturally competent care.


AboutKidsHealth at SickKids has created an excellent range of patient education materials inEnglish and is leading the translation of many of these materials into the languages spokenmost frequently by SickKids patients and families. The Translation Project focuses on the:

Translation of approximately 300 health-related patient education resources and othermaterials (e.g., consent to treatment form) into at least five and up to nine languages:French, Chinese (simplified and traditional), Arabic, Spanish, Tamil, Urdu, Portugueseand Punjabi

Creation of audio files in these languages for the patient education materials selected fortranslation; audio files help address barriers related to literacy and vision impairments

Translation of the AboutKidsHealth.ca website into French and simplified Chinese

1.1.1.2 Cultural Competence Education ProjectThe Education Project has focused on developing cultural competence curriculum anddelivering workshops to clinicians and other hospital staff who have contact with patients andfamilies. The project builds on the premise that understanding and providing culturallycompetent care is a strategy to reduce health disparities and enhance the health outcomes ofmany cultural groups (Canadian Nurses Association, 2005). Through comprehensiveworkshops, the project aims to build the capacity of staff at SickKids to provide culturallysensitive and appropriate care and services.

1.1.2 The Case for Cultural Competence

competent care. Toronto has a culturally diverse population, with over 40 per cent of the250,000 immigrants to Canada each year settling here (Statistics Canada, 2006). The patientpopulation atnewest settlers are subject to health disparities and health care inequity (Beiser & Stewart,2005). There is growing evidence that the quality of care and patient safety can becompromised when healthcare providers do not respond appropriately to language and culturalbarriers. Cultural competence, therefore, was seen as a key strategy to enhance the quality ofcare and to promote health equity and it aligned well with the SickKids strategic plan.

The NISN has consistently used this case internally in promoting awareness of the importanceof cultural competence in delivering equitable, safe, high-quality care.

1.1.3 The Approach

A number of frameworks informed the NISN , including the American National Standardsfor Culturally and Linguistically Appropriate Services (CLAS). The practical framework foraddressing health disparities proposed by Betancourt, Green and Ananeh-Firempong (2003)best summarizes the approach that the NISN used to understand and address the issues ofcultural competence at SickKids. The framework identifies clinical, organizational and structuralbarriers that can contribute to the health disparities experienced by racial and ethnic minoritiesand suggests interventions to address these barriers.


Betancourt et al. (2003) define clinical barriers as those pertaining to the interaction between thehealthcare provider and the patient/family. These barriers occur when socio-cultural differencesbetween the patient and provider are not fully accepted, appreciated, explored or understood.These barriers can best be addressed through cultural competence education. The CulturalCompetence Education Project at SickKids aims to enhance the quality of the interactionbetween the patient/family and the clinician.

Structural barriers refer to the processes of care, including the availability of interpreter servicesand of culturally/linguistically appropriate health education materials. The Translation Projectand other work focusing on enhancing access to interpreter services aims to address structuralbarriers at SickKids.

Organizational barriers refer to the degree to which the institution leadership and workforcereflect the diversity in the general population. We have broadened this definition to includecorporate policies and procedures that can create inequities in care and service. Although theprimary focus of the NISN has been on developing and implementing interventions aimed ataddressing clinical and structural barriers, it is now beginning to examine organizational culturalcompetence.

Adapted from Betancourt et al. (2003).

1.1.4 Considerations for the Development and Implementation of aStrategy to Advance Cultural Competence

Preliminary evaluation results indicate that the NISN has been successful in advancing culturalcompetence at SickKids in a relatively short time. A number of factors have contributed to thissuccess and a number of lessons were learned through the implementation process:

Have a clear vision of what you are trying to accomplish and communicate this visionbroadly; doing so facilitated the implementation of our plans.

ImprovedHealth

Outcomes

ClinicalCultural

Competence

OrganizationalCultural

Competence

StructuralCultural

Competence


Anchor the work tcaring and compassion, family-centred care, patient safety and service excellence areimportant to the leaders and staff at SickKids. The importance of cultural competencewas framed around these concepts.

Use research findings and evidence when making your case with both leadership andstaff.

Identify and engage an executive sponsor. Doing so can send strong signals to staff andleaders and can add clout to cultural competence initiatives.

Connect personally with leaders and decision-makers in the organization to

Develop a strong communication plan:

o Present at key forums and to key committees

o Engage staff and champions in promoting awareness

o Use internal communication tools, such as newsletters and intranets, to raiseawareness

Look for opportunities to collaborate with key participants and stakeholders as a way ofbuilding capacity and embedding cultural competence into the organization.

Look for opportunities to ingrain cultural competence into the fabric of the organization(e.g., orientation programs, policies and procedures) for longer-term impact.

Understand the needs of patients and families, staff and the organization through astrong needs assessment and build programming to address these needs.

Engage staff through focus groups, a champions program and other activities.

Ensure that trainers/educators have strong facilitation skills to navigate through sensitivecontent and challenging questions.

Understand that you will not be able to convince some resistors.

1.1.5 References

Beiser, M., & Stewart, M. (2005). Reducing health disparities: A priority for Canada(preface). Canadian Journal of Public Health, 96 (Suppl 2), S4 S5.

Betancourt J., Green, A. & Ananeh-Firempong, O. (2003). Defining cultural competence: Apractical framework for addressing racial/ethnic disparities in health and health care (featurearticle). Public Health Reports, 118, 293 302.

Canadian Nurses Association. (2005). Promoting cultural competence in nursing: CNAposition. Ottawa: The Association.


Flores, G. (2005). The impact of medical interpreter services on the quality of health care: Asystematic review. Medical Care Research and Review, 62(3), 255 99.

His Highness the Aga Khan. Peterson Lecture to the annual meeting of the InternationalBaccalaureate, Atlanta, Georgia. April 18, 2008. Available athttp://www.ibo.org/announcements/peterson08_agakhan.cfm.

Ngo, H. V. (2008). Cultural competence: A guide for organizational change. Available athttp://culture.alberta.ca/humanrights/publications/docs/Cultural_Competence_Guide.pdf.

Statistics Canada (2006). Census of Population. Retrieved July 26, 2010 fromhttp://www12.statcan.ca/census-recensement/2006/rt-td/index-eng.cfm


1.2 Building a Cultural Competence Champion Program

committed citizens can change the world. Indeed, it

Margaret Mead

1.2.1 Introduction

A cultural competence champion program was developed as a key component of the NISNsustainability strategy at SickKids. The goal of champions is primarily to convince others toaccept innovation through education, advocacy, building relationships and navigatingboundaries (Soo, Berta, & Baker, 2009). The goal of the NISN champion program is to shiftorganizational culture and sustain cultural competence within the organization. Although widely

2009, p. 123). Despite this, champions have been thedriving force behind the implementation of a wide range of initiatives in health care settings,particularly those pertaining to patient safety (Soo et al., 2009).

Champions may hold different organizational positions (e.g., executive, managerial, front-line)and may come into their role either formally or informally. Traits of successful championsinclude:

Passion for the cause belief and interest reinforce how they champion

Well-developed communication skills they tend to be personable, well-respected andcapable of building important intra-organizational relationships

Excellent organizational knowledge

Familiarity with organizational culture

Political acumen (Soo et al., 2009)

At SickKids, cultural competence is seen as integral to providing family-centred care andessential to patient safety. Champions promote these concepts in their areas of practice and actas resources, advocates and change agents for clinical cultural competence and its elements.Champions also need to understand the concept of health equity and to work to promotecultural competence as a strategy in addressing health disparities and in achieving health equityand optimal clinical outcomes for all patients and families.


The cultural registerednurse (RN) Council. This pre-existing group of elected frontline RNs represented different areaswithin the hospital. The RN Council provides leadership and acts as a liaison between the

clinical areas and the council to disseminate information about hospital activities,leadership opportunities and nursing issues while developing, implementing and evaluating aproject (NISN champion) to increase nursing engagement (RN Council Chairs, 2008). Theprogram was structured, with a monthly meeting, objectives, readings and suggested activities.We used the experience with the RN Council to develop an inter-professional championprogram. A formal call for interest (Appendix 1.1) was used to identify 30 championsrepresenting diverse professions and departments across the hospital.

1.2.2 Champions of Cultural Competence

The following is an outline of the current program structure:

Champions commit to the following:

o Attending a one-day workshops at initiation and midway through the program aimedat enhancing the skills of champions; topics include cultural competence and healthequity content, how to be a mentor and how to have difficult conversations

o Attending monthly meetings with education and debriefing componentso Reviewing suggested readings and resources provided monthlyo Submitting monthly documentation outlining their champion-related activities

(Appendix 1.2)

Champions each submit a plan for activities they would like to undertake in their area(plans vary greatly depending on experience, expertise, profession,and area of work); examples include:

o Development of an online calendar and resource describing different faithcelebrations during the year

o Development of a pictorial tool for intravenous (IV) teams to use with families havinglimited English proficiency during IV insertion

o Organization of team rounds on culture in bereavement and palliative careo Development of a hospital tour for newcomer families

Ongoing activities of champions include:

o Encouragement of staff participation in cultural competence workshopso Dissemination of information on organization initiatives and strategies supporting

culturally competent careo Acting as role models and resource people in the area of cultural competence

1.2.3 Key Lessons Learned

The champion program at SickKids has been an important strategy for influencing bothorganizational change and the culture of the hospital with regard to cultural competence. Theliterature, in addition to our experience, informs us that providing appropriate support for the


champions is integral to the success of a program. The following are key lessons learned fromthe champion program at SickKids:

Champions who have an interest (a passion in the area) will be more successful.

Champions require education in cultural competence and how to be a champion.

Organizational leaders, managers and supervisors need to promote and support culturalcompetence and champion activities.

Having dedicated time and working in teams helps champions.

Having guidance in planning and carrying out activities, while having flexibility to engagein activities that meet the unique needs of the champion s area of the organization, is apositive strategy.

Providing concrete examples of possible activities can help champions.

Champions require opportunities to come together, discuss their role and solveproblems.

Facilitators should be aware that champions may face power imbalances and resistancein their areas and should be prepared to support champions in difficult situations.

Championing cultural competence can be challenging; support is required for theprogram to be successful.

1.2.4 References

RN Council Chairs. (2008). RN Council report. Toronto: Hospital for Sick Children.

Soo, S., Berta, W., & Baker, G. (2009). Role of champions in the implementation of patientsafety practice change. Healthcare Quarterly, 12:123 28.

Srivastava, R. H. (2007). The healthcare professional s guide to clinical cultural competence.Toronto: Mosby/Elsevier Canada.

Appendix 1.1


SickKids Champions of Cultural Competence

The New Immigrant Support Network and Diversity in Action would like to invite you to considerthe following exciting opportunity. As we work together as an organization to provide culturallycompetent care, we seek to expand our group of passionate, motivated individuals to bechampions of cultural competence. At SickKids cultural competence is recognized as beingintegral to family-centred care and linked to patient safety.

Champions will promote these concepts in their areas of practice and act as resources, advocatesand change agents with regards to cultural competence and its elements (below). Championsunderstand the concept of health equity and will promote cultural competence in their areas ofpractice as a strategy in addressing health disparities and achieving health equity and optimalclinical outcomes for all patients and families. Thirty-two champions will be recruited.

What is cultural competence? Cultural competence is a set of congruent behaviours, attitudes andpolicies that come together to enable a system, organization or professionals to work effectively incross-cultural situations (adapted from Cross et al., 1989, as cited in Srivastava, 2007).

What are the elements of cultural competence?

Valuing cultural diversityHaving a capacity for self-assessmentBeing conscious of the dynamics inherent in cross-cultural interaction

Developing adaptations in service delivery that reflect an understanding of culturaldiversity (adapted from Hudacek, 2002)

What are the key activities of champions? Champions provide leadership, educate,advocate, build relationships and navigate boundaries.

Who should apply? Applications are invited from all clinical disciplines and all levels of staff.Although Champions will be selected primarily from clinical areas, non-clinicians who havecontact with patients and families are also invited to apply.

What are the qualities of a champion?

Minimum of one year working with children and familiesPassion for cultural competenceCommitment to reducing disparities, achieving health equity and optimal clinicaloutcomes for all patients and familiesStrong interpersonal, communication and organizational skillsEffective leadership skillsAbility to work well on a team

Appendix 1.1


Attend initial champion workshop (Oct. 1, 2010)Attend monthly champion rounds (one session/month over lunch)Carry out activities in your area of practice that promote cultural competence and healthequity (suggested activities will be provided)Meet with leaders or key stakeholders in your area of practice to discuss the role ofchampion and to plan activities

How are champions accountable? Champions submit a monthly record of champion activitiesin your area.

What is the time commitment? Champions must make a minimum commitment of six months:October 2010 to March 2011.

What supports are available?

Monthly rounds with the NISNResources provided monthly by the NISNChampions will be paired with another champion for support and collaboration

What are the perks of being a champion? Champions will receive $500 each to attend aconference or training of their choice related to cultural competence or the role of champion.

What is the dedicated time? Departments will be reimbursed for champions to attend a one-day kick-off workshop (Oct. 1, 2010) and one day per month to spend working on activities fromOctober to March.

Is other funding available? Funds will be provided to support champions in the activities theyare organizing in their areas.

Appendix 1.2


New Immigrant Support Network Champions of Cultural CompetenceMONTHLY REPORTChampion:

CHAMPION DAYDATE

HOURS WORKED START TIME : END TIME:

TOTAL HOURS (please circle): 4 hr 7.5 hr 9.38 hr 11.25 hr

L OCATION WORKED

O Unit / Area

O Home

O SickKids Library

O Other

O Other

DESCRIPTION OF WORK

CHAMPION DAYDATE



L OCATION WORKED

O Unit / Area

O Home

O SickKids Library

O Other

O Other

DESCRIPTION OF WORK

CHAMPION DAYDATE



L OCATION WORKED

O Unit / Area

O Home

O SickKids Library

O Other

O Other

DESCRIPTION OF WORK

I confirm that information contained in this report is true and accurate to the best of my knowledge.

CHAMPION SIGNATURE: DATE:____________________

PLEASE SUBMIT BY THE FIRST WEDNESDAY OF THE FOLLOWING MONTH

Appendix 1.2


New Immigrant Support Network Champions of Cultural CompetenceMONTHLY REFLECTIONChampion:

NISN PERSONAL REFLECTION

How do I see my area in relation to clinical culturally competent care?

Trust/cooperation/communication among my inter-professional team

Trust/cooperation/communication in my team s care with families

Have I seen any interesting clinical practice situations? (Please share examples of both good clinical cultural competenceand those where clinical cultural competence could be improved.)

Have I been a good role model and mentor this month? Yes No Maybe Explain:

Have there been any challenges for me?

Clinical practice / inter-professional / system Yes No Maybe Explain:

How did I deal with challenges? Well Poorly Not sure Explain:

Did I have a

Could I have used additional support or resources? Yes No Maybe Explain:

Other thoughts?

CHAMPION SIGNATURE: DATE:_________________

PLEASE SUBMIT BY THE FIRST WEDNESDAY OF THE FOLLOWING MONTH

Appendix 1.2


Train-the-Trainer

Manual

2011

Section 2Evaluation

2.1 Program Goals

2.2 Needs Assessment

2.3 Workshop Evaluations

2.4 Commitment to Change Activity

2.5 Other Indicators


2 Evaluation

is formalized curiosity. It is poking and

Zora Neale Hurston

2.1 Program Goals

To determine why you should provide cultural competence education to staff at your organization,ask questions and work through the answers to help solidify program goals. It is best to startasking questions early in program conceptualization. Some questions to consider are:

What do you want to do?

Why do you want to do it?

What do you hope to achieve in the short, medium and long term?

The specific questions, and their answers, will be as different as the organizations and peoplewho ask them.

Creating measurable goals is necessary to monitor and evaluate progress. Below we providesome guidance on how goals can be evaluated and what indicators may contribute to assessingchange in culturally competent behaviour.

2.1.1 Long-term GoalsWhen SickKids and NISN leaders decided to initiate cultural competence education for hospitalemployees, we had in mind the long-term goal of improving health outcomes for newcomer

aediatric health and our knowledgea familial context. This goal also reflects changes in our city

and recognizes that newcomers to Canada and other vulnerable populations have adisproportionate burden of disease, differential access to quality health care and disparatehealth outcomes.

Improving health outcomes for newcomer patients and families is a long-term goal we hope toachieve in five or more years. A number of program and policy changes will need to contributeto tackling this goal. For the NISN, creating a more culturally competent organization, in partthrough offering cultural competence education for staff, is one area in which we decided toconcentrate our resources.

2.1.2 Short-term GoalsFor us, the short-term goals were ones we could achieve over the course of our project, whichwas roughly a year and a half. Through cultural competence education we wanted 1) cliniciansto provide culturally competent care, 2) clinicians to conduct an appropriate clinical assessment

health care needs and 3) to improve newcomer patientaccess to culturally competent care within our organization.


2.1.3 Implementation GoalsIn addition to long- and short-term goals, at the beginning of our project we also outlinedimplementation targets. We had specific goals for how many workshops we wanted to deliverand how many staff members we wanted to attend the workshops. We were also interested intracking attendance by hospital area and profession.

2.2 Needs Assessment

As part of the process of preparing to implement a cultural competence program at SickKids,NSIN staff conducted both an organizational assessment and a needs assessment.

2.2.1 Organizational AssessmentTo make a compelling argument for cultural competence at your organization, and to determinewhat values will form the cornerstones of your cultural competence program, think about thevalues that people are already talking about, along with ways to align cultural competence withthese values. Cultural competence aligns well with the values of many healthcare organizations:human dignity, compassion, caring, equity, kindness, respect, diversity, social responsibility andservice, for example. Choosing the values with which to best frame cultural competence at yourorganization will require reflecting on what is most meaningful to the organization and talking topeople at different levels of the organization about what they value.

we could ground our approach to cultural competence within a framework that would be locallymeaningful.

This assessment was largely an informal process whereby we engaged in conversations withour findings, we

-centred care and patient safety and embedded these inour cultural competence program. We chose to focus on family-centred care and patient safetybecause they are meaningful values at all levels of our organization. They are as likely to arisein a conversation with a front-line healthcare provider as they are with someone in an executiveoffice. These values resonate with both staff and leaders.

2.2.2 Staff Needs AssessmentWe also conducted needs assessment focus group discussions with staff prior to developing the

experience and practice. The purpose of the staff needs assessment was to understand wherehealthcare providers were on their journeys to cultural competence and what aspects of carethey struggled with when working with diverse populations. We were also interested in gatheringcase studies that could be used in the workshops. Appendix 2.1 contains the focus groupdiscussion consent form and facilitation guide we used.

We sought to recruit participants for focus group discussions from various areas of the hospitaland from different roles, including clinical and non-clinical. We recruited participants through e-mail and information flyers in the units. The focus group discussions were each approximately


one hour long and were held over the lunch hour to make it more feasible for people to attend.The focus group discussions were audio recorded, transcribed and thematically analyzed.

2.3 Workshop Evaluations

At the end of each workshop we asked participants to complete a workshop evaluation. Theevaluation forms for Workshops A, B and C are in Appendix 2.2. We structured the workshopevaluations to assess participants learning in relation to some of the key objectives of eachworkshop. In addition, evaluationscontent and relevance to their roles within the hospital. The evaluations provided real-timefeedback to workshop facilitators and educators. Moreover, as the educators used a continuousimprovement model of workshop development, the evaluations helped modify the workshops.

2.4 Commitment to Change Activity

The Commitment to Change activity serves two purposes. First, it is an educational intervention,as it has been shown to promote behaviour change (White, Grzybowski & Broudo, 2004).Second, it is a means of evaluating intended and actual change following education.

As the last activity in Workshop C, we asked all participants to write down three things theyintend to do differently as a result of attending the workshops. We asked them to try to think ofconcrete changes so that they would be able to self-assess whether they had achieved theirgoals. Otherwise, we purposely kept the instructions vague because we knew we could notpredict the range of changes people would be interested in making and we did not want tohamper their creativity.

We printed the commitment to change sheet on triplicate paper. We asked workshop attendeesto take one copy of their commitments with them as a reminder. If attendees provided us withtheir contact information, we sent them a copy of their commitments one month after theyattended the workshop. Then, we followed up with a subsample of participants to talk abouttheir success and challenges in carrying out their commitments. We conducted the interviews ata mutually agreeable time and location. The interviews were audio recorded, transcribed andthematically analyzed.

In Appendix 2.3 we have included 1) commitment to change activity information and consent, 2)commitment to change sheet and 3) follow-up interview guide.

commitments people made. We also grouped the commitment by theme to analyze what typesof commitments participants identified.

Interview results provided information on the extent to which participants were able to achievethe commitments they had outlined in the workshop. We could then determine whether the

discovering this,we were interested in understanding the factors that facilitated cultural competence, where


people had difficulty being culturally competent and what barriers prevented participants fromachieving their commitments.

2.5 Other Indicators

In planning how to evaluate the cultural competence program we considered what data werealready being collected at SickKids that might provide meaningful indicators of change related tocultural competence education. We were looking for indicators that could be linked to thetraining and would not have other confounding factors. We also collected some of our ownprogram data.

2.5.1 Number of Workshops DeliveredWe kept track of the number of workshops of each type that we delivered.

2.5.2 Workshop AttendanceWe recorded the number of people who attended each workshop, along with their discipline anddepartment. From these data we were able to report on the number of people who had attendedworkshops in each profession and area. We also collected headcount data from our HumanResources Department so that we could calculate what percentage of staff we had reached andcould compare attendance among different departments and disciplines.

2.5.3 Interpreter Services Requests and LanguageLine (Phone Interpreter) Use

SickKids tracks interpreter services requests and the number of minutes spent on LanguageLine (an over-the-phone interpreter service). Because the cultural competence educationemphasized the importance of assessing English proficiency and working with interpreters whenpatients and families have limited English proficiency, we decided to monitor the use ofinterpreter resources to see whether there was an increase over time.

2.5.4 Patient Satisfaction Reports

sensitive to your (your childwhether patients have experienced a greater

level of staff cultural sensitivity since the initiation of cultural competence workshops.

2.6 References

Fox, R. D., Maxmanian, P. E., & Putnam, R. W. (Eds.). (1989). Changing and learning in thelives of physicians. New York: Praeger.

White, M., Grzybowski, S., & Broudo, M. (2004). Commitment to change instrument enhancesprogram planning, implementation, and rvaluation. Journal of Continuing Education in theHealth Professions, 24, 153-62.

Appendix 2.1


Consent Form: Needs Assessment Focus GroupsProject Title:

<<Department>> Needs Assessment Focus Groups

Evaluation Project

<<Department>> is a newly established department within <<Organization>> responsible forimproving access to, and quality of, care for new immigrant patients and families.<<Department>> works to enable this improvement by 1) providing cultural competencyeducation to all Hospital staff and 2) translating relevant patient education materials and otherdocuments into various languages.

As part of this initiative, the <<Department>> seeks to conduct focus groups to identify 1) thenature of issues that immigrant children and their families face at <<Organization>>, 2) staffneeds with respect to cross-cultural skills/knowledge and 3) what multilingual resources mightenhance care for new immigrant patients/families that have limited English proficiency.

Insights gleaned from focus group sessions will be used to inform 1) the curriculum for culturalcompetence education that will be given to all Hospital staff and 2) the relevant translated healthinformation that will be made available to new immigrant patients/families. Material from thefocus group sessions may be used in the future to inform a case management program for newimmigrant patients and families within the Hospital.

Results from the focus groups will be shared among <<Department>> staff by email and/ordistribution of hard-copy notes. Results may ultimately be shared throughout <<Organization>>,with Citizenship and Immigration Canada and with other Ontario health centres through a formalprogram evaluation report. Results may also be shared at conferences through presentationsand other means.

Focus Group Sessions

to 15 focus groupsessions will be conducted. Participants will include a cross-section of staff from both clinicaland non-clinical areas of the Hospital. Each focus group will consist of approximately four toeight participants and will take approximately one hour. A set of semi-structured discussionquestions will be used to help staff identify their education needs and ways to improvecommunication with patients/families that have limited English proficiency. Facilitators will also

education sessions.

Appendix 2.1


Potential Benefits, Harms and Inconveniences

Benefits:

Information collected from the needs assessment will help determine:

What kind of challenges new immigrant patients/families commonly face in the hospitalsetting.The current level of cultural competency knowledge/skills staff possess.What type of cultural competency education would be most beneficial to staff.The types of materials/resources requiring translation that would improve access to relevanthealth information for new immigrant patients/families.

Harms:

There are no known harms to participants resulting from taking part in the evaluation projectfocus groups.

Potential Inconveniences:

Focus groups will take place during lunch hours in an effort to make participation as convenientas possible. For some, however, this may pose an inconvenience, as participation in a focusgroup session would take the place of a lunch break.

Reimbursement

Lunch and refreshments will be provided at each focus group session in appreciation of

Confidentiality

No personally identifying information will be collected in the focus groups. To maintainanonymity, we ask that you refrain from using names during focus group discussions. Projectresults will not reveal your identity.

During focus group meetings we will remind everyone that the information shared is private andshould not be repeated outside the group, but we cannot be sure that information about you willbe kept private. It is possible that people in groups may share information with others outsidethe group.

Focus group discussions will be audio taped. Any names, places, positions or other identifyinginformation inadvertently mentioned during focus group discussions will be de-identified duringtranscription.

Appendix 2.1


Audio taped data will be erased once the recordings have been transcribed. Followingcompletion of the evaluation project, the transcripts and other data will be kept as long as

Notes will also be taken by hand during the session by a research assistant. Any names,places, positions or other identifying information inadvertently mentioned during focus groupswill not be recorded by the research assistant.

Your decision to participate in a focus group is voluntary and will in no way affect youremployment at <<Organization>>. You may also decide to leave a focus group session at anytime after it has started.

Consent

By signing this form, I agree that:

1. You have explained the project to me and have answered all my questions.2. You have explained the possible harms and benefits (if any) of this project.3. I understand that I have the right not to take part in the project and the right to stop at any time. My

decision about taking part in the evaluation project will not affect my employment at<<Organization>>.

4. I am free now, and in the future, to ask questions about the project.5. I have been told that the project data will be kept private except as described to me.6. I understand that no information about who I am will be given to anyone or be published.7. I agree, or consent, to take part in this evaluation project.

Printed name of participant

Printed name of person who explained consent Signature of person who explained consent& date

Appendix 2.1


Interview Guide for Focus Groups<<Organization>>

Key Area Key Issues to be Addressed

Overallexperience ofworking with newimmigrantchildren andfamilies

General Beliefs

Please describe a child (and family) that you have cared for who was a newimmigrant.

What was rewarding, and what challenging, about this experience? Why?

What, if any, were the barriers in working with this immigrant child and family? Isthis the same or different from non-immigrant children and families that you havecared for?

What are the most common issues in the delivery of health care for newimmigrant children and families?

Effectiveness

How would you define culturally competent care?

Do you think we deliver effective culturally competent care to new immigrantchildren and families? Why or why not?

What does it mean to be effective in your care of immigrant children andfamilies?

Tell me what you think would be useful in helping you be more effective inproviding culturally competent care to new immigrant children and families.

Education Learning Needs

What are the most common issues that you face when providing healtheducation to new immigrant children and families?

What materials that currently exist are most valuable for educating newimmigrant children and families?

What materials do you wish existed for educating new immigrant children andfamilies?

What modes of delivery do you find most effective in teaching new immigrantchildren and families?

Appendix 2.1


Communication / Language

What or who do you use to help you communicate when you experience acommunication or language barrier?

When would you choose to book an interpreter for a family (e.g., only if they ask;if they do not speak any English; if they have some English but do notunderstand medical terms)?

How often do you contact interpreter services when there is no or little sharedlanguage (e.g., 25%, 50%, 75% of the time)?

What are the key language challenges to providing effective health care to newimmigrant children and families?

Translation What do you consider the most essential documents for translation (e.g., accessto services, consent, confidentiality)?

What documents (e.g., patient educational materials) would you most like tohave translated? Why?

What documents do you wish existed (e.g., patient education materials, healthsystem information)?

What are the key languages that we need to translate documents into?

Are there any key issues in providing interpreter services or translateddocuments to new immigrant children and families? What are they?

Casemanagement

Identification and Navigation

Tell me about an immigrant child and family you have worked with who has had(or not had) a satisfactory experience (e.g., fell through the cracks) in navigatingthe health care system?

What services do immigrant patients most need when they 1) arrive at thehospital and 2) are discharged from the hospital?

What are the current gaps?

Diversity As an organization, we value diversity. Do you as a staff member feel respectedand valued in light of your own identity and diversity? Why or why not?

What can we as an organization do to enhance the value we place on diversity?

Appendix 2.2

Thank you for your participation.

Cultural Competence for Healthcare Professionals Workshop A Evaluation

Profession:____________________________ Date:_______________

Comments? Please use reverse.

1. I felt this workshop was aworthwhile learning experiencefor my role at <<Organization>>.

2. The workshop increased myknowledge of stressors newimmigrant families and childrenface in the settlement process.

3. The workshop increased myunderstanding of factors thataffect health care equity for newimmigrants.

4. This workshop made me moreaware of my own culture, valuesand beliefs and how these maydiffer from those of newimmigrants.

5. The workshop helped highlightthe many elements of culture thatare non-visible.

6. The workshop increased myunderstanding of what clinicalcultural competence might looklike in my role.

7. The workshop increased myunderstanding of how to conducta cultural assessment in clinicalpractice.

8. The presentation materials anddiscussion situations included inthis workshop were relevant andappropriate.

9.

10. The presenter(s) met the outlinedlearning objectives.

Stronglydisagree

Disagree Neither agreeor disagree

Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

28

Appendix 2.2


Cultural Competence for Healthcare Professionals Workshop B Evaluation

Profession:____________________________ Date:_______________


2. The workshop increased myunderstanding of differentcommunication styles.

3. The workshop increased myunderstanding of how to applycollaborative conversations inpractice.

4. I know what health literacy is andunderstand how to communicateto overcome low health literacy.

5. I understand the need for usinginterpreter services or theLanguage Line when there is alanguage barrier.

6. The workshop provided me anunderstanding of how a familculture plays a role in variousclinical situations.

7. The presentation materialsincluded in this workshop wererelevant to my practice.

8. Which module did you find mostrelevant to your practice?

parenting mental health pain

9.



Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

29

Appendix 2.2


Cultural Competence for Healthcare Professionals Workshop C Evaluation

Profession:____________________________ Date:_______________


2. The workshop provided me an

culture plays a role in variousclinical situations.

3. The use of standardized patientsin the workshop enhanced mylearning.

4. The workshop increased myunderstanding of how toincorporate cultural assessmentin clinical practice.

5. The presentation materialsincluded in this workshop wererelevant to my practice.

6. Which module did you find mostrelevant to your practice?

grief & bereavement CAM

7.


9. Based on what I learned in theworkshops, I see a need tochange the way I practice.

10. Based on what I learned in theworkshops, I will change the wayI practice.


Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

No, I do not want tobe culturallycompetent

1

Yes, I see a fewthings I need to

change

Yes, I see a lotof things I need

to change

No, I was alreadypracticing 100%

culturally competentcare

42 3

Stronglydisagree


Agree Stronglyagree

1 2 3 4 5

No, I do not want tobe culturallycompetent

1

I would like tochange, but I think it

will be too hard

Yes, I willchange the way

I practice

No, I was alreadypracticing 100%

culturally competentcare

42 3

30

Appendix 2.3


Cultural Competence for Healthcare ProfessionalsEvaluation Information

Background

We are evaluating the Cultural Competence for Healthcare Professionals curriculum and weneed your help! We would like to know the following: What messages have you taken from theworkshops? How do you intend to apply this knowledge to your professional practice or otheraspects of your life? Your input is important to us.

Process and Follow-up

workshop, we will follow up with a randomly selected sample of 5% of participants to discuss incommitments to change. If

you are selected and participate in a follow-up interview, you will receive a $10 gift card forStarbucks or Tim Hortons.

Confidentiality

We are collecting your name to send you a reminder letter and to contact participants selectedfor follow-up. Your name and the associated information you provide us will be used for follow-up only. Your reflections and commitments will be kept confidential. They will be madeanonymous and aggregated before they are shared with other hospital staff, including workshopeducators.

Consent

Participation in this evaluation is voluntary. If you decide not to participate, your participation inthe Cultural Competence for Healthcare Professionals Workshop or your employment at<<Organization>> will not be affected.

I consent to participate in the evaluation as described.

Name:______________________________ Participant #: «Participant_Code»

Signature:_______________________________________ Date:_______________

Appendix 2.3


Participant #: «Participant_Code»

Cultural Competence for Healthcare ProfessionalsCommitment to ChangeAs a result of attending the Cultural Competence for Healthcare Professionals Workshops, I willattempt to make the following three changes in the next three months (try to make theseconcrete):

1.

2.

3.

Once you have completed this sheet, please take the pink copy with you as a reminder of yourintentions.

Appendix 2.3


Commitment to Change Follow-up Interview Guide

In the development of this interview guide we drew on the work of Fox, Maxmanian & Putnam(1989).

Introduction

Thank you for giving us the opportunity to speak to you about the curriculum on culturalcompetency for healthcare p research assistant

el comfortable todiscuss any experiences, regardless of whether or not you have had a chance to make anychanges. The purpose is not to judge you but to hear, and take into account, your feedback.

For the purposes of analysis, the conversation will be recorded and transcribed in confidenceand your replies will be kept confidential. Are you comfortable with me recording this session?

Yes No

Did you receive the one-month follow-up letter in the mail? Yes No

Questions

At the end of the workshop, you completed a survey that asked you to try to make threecommitments towards providing culturally competent care.

I want to ask you some questions pertaining to those identified changes.

For Commitment #1 (read commitment), were you able to implement this specific change?Partially? Completely? Not at all?

If the change was made, either partially or completely, ask the following questions. If the changewas not implemented, skip to the next section.

1. Please tell me about the change you made.Probe: Can you provide an example of a situation and how you changed yourpractice in relation to that situation?

2. Why did you decide to make this change?Probe: What motivated you to make the change?

3. How did you prepare to make this change?Probe: What knowledge did you need to make the change?

4. What enabled you to make the change?

Appendix 2.3


5. What challenges did you face in making this change?Probe: How did you feel about the level of difficulty of the change?

6. Did the Cultural Competence Workshops at <<Organization>> play a role in making thischange? If so, what role did the education play?

For those changes that were not implemented, ask the following question:

1. Why were you not able to make this change?Probe: What were the barriers you faced?

Repeat the above process for the two remaining identified commitments.

You may have had the opportunity to make changes other than the ones we just discussed. Ifthis is the case, can you tell me what changes you made personally or professionally in the lastthree months? (record each)

For each change identified, ask the following questions.

1. Please tell me about the change you made.Probe: Can you provide an example of a situation and how you changed yourpractice in relation to that situation?

2. Why did you decide to make this change?Probe: What motivated you to make the change?

3. How did you prepare to make this change?Probe: What knowledge did you need to make the change?

4. What enabled you to make the change?

5. What challenges did you face in making this change?Probe: How did you feel about the level of difficulty of the change?

6. Did the Cultural Competence Workshop at <<Organization>> play a role in making thischange? If so, what role did the education play?

As we wrap up our conversation, do you have any feedback about the workshop?Probe: What do you think of the program? Is there anything that you wouldchange?

Do you have any feedback about cultural competence in the hospital in general?Probe: Is cultural competence increasing or decreasing in your area of thehospital? Are there any resources that you might need to be able to provideculturally competent care? Do you have any stories to share from yourdepartment?

Appendix 2.3


Train-the-Trainer

Manual

2011

Section 3Cultural Competence Curriculum

Section 3.1Teaching Methodologies

Section 3.2Educational Content

Section 3.3Facilitation Strategies

Appendix 2.3



3.1 Teaching Methodologies

than dogmatizes, and inspires his listener with the

Edward Bulwer-Lytton

3.1.1 Introduction

The goal of a clinical cultural competence education program is to transfoof what cultural knowledge is, how it is acquired, and how it can be used to promote healthequity. Culture and learning are intimately intertwined; in fact, most learning theories considerculture to be an integral factor that influences both our desire to learn and what we considerknowledge. An educational program that seeks to improve the cultural competence of careproviders must be designed to motivate learners to transform their thinking about culture andpatient care.

To achieve this change the New Immigrant Support Network (NISN) applied aspects ofconstructivist learning, including transformative learning and narrative pedagogy, to increaseculturally competent knowledge and actions through reflection and discussion.

The following section describes transformative learning theory and narrative pedagogy in thecontext of cultural competence education and presents the ABCDE Cultural CompetenceFramework as a guideline for action.

LEARNING OBJECTIVE 1

3.1.2 Learning Objective 1: Transformative Learning

Transformative learning is built on constructivist learning principles. In the traditional empiricalapproach to learning, educators act as the sole source of knowledge and the learners as emptyvessels to fill. Constructivist learning instead places greater responsibility on the educator to act

Learning Objectives

On completion of this section the educator will be able to:

1. Describe transformative learning and its relation to cultural competence education.

2. Describe narrative pedagogy and its relation to cultural competence education.

3. Describe the ABCDE Cultural Competence Framework.

Describe transformative learning and its relation to cultural competence education.


as a facilitator and on the learner to act as an active participant in the teaching-learning process.Meaning is created through shared experiences.

Key principles of constructivist learning include:

1. The learner is a unique individual.

2. fected by his or her culture and worldview.

3. Learning cannot be separated from social influences learning depends on context.

4. The learner is an active participant in the learning process.

5. Motivation for learning depends on the learner having successful learning experiences.

Transformative learning considers creatingmeaning. Tthinking and acting. The goal of transformative learning in clinical cultural competence education

awareness, enabling the learner to provide more culturally competent care.

Through a theoretical concept map and discussion, the following section describes howtransformative learning could facilitate change in healthcare providers that acts to minimize thenegative influences of healthcare provider ethnocentrism on patient care.

3.1.2.1 Transformative Learning and Healthcare Provider EthnocentrismAlthough the reasons for health disparities are numerous, healthcare providers ethnocentricbehaviour has been shown to be a factor in differences in health outcomes among certaingroups (Smedley, Stith & Nelson, 2003).

Although people learning cultural competence may have varying levels of ethnocentrism,minimizing the negative influence of ethnocentrism in the patient care provider relationship iskey to providing equitable care; but how can this be accomplished? Jack Mezirow (2006)

sets ofa to make them more inclusive, discriminating, open, reflective

(p. 92).

According to Mezirow (2006) a central concept of transformative learning is the frame ofreferenceshape and delimit our perception by predisposing our intentions, beliefs, expectations and

92). Frames of reference occur both within and outside our awareness and arecomposed of two dimensions: habits of mind and points of view (Mezirow, 1997).

that are influenced by assumptions (Mezirow, 1997, p. 6). An example of a habit of mind isethnocentrism(Mezirow, 1997, p. 6). A point of view resulting from an ethnocentric habit of mind could be anegative feeling, belief, judgment or attitude towards an individual or group of differing culturalbackground (Mezirow, 1997, p. 6).


Together, a habit of mind and the resulting point of view form a frame of reference that sets inmotion a line of action, a programmed movement from one mental or behavioural activity toanother that tends to reject ideas that fail to fit one s preconceptions (Mezirow, 2006). Tochange an ethnocentric frame of reference we must first critically reflect on the core influencesof our beliefs, perceptions and assumptions (our own culture and language), and second,

[cultural] interpretations, by critically examining evidence, arguments, and alternative points of6). But how is the process of self-reflection and discussion first initiated

and what is the sequence that leads to transformative learning through these processes?

internal conflict in an existing frame of reference; rejection (and transformative learning) wouldnot occur if two frames of reference fit together (Mezirow, 1997, p. 7).

In an ethnocentric person, rejection of an idea could result from an immersive experience inanother culture, or from an interaction with a less ethnocentric person. This experience drivesthe ethnocentric person to critically self-reflect on his or her misconceptions; misconceptionsbased on existing values, beliefs and assumptions (Mezirow, 1997, p. 7). Thus, self-reflection inthe context of ethnocentrism relies more on intuitive (unaware) communicative learning(understanding purposes, values, beliefs and assumptions by analyzing the experiences ofothers to arrive at a common understanding), than on instrumental-empirical (aware) learning(Mezirow, p. 6).

In relation to ethnocentrism, self-reflection can include an exploration of learner perspectives onnew immigrant health, which may or may not be validated through comparison with theknowledge or experiences of others. In this way, bias towards a particular group is bothidentified and analyzed in the context of the existing frame of reference. If the reasoning for theexisting frame of reference fails to be supported through self-reflection and dialogue, the resultmay be a change in viewpoint to one of greater tolerance and inclusiveness (Mezirow, 1997,p. 7).

For example, the cultural competence w

health of new immigrants on arrival is better or worse than that of the average Canadian-bornperson, 80 to 100 per cent of learners confidently stated variousreasons were given to support their claim. However, when presented with data that showed theaverage health of immigrants on arrival is better than those born in Canada, existing frames ofreference were challenged and critical self reflection was initiated.

Through discussion (e.g., asking learners what might be contributing to the healthy immigranteffect) the facilitator can reinforce key concepts and support the learners as they attempt tocreate new meaning from this information. Thus, through strategic use of information thatchallenges assumptions and by exploring the beliefs that underlie these assumptions, culturalcompetence educators can set the stage for transformative learning to occur.


Transformative Learning Theory Concept Map

Habit of Mindbroadabstractorienting

Point of Viewbelief

value judgmentmemoryattitude

EXISTINGFRAME OFREFERENCE

Affected by:culture, language

Affected how?By predisposing

intentions, beliefs

What is affected?Perception,

cognition, beliefs

meaning

Way of Thinking Shape Perception

Line of Action

REJECTEDIDEA

Aware UnawareTask-Oriented Critical Self-Reflection

Communicative LearningInstrumental Learning

NEWFRAME OF REFERENCE

Martin, S. (2010), based on Jack Mezirow s Transformative Learning Theory (1978).


3.1.3 Learning Objective 2: Narrative Pedagogy

While a number of teaching methods were used to initiate learning in the cultural competenceworkshops, including informative and experiential learning, the goal of these methods was tocreate a dialogue between facilitators and learners and among learners.

The topic of culture in relation to cultural competence lends itself to teaching methods thatinvolve the facilitator and learners sharing experiences and ideas; what better way to sharethese than through open discussion? Unlike traditional educator-focused teaching methods thatplace the knowledge and expertise in the educator and thus minimize learner participation,

Simply stated, narrative pedagogy is storytelling.

To quote medical sociologist Arthur Frank, To think about a story is to reduce it to its content

(Frank, 1995).

In cultural competence education, expertise is in creating meaning from theinformation presented in the narrative; in effect, creating a context that links a story to thelearning objectives. The relationship between transformative learning and narrative pedagogy isclear; discussion leads to critical self-reflection that can enable transformative learning .

Thus, by sharing stories we not only facilitate the sharing of knowledge, but also the creation ofknowledge.interpretations and perspectives that emerge when discussing a story with others; the verynature of interpretive ambiguity, challenges the single, authoritative view of healthcareproviders, thus decreasing ethnocentric ideologies (DasGupta, 2006, p. 317).

3.1.3.1 Narrative MethodsThe cultural competence workshops used a number of narrative methods to promote learnerparticipation and facilitate dialogue:

StorytellingStory writingVideoJournalingCase studies

Describe narrative pedagogy and its relation to cultural competence education.


3.1.4 Learning Objective 3: Adapted ABCDE CulturalCompetence Framework

(2008) ABCDE framework as an approach to developingcurriculum content, and applied principles of transformative learning and narrative pedagogy topromote cultural competence learning. The framework focuses on five key domains of culturalcompetence: affective, behavioural, cognitive, dynamics of difference, and equity.

(Adapted from Srivastava, 2008)

3.1.4.1 Affective Domainhe cultural competence journey.

29).

Describe the ABCDE Cultural Competence Framework.


Cultural Awareness and Sensitivity

Cultural awareness includes curiosity, perceptiveness, respect and a desire to connectwith the patient and family (Suh, 2004, in Srivastava, 2008).

Self-these may influence clinical interactions (Srivastava, 2008).

Cultural awareness includes awareness of others as cultural beings and of multipleworldviews and ways of being (Srivastava, 2008).

Sensitivity reflects an intentional respect for cultural differences and having an acceptingattitude (Srivastava, 2008).

3.1.4.2 Behavioural Domain

08, p. 29). Because the behavioural domainrequires awareness, knowledge and skill, it is difficult to translate in practice (Srivastava, 2008).

Learning a . Learning about the culturalvalues, beliefs and practices of patients and families includes the following:

Determining the most appropriate goals and interventions (Camphina-Bacote, 2002;Sue, 1996, in Srivastava, 2008)

Focusing on behavioural requirements during the clinical encounter:

o Engagement (trust-building)

o Treatment (cross-cultural communication and negotiation that minimizes risk andovercomes barriers)

o Discharge (ongoing contact, re-establishing patient care provider relationship,referrals to other organizations for ongoing treatment).

3.1.4.3 Cognitive DomainThe cognitive domain identifies that cultural competence is not simply an attitude; it isknowledge-based care (Srivastava, 2008). According to Srivastava (2008), cultural knowledgecan be divided into two categories: generic and specific. While knowledge is a crucialcomponent of culturally competent care, Srivastava (2008)

31).

Generic and Specific Cultural Knowledge. Generic cultural knowledge is foundationalknowledge of cultural issues that can be applied across cultural groups and clinical populations(e.g., communication styles, effects of immigration and resettlement). Specific culturalknowledge is in-depth knowledge of particular cultural groups that can be built throughinteractions with patients and families.


3.1.4.4 Dynamics of DifferenceAccording to Srivastava

31). Thus, whilethe dynamics of difference may be implied during discussions of cultural sensitivity or culturalknowledge, Srivastava (2008) suggests that these differences should be discussed as aseparate domain.

The concept of privilege is also cited as a key concept in the dynamics of difference:need to understand their own privilege and use it to challenge barriers that result in inequities in

31).

Understanding the Dynamics of Difference at Two Levels. At the patient healthcareprovider level, issues of power can be magnified when patients and clinicians represent differentcultural identities (Institute of Medicine, 2002).

At the patient healthcare system level, successful interactions require an understanding of theimpact of systemic oppression, discrimination and racism (Srivastava, 2008).

3.1.4.5 Equity

32). Equality focuses on equal opportunity and equalprocesses; equity focuses on providing the same opportunity for positive outcomes outcomesthat may require very different processes to achieve. Fortunately, evidence supports the factthat equal health care for all results in health disparities, while equitable care reduces healthdisparities.

Reducing disparities means we must focus on creating the same opportunity for positive healthoutcomes for all, not on providing the same processes for all. We must also recognize thatdifferent people may require more or different support to achieve the same health goals.

3.1.5 Summary

A strong theoretical foundation that values and builds on the experiences of the learner whilelinking to key domains of cultural competence is crucial to the effectiveness of a culturalcompetence education program. The NISN applied a transformative/narrative approachgrounded in constructivist learning to motivate and build knowledge and awareness in learnersto make changes that support culturally competent practice.

3.1.6 References

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcareservices: A model of care. Journal of Transcultural Nursing 13(3), 181-84.

DasGupta, S. (2006). How to catch the story but not fall down: Reading our way to moreculturally appropriate care. Medical Education, 8(5), 315-18.

Frank, A.W. (1995). The wounded storyteller: Body, illness, and ethics. Chicago: University ofChicago Press.


Illeris, K. (Ed.). (2009). Contemporary theories of learning: Learning theorists in their own words.New York: Routledge.

Institute of Medicine (2002). Unequal treatment: Confronting racial and ethnic disparities inhealth care. Consensus report. Washington, D.C.: The Institute.

Mezirow, J. (1997). Transformative learning: Theory to practice. New Directions for Adult andContinuing Education, 74, 1-12.

Mezirow, J. (1978). Perspective transformation. Adult Education, 28, 100-10.

Mezirow, J. (2006). An overview on transformative learning. In K. Illeris (Ed.), Contemporarytheories of learning (pp. 90-105). New York: Routledge.

Smedley, B., Stith, A., & Nelson, A. (Eds.), (2003). Unequal treatment: Confronting racial andethnic disparities in health care. Institute of Medicine, National Academy of Sciences. RetrievedJuly 6, 2009 from http://www.nap.edu/openbook.php?record_id=12875&page=R1.

Srivastava, R. H. (2008) The ABC (and DE) of cultural competence in clinical care. Ethnicity andInequalities in Health and Social Care, 1(1), 27-33.


3.2 Educational Content

care for someone I must know who the other is; tocare for someone I must be able to bridge the gap

Jean Watson

3.2.1 Introduction

The simple yet poignant quote above illustrates the relationship between theoretical knowledge(self-understanding and sensitivity to others) and experiential knowledge (bridging the theory-practice gap) when practicing in a culturally competent manner.

Cultural competence education aims to enhance self-awareness and cultural knowledge, to shiftattitudes to a new more equitable set of norms, and to provide an opportunity to practice newskills necessary to apply this knowledge in practice. While the specific content of culturalcompetence education g.,its specific patient population or target audience), the content should remain focused onaddressing the knowledge, attitudes and skills of the learners in the context of culturallycompetent care.

Although specific cultural knowledge is of benefit to cultural competence, designing aneducational program that focuses on specific cultural attributes is not only impractical from adiversity perspective, but could also lead to stereotyping. Thus, despite requests for culture-specific education the approach taken by the NISN in the development and delivery of theworkshops focused on generic cultural knowledge applicable to all cross-cultural interactions.

In developing the cultural competence curriculum we relied on ideas, cases and activities thatincorporated and adapted a variety of frameworks, such as social justice, diversity, anti-racismand interculturalism.

Consistent with this approach, when teaching about the practice of culturally competent healthcare, educators must:

Stress the importance of inclusiveness and equity

Help learners grasp why there are access barriers and health disparities

Clearly illustrate the destructiveness of unacknowledged privilege and power

Encourage learners to increase and enrich their skills

Cultural competence is an integral part of family-centred care and a key strategy to enhance therelationship between patients/families and care providers. Cultural competence is:


Possible because healthcare providers can practice the skills and develop along acontinuum learning about clinical cultural competence is a journey rather than anevent. No one is born culturally competent; we all have to undergo some unlearning ofethnocentrism and prejudice to become culturally competent.

Tangible because there are things one can choose to do or do differently that will lead topositive patient care outcomes. These include incorporating cultural assessments intopractice, working with an interpreter, assessing and responding to a patient familylevel of health literacy, respecting differences and taking the time to develop meaningfulrelationships.

Desirable because it will create positive, caring interactions.

3.2.2 Knowledge

Knowledge in the context of clinical cultural competence can be divided into the followingcategories:

Self-knowledge

Cultural knowledge

Demographic knowledge

Regulatory and policy-related knowledge

Evidence-based knowledge

3.2.2.1 Self-KnowledgeSelf-knowledge (or self-awareness) describes an individua his or her ownbeliefs, values, stereotypes and biases. In the patient care provider relationship, a lack of self-knowledge creates the potential for personal beliefs, values, stereotypes or biases to influenceclinical decision-making. The needs and desires of the patient are then disregarded. In light ofits particular importance in cultural competence, enhancing care provider self-knowledge was akey focus of the workshops developed by the NISN.

Evidence suggests that a lack of care provider self-knowledge creates disparities in healthtreatment and outcomes among minority group patients (Todd, Samaroo & Hoffman, 1993;Sequist, Adams, Zhang, Ross-Degnan & Ayanian, 2006). Key to the notion of self-knowledgeand culturally competent care is the concept of ethnocentrism that is, the tendency to view

. Learners must understand how theirown ethnocentrism can affect the patient healthcare provider relationship and the quality ofcare provided.


3.2.2.2 Cultural KnowledgeA common misconception among healthcare providers is that to be culturally competent onemust understand the beliefs and practices of all cultures. But clearly care providers cannot meetthis expectation, nor do they need to.

In fact, mastering competence in a specific culture may be detrimental to the patient becausecultures are dynamic systems and thus require continuous reconsideration (Simon, Chang &Dong, 2010). Rather than have an encyclopaedic knowledge of individual cultures, care

behaviours about health and illness.

Having an understanding of the concepts of culture and clinical cultural competence provides afoundation on which providers can build specific cultural knowledge relevant to their workplaceand those seeking care. Topics to be considered in terms of specific knowledge at the level ofthe individual and/or family include family dynamics, specific health beliefs, the use ofcomplementary and alternative medicine, religion and spirituality, and communication styles.

Related to self-knowledge, cultural knowledge should also include an exploration of the cultureof Western medicine. Further consideration in the context of cultural knowledge can include theculture of the healthcare organization and the culture of specific professions (medicine, nursing,etc.).

3.2.2.3 Demographic KnowledgeThe importance of demographic knowledge is reflected in the ability of care providers torecognize past, current and future trends as they relate to health care use. Information oncurrent local demographics allows healthcare organizations to provide services that betterreflect those seeking care; organizations can use trend data to plan for future needs.

Learners should be aware of the local and national significance of immigration. Care providerscan use demographic information on specific populations to further tailor health care to patientneeds.

3.2.2.4 Regulatory and Policy-Related KnowledgeThe efforts of local and national organizations to establish standards pertaining to culturallycompetent care reflect the importance of clinical cultural competence. Policies, guidelines andstandards may exist at the level of the health care organization, professional regulatory bodiesor provincial or federal governments.

An awareness of these documents adds to the significance of clinical cultural competence inpractice and provides resources that care providers can use to facilitate more culturallycompetent care.

3.2.2.5 Evidence-Based KnowledgeAt the root of Western medical culture is the concept of evidence-based medicine. Within thisculture, care providers use scientific evidence to guide clinical decision-making. Evidence-basedliterature should be used whenever possible to support the acceptance and use of culturallycompetent practices among care providers.


Educators should make learners aware of the evidence indicating the existence and causes ofdisparities in health status and health care access faced by new immigrants. Evidenceindicating direct links between culturally competent care and patient safety should also beprovided.

3.2.3 Attitudes

Merriam- (2010) defines an aor state. Attitudes are judgments based on knowledge gained through experience. Untilknowledge relating to cultural competence is enhanced, shifting attitudes to a new set of moreculturally competent norms will be difficult.

Key attitudes to advocate in a cultural competence education program are those of respect andopen-mindedness. Learners should understand the concept of equity and how valuing diversitypromotes culturally competent and family-centred care.

With the aim of promoting the long-term success of a cultural competence education initiative,educators should communicate to learners that cultural competence is not a one-time skill to beachieved; rather, it is a process that requires a commitment to continuous learning and self-reflection. Educators should espouse an attitude of cultural desire want toengage in the process of becoming culturally competent; not the have to -Bacote,2003; as cited in Campinha-Bacote, 2008, p. 142).

3.2.4 Skills

3.2.4.1 Self-Reflection SkillsWhile many skills are necessary in the practice of culturally competent care, the first andforemost skill is that of self-reflection, an individual ability to identify his or her personal beliefs,values, stereotypes and biases.

Learners should be aware that constant self-reflection promotes self-awareness and that beingself-aware enhances the ability to act in a manner that considers the needs and desires of thepatient and family. It is through critical reflection and a purposeful commitment to learning fromand about others that one begins the journey towards cultural awareness. Learners should alsounderstand the importance of adaptability, and that adaptability results from constant self-reflection and re-evaluation.

3.2.4.2 Cross-Cultural Communication SkillsAlthough we may assume that the most important aspect of communication is that which isexpressed in words, much of our meaning is communicated nonverbally. Interpretation of verbaland nonverbal communication can be difficult when the interaction is between people fromdiffering cultures. Assuming that everyone shares our communication behaviours andpreferences can lead to misunderstanding (UBC, 2010). Care providers can use numerouscommunication skills, strategies and tools to promote culturally competent care, including:


Translated materials

Trained interpreters (in-person or over the phone)

Tools that allow care providers to assess their own proficiency in languages other thanEnglish

Tools that enhance the care provider s ability to obtain medically relevant information(personal/family medical history, biological/psychological/social considerations, culturalbeliefs and practices)

Tools that promote consideration of and collaboration with community-based resources

3.2.4.3 Treatment SkillsCulturally competent treatment skills incorporate the influence of culture on perceptions ofhealth and illness, treatment preferences, and treatment effects. Supported by strong self-reflection and communication skills, culturally competent treatment reflects care that considersand honours individual beliefs and values. To provide culturally competent care, providersshould:

Understand the patient conceptmay influence a treatment plan

Understand cultural differences in the expression of pathology to aid in diagnosis

Understand cultural and biological differences that may affect response to medical orpharmacological interventions

Identify when additional consultation is needed

Regularly assess their own responses, biases and cultural preconceptions

3.2.5 NISN Cultural Competence Curriculum Overview

As a key component of the education initiative the NISN developed educational workshops forboth clinical and non-clinical staff. These workshops are built on the theoretical foundationsdiscussed in section 3. Initially designed as a two-day workshop, participant feedback resultedin the modification of the two-day workshop to three half-day workshops for clinical staff (A,Band C), and a single half-day workshop for non-clinical staff. The following section highlightsthe core content of each workshop.

Session A: Introduction to Cultural Competence

This workshop introduces learners to the concepts of cultural competence, and encourageslearners to explore and reflect how personal values, biases and assumptions can impact thequality of interactions between healthcare providers and patients/families. We engagedlearners in discussions about settlement stressors, presented key demographic data andresearch to describe the effects of health disparities on the new immigrant population, and


used activities designed to challenge assumptions and increase awareness of personalbiases.

Session B: Cross-Cultural Communication and Practical Applications

This workshop builds upon the concepts of health disparities, personal biases andassumptions, and the benefits of cultural competence as it introduces the learner toconcepts regarding cross-cultural communication as well as strategies and resources whichcan be utilized by healthcare providers to facilitate effective communication. The workshopalso introduces the learner to concepts associated with parenting practices, mental health,and the expression of pain across cultures.

Session C: Complementary and Alternative Medicine, Bereavement and Grief,and Practical Applications

This workshop introduces the learner to cross-cultural concepts regarding complementaryand alternative medicine (CAM), as well as bereavement and grief. Building on Session B,further strategies and resources are presented that can be utilized by healthcare providersto facilitate culturally competent care. Session C also includes an activity involvingstandardized patients designed to reinforce the concepts presented in the sessions byputting them into practice in a simulated and safe environment. In effect, the standardizedpatients provide the opportunity for participants to apply the knowledge they have gainedthroughout the sessions to a scenario that develops culturally competent attitudes andcommunication skills.

Non-Clinical: Cultural Competence for Non-Clinicians

The non-clinical workshop is an adapted workshop for hospital staff employed in non-clinicalpositions. While much of the material is borrowed from Session A, specific material isincluded that links the concepts of cultural competence and service excellence. Activitiesare also designed with an emphasis on culturally competent service provision rather thanclinical care, including case studies and group discussion.

3.2.6 Summary

When considering content to include in a clinical cultural competence education program, onemust reflect on how the content will enhance cultural knowledge, attitudes or skills. While manyskills and practices are associated with culturally competent care, including those associatedwith self-reflection, cross-cultural communication and treatment, educators should also do thefollowing:

Think about the importance of addressing the different types of knowledge that culturalcompetence encompasses.

Actively promote the attitudes of respect and open-mindedness.


Emphasize how equity and valuing diversity promote culturally competent family-centredcare.

Promote adaptability, as the ability to react to changes in the dynamics of thepatient/family healthcare provider relationship is a necessary, permanent component ofculturally competent care.

Clearly articulate that clinical cultural competence is a process and that a life-longcommitment to self-reflection and learning are required.

3.2.7 References

Anderson, J. M. (1987). The cultural context of caring. Canadian Critical Care Nursing Journal,4(4), 7-13.

Campinha-Bacote, J. (2003). Many faces: Addressing diversity in health care. Online Journal ofIssues in Nursing, 8(1). Retrieved July 19, 2010, fromhttp://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No1Jan2003/AddressingDiversityinHealthCare.aspx.

Merriam-Webster On-Line. (2010). Retrieved August 14, 2010, from http://www.merriam-webster.com/

Sequist, T., Adams, A., Zhang, F., Ross-Degnan, D., & Ayanian, J. (2006). Effect of qualityimprovement on racial disparities in diabetes care. Archives of Internal Medicine, 166(6), 675-81.

Simon, M., Chang, E., & Dong, X. (2010). Partnership, reflection and patient focus: Advancingcultural competency training relevance. Medical Education, 44(6), 540-42.

Srivastava, R. H. (2007). .Toronto: Mosby/Elsevier Canada.

Todd, K., Samaroo, N., & Hoffman, J. (1993). Ethnicity as a risk factor for inadequateemergency department analgesia. Journal of the American Medical Association, 269(12), 1537-3

University of British Columbia. (2010). Cross-cultural communication in health care education: Acourse manual for students and teachers. Retrieved Oct 15, 2010 fromhttp://www.chd.ubc.ca/dhcc/sites/default/files/documents/Introduction%20to%20Cultural%20Competence.pdf


3.2 Facilitation Strategies

move from a point of view to a viewing point ahigher, more expansive place, from which you can

Thomas Crum

3.3.1 Introduction

By definition, the goal of transformative learning is to initiate internal change through critical self-Cultural competence educators

must therefore use information and methods that challenge a l

5). Thus, clinicalcultural competence educators should have a strong understanding of strategies thatconstructively incorporate conflict into the teaching-learning process. This section discussesstrategies NISN educators used to establish a positive learning environment, set group normsand rules, stimulate participation and respond to sensitive comments in a respectful andconstructive manner.

PART IV

LEARNING OBJECTIVE 1

Learning Objectives

On completion of this section the educator will be able to:

1. Establish a positive environment for learning cultural competence that is conducive to anopen and sharing dialogue among learners and between learners and educators.

2. Recognize the dynamics of learning about cultural competence in a group setting andestablish rules to facilitate receptive and sensitive group behaviour.

3. Recognize sensitive (conflictive or discriminatory) comments and how they can be usedto facilitate cultural competence learning.


3.3.2 Learning Objective 1: Learning Environment

The importance of establishing a positive learning environment for cultural competenceeducation cannot be overstated; setting a tone that presents the learning environment as aplace of acceptance and respect is critically important. While a feeling of safety supportslearners of all ages, adult learners require some specific considerations.

Key environmental factors that stimulate adult learners include the following:

1. The environment must be one where learners feel safe and supported; whereindividual needs and uniqueness are honoured and where abilities and life achievementsare acknowledged and respected.

Educators should articulate the attitudes engendered by cultural competence and modelcultural competence skills and knowledge so that they can lead by example.

Educators need to make learners aware that the workshop is not directed at what theypractice; rather, the workshop is a forum in which to share

group knowledge and experience and create new perspectives and meaning. Healthdisparities need to be placed in context; participants need to leave the workshop feelingempowered enough to make a difference.

Simply having learners introduce themselves to each other can initiate recognition of thelearner s role.

Learners must be made aware that the subject of cultural competence may bring aboutcomments or ideas that may be personal or even offensive. While the natural tendencyfor both learners and facilitators is to become defensive in these situations, facilitatorsmust seize these moments as learning opportunities (see case examples below).

or question is intended to provoke, onestrategy involves taking a moment to breathe and asking others to contribute what they

group think this (belief, action, etc.) couis offering to respond to the individual during break time.

2. The environment must foster intellectual freedom and encourage experimentation andcreativity.

People learn in different ways and vary in their ability to perform certain tasks. Understandingthat each individual has his or her own strengths and challenges when it comes to approachinglearning is an important component of effective education. Providing a variety of learning

Establish a positive environment for learning cultural competence that is conducive to an openand sharing dialogue among learners and between learners and educators.


activities for a class increases the likelihood that individual learners will participate in activitiesthat are most effective for them.

3. The environment must be one where educators treat learners as peers accepted,respected, intelligent, experienced adults whose opinions are listened to, honoured andappreciated.

One of the most important factors in learner motivation is the interaction between learners andeducators. Educators should encourage informal interaction between educators and learnersbecause it creates a greater feeling of acceptance and respect and increases the likelihood ofopen, honest communication. A healthcare professional who is an educator has much incommon with the healthcare professional who is a learner, both in experience and motivation;this fact should be highlighted. Educator-learner connectedness is a key to establishing opencommunication.

Learning is enhanced when it is perceived as a collaborative, co-operative effort betweeneducators and learners. The opportunity to share ideas without threat of ridicule and the

understanding.

3.3.3 Learning Objective 2: Group Norms

Providing cultural competence education in groups requires special considerations. Exploringaspects of culture involves concepts and topics that may be both personal and sensitive.According to Montiel-Overall (2009

5), while Keesing

-Overall, p. 5), because uncovering notions of culturerequires mental effort to discover ideas hidden beneath our everyday behaviour.

While some educators and learners shy away when they perceive conflict, others become vocal.Rather than fall into defensive and less productive communication, educators must recognizeconflict as a learning opportunity and explore the ideas hidden beneath the surface.

Specific considerations when establishing group norms include the following:

Recognize the existence of power dynamics in the educator-learner relationship.

Confidentiality must be openly upheld (what is spoken within the group remains withinthe group).

Encourage active listening.

Recognize the dynamics of learning about cultural competence in a group setting and establishrules to facilitate receptive and sensitive group behaviour.


educator is not there to simply provide information; rather, the role of the educator is tofacilitate group discussion, link discussion to learning objectives and highlight take-homemessages.

3.3.4 Learning Objective 3: Sensitive Comments

Recognize sensitive (conflictive or discriminatory) comments and how they can be used tofacilitate learning about cultural competence.

norms, learner comments occasionally reflect perceived personal disagreement or disrespect,including racism or discrimination.

While such comments hold the potential to be destructive, educators can use them to exploremany concepts of great value to cultural competence education, including bias, prejudice,racism and discrimination. However, redirecting sensitive comments in a positive mannerrequires the educator to first recognize the sensitive comment, and second, address it in a

a non-defensive manner

The following example illustrates a strategy for educators to facilitate learning from a potentiallysensitive or destructive learner comment.

Case Examples of Sensitive Comments and Educator ApproachesExample 1

t immigrants prepared when they get here? Why don t they know

Educator:

The educator redirects the learner to explore other resettlement challenges (recognition ofcredentials, employment, limited government resources, etc.).

The educator redirects the learner to explore the cost of English as a second language classes,availability, time commitments, fear of using a new language in public and the differencesbetween everyday language and medical language.


savailable for new immigrants. Language barriers can also affect the types and availability of

The educator redirects the learner to explore resource availability and language barriers despiteaccess to resources.

t family members who are already here be

what about those who have come alone, who have no family resources in Canada? Or thosewho have come with their family, but then have to struggle with an unexpected accident or

The educator redirects the learner to consider lone immigrant or refugee experiences andresources and their impact on resettlement.

Example 2

responsible for how someone else feels; for example, when

assumptions of both the

The educator redirects the l

be perceived as defining the individual as not Canadian-born based on the colour of their skin oran audible accent. This perceived assumption may be the source of the offended feelingexperienced by the patient. Thus, to be more culturally competence care providers should beaware of their own assumptions, and how they frame communication methods and theirphrasing. Self-awareness enhances the ability of care providers to act in a manner thatconsiders how their own assumptions may be perceived by others.

From these examples you can see that what at first may have seemed an insensitive ordetrimental comment can in fact be used to engage learners in an informative and perhapstransformative dialogue.


3.3.5 Summary

Facilitating group learning in the context of cultural competence is challenging. By nature, open

create a feeling of internal conflict for the learner. While internal conflict is often the spark thatdrives transformative learning, externalizing this conflict can negatively affect the learningprocess. To support a positive learning experience, facilitators must:

Create a safe learning environment that encourages open dialogue.

Be aware of and establish clear group norms.

Recognize sensitive comments and use them as learning opportunities.

Be prepared to explore the values, beliefs and assumptions underlying a particularviewpoint.

3.3.6 References

Berstene, T. (2004).The inexorable link between conflict and change: Conflict can be managedto create a positive for change. Journal for Quality and Participation, 27(2), 4-9.

Keesing, R. M. (1981). Cultural anthropology: A contemporary perspective. (2nd Ed.), pp. 1-75.New York: Holt, Rinehart & Winston.

Montiel-Overall, P. (2009). Developing cultural competence to create multicultural libraries.American Library Association International Papers Committee, 2009 Annual Conference, IRRTPaper Presentation.

Train-the-Trainer

Manual

2011

Section 4Session Guides

Session A

Session B

Session C

Non-Clinical

Session A

Clinical Cultural Competence and Health

Central Themes

This workshop introduces learners to the concepts of cultural competence and encourageslearners to explore and reflect on how personal values, biases and assumptions can impact thequality of interactions between healthcare providers and patients/families. We engage learnersin discussions about settlement stressors, present key demographic data and research todescribe the effects of health disparities on the new immigrant population, and use activitiesdesigned to challenge assumptions and increase awareness of personal biases.

Session A Learning Objectives

Following completion of Session A learners will be able to:

1. Recognize the different types of settlement stressors experienced by new immigrantfamilies and their effects on health

2. Identify how the Social Determinants of Health affect immigrants and refugees

3. Understand the meanings of culture and cultural competence

4. Recognize how personal biases affect the patient/family-healthcare providerrelationship

5. Describe the relationship between clinical cultural competence and family-centredcare

6. Complete a cultural assessment

Session A

Learning Objective 1.

The workshops open with a discussion of the importance of clinical cultural competence and itsrole in alleviating health disparities. We engage learners in discussions about settlementstressors, present research data to describe the effects of health disparities on the newimmigrant population, and use activities designed to challenge assumptions and increaseawareness of personal biases.

Content

Content to address this learning objective focuses on key demographic data (both current andanticipated) as well as research evidence indicating the existence and extent of healthdisparities experienced by new immigrants, as well as the relationship between culturallycompetent care and positive health outcomes.

Activities

Activities to address this learning objective are designed to provide learners with perspective onthe distribution of resources that affect the health and well-being of humans around the globe,as well as the realities of the stress of resettlement and health impacts in the Greater TorontoArea.

Recognize the different types of settlement stressors experienced by new immigrantfamilies and their effects on health

Cultural Competence forHealthcare Professionals

Part A:Introduction to ClinicalCultural Competence

1

Facilitation Tips

Comment

Housekeeping

Washrooms, breaks,

Acknowledge the experience and expertise of audience

Presented information may not new, but perhaps a new perspective is created.

Stress the importance of discussion, sharing ideas and stories, and that your role is tofacilitate discussion and connect the discussion to the learning objectives.

-based.Discussion of ideas and feelings is a key aspect of enhancing understanding.

Have the learners introduce themselves.

Explain the importance of confidentiality, as personal stories and thoughts will beshared.

Why are you here today?

2

Facilitation Tips

Comment

Further examine your own cultural values and beliefs

Explore your awareness of, and sensitivity to, other cultural values and beliefs

Begin to consider how we can effectively span cultural differences to addresshealthcare inequities and achieve the best possible healthcare outcomes forchildren and their families

Workshops

Session A

Introduces health disparities, the immigrant experience,social determinants of health (SDOH), and clinical culturalcompetence.

Session BDevelops knowledge and skills on collaborative communication, cross -culturalcommunication, and clinical cultural competence as it pertains to parenting,mental health and pain management.

Session CDevelops knowledge and skills on clinical cultural competence in the use ofcomplementary and alternative medicine, bereavement and grief. Participantswill have an opportunity to practice with Standardized Patients.

3

Facilitation Tips

Comment

This slide illustrates the path that will be taken throughout the course of the workshops.The path follows the general steps of :

o Workshop A Is there a problem? What is the problem? Why is there aproblem?

o Workshop B What can I do about it?o Workshop C What can I do about it?

Clarify the definition of health disparities

Learning Objectives

Upon completion of Workshop A participants will be able to:

Recognize the different types of settlement stressors experienced bynew immigrant families and their effects on health

Identify how the SDOH affect immigrants and refugees

Understand the meanings of culture and cultural competence

Recognize how personal biases affect the patient/family-healthcareprovider relationship

Describe the relationship between clinical cultural competence andfamily-centred care

Complete a cultural assessment 4

Facilitation Tips

None

Miniature Earth

Miniature Earth

5

Facilitation Tips

Miniature Earth

This short, web-based video clip presents the global community if it could be reduced toa total population of 100 people. Themes presented include privilege, poverty, diversity,and disparity among others.

http://www.miniature-earth.com/me_english.htm

Comment

It is human nature to see and interpret the world from the perspective of our ownworldview

This short video encourages us to open ourselves to new perspectives on thedistribution of resources that affect the health and well-being of humans around theglobe

Ask the Learners (after the video)

How do you feel about what you have just watched and what part of the video was mostsurprising/distressing?

How might this relate to where you live, work?

The Health of New Immigrants

How would you describe the health status of newimmigrants upon arrival in Canada?

New immigrants arrive with better health scores thanaverage Canadians. Five years later their healthscores are lower than those of the generalpopulation.

6

Facilitation Tips

The Healthy Immigrant Effect

The goal of this activity is to identify and challenge stereotypes as they relate to thehealth of new immigrants. Ask the question, and have the learners raise their hands ifthey believe the health of new immigrants upon arrival is:

a. Worse on average

b. Better on average

c. The same on average

Typically, the majority of the learners will choose option A.

Ask the Learner:

Why do you think the Healthy Immigrant Effect exists in Canada?

After they answer this question, explain to the group that health is an immigrationscreening criteria, put simply, Canada wants a healthy population. The questionis:

What is contributing to the deterioration in health after a new immigrant arrives inCanada?

Walk around and review the posted data andstatement clusters.

beside the cluster that most affected you.

Walkabout Activity

7

Facilitation Tips

Walkabout Activity

-knowledge through the provision ofcultural, demographic, and evidence-based knowledge. To conduct this activity theeducator is required to collect and post on the walls of the training room demographicand evidence-based information relevant to the topics of poverty, disability, immigration,refugees, health disparity, socioeconomic status, racism, place of origin, gender,language, sexual orientation, religion, and marital/family status. Post the information inclusters of like-topics.

Ask the Learners

Ask the learners to review the posted data and after 10 minutes choose a cluster thatthey identify with, are surprised by, or interested in. Tell them to stand beside the cluster.

Choose people randomly to explain why they are standing in front of a specific group.

Comment

This exercise was intended to help us begin thinking about our own perspectives onsocial determinants of health, diversity and equity

**You may also take this opportunity to describe the differences between racializedgroups, marginalized groups and new immigrants

Health Equity Terminology

Equal: to treat the same.

Equitable: the same opportunity for positive outcomes.

Disparities: differences in outcomes.

Equitable Access: ability or right to approach, enter, exit,communicate with or make use of health services.

Social Inequities in Health: disparities judged to be unfair, unjustand avoidable that systemically burden certain populations.

8

Facilitation Tips

Comment

Social equity in health

Refers to an absence of unjust health disparities between social groups, within

Social inequities in health

Refer to health disparities, within and between countries, that are judged to beunfair, unjust, avoidable, and unnecessary

Pursuing social equity in health entails actions aimed to minimize social inequities inhealth and improving average levels of health overall.


Marginalized: Confined to an outer limit, or edge (the margins),based on identity, association, experience or environment.

Racialized Groups: Racial categories produced by dominantgroups in ways that entrench social inequalities andmarginalization. The term is replacing the former term known as

9

Facilitation Tips

None

The Importance of CulturalCompetence at SickKids

Increasing Immigration

Toronto is the destination of choice for 45.7% of all newimmigrants to Canada (Stats Canada, 2006)

racialized groups (Stats Canada, 2010)

Culturally competent health care is one strategy foraddressing and ideally reversing health disparities.

10

Facilitation Tips

Comment

The need for cultural competence education is not solely the result of an increasingproportion of non-Canadian born citizens, but also due to the documented healthdisparities in this population.

This slide illustrates a key point in terms of the need for this type of clinical culturalcompetence education.

All patients and families, regardless of their origins, deserve and benefit from culturallycompetent care.

Family-centred care and culturally competent care are integral to one another.

Immigration andthe Immigrant

Experience

11

Facilitation Tips

RESETTLEMENT STRESSORS AND HEALTH

Unemployment, poverty, and lack of access to services are stressful, and immigrants frequentlyexperience all three of these situations (Beiser, 2005).

Following arrival in Canada new immigrants are much more likely to live in poverty than theirnative-born counterparts, a fact that increases the likelihood of exposure to risk factors fordiseases, while also compromising access to treatment (Beiser, 2005).

Other stressors experienced by new immigrants that carry the potential to negatively affecthealth include:

lack of recognition of credentials and/or training,access to affordable housing,language barriersracism/racialization.

Content chosen to address this learning objective focuses on introducing the learners toCanada s immigration policy, the immigration experience, and health care challenges faced bynew immigrants.

Immigration

Why do families immigrate here?

What is culture shock?

12

Facilitation Tips

Comment

is an economic policyarrival of skilled workers and professionals is a response to labour marketshortagesis in response to a low national birth rate

Why emigrate? Families immigrate to Canada because: Most often they are hoping togain something (i.e. opportunity, education, lifestyle, freedom, health care) and/or leavesomething behind.

Culture Shock: Arises when individuals suddenly find themselves in a culture in which

over which cultural practices to maintain or change. Culture shock can be decreased ifthe move is positive and planned and if cultural beliefs can be maintained whileintegrating into the new culture.

Considerations:

New immigrants experience challenges in knowing how to access health careand navigating new and complex healthcare systems

Health care disparities exist in Canada

Based on some of the challenges new immigrants face, reactive symptomsincluding anxiety and isolation are understandable and should be approachedwith understanding and sensitivity.

Background Information

Canadian Immigration

o One of every six Canadian residents was born outside the country. Immigrationhas helped to make Canada a culturally rich, prosperous and progressive nation.(Citizenship and Immigration Canada, 2010)

o Net international migration continues to be the main engine of population growthin Canada, accounting for about two-thirds of the annual increase in 2005/2006(Statistics Canada, 2006).

o Between July 1, 2005 and July 1, 2006, Canada's population increased by324,000 of which 254,400 were immigrants, 9,800 more than in the previous year(Statistics Canada, 2006).

Regulations provide for the admission of new immigrants under 5 categories;

Skilled Workers andProfessionals

Skilled workers are selected as permanent residentsbased on their education, work experience, knowledgeof English and/or French, and other criteria that havebeen shown to help them become economicallyestablished in Canada.

Family Class A Canadian citizen or permanent resident may sponsorher or his spouse, common-law partner or conjugalpartner, or dependent children to come to Canada aspermanent residents.

Canadian Experience Class A temporary foreign worker or a foreign student whograduated in Canada often has the qualities to make asuccessful transition from temporary to permanentresidence. Familiarity with Canadian society and theability to contribute to the Canadian economy are keyconsiderations. Applicants should have knowledge ofEnglish or French and qualifying work experience.

Investors, entrepreneurs andself-employed persons

The Business Immigration Program seeks to attractexperienced business people to Canada who willsupport the development of a strong and prosperousCanadian economy. Business immigrants are expectedto make a C$400,000 investment or to own and managebusinesses in Canada

Refugee Refugees are individuals fleeing their homeland due tofears of persecution based on race, religion, nationality,membership in a particular social or political group, war,or massive human rights violations.

Source: Citizenship and Immigration Canada, 2007

Cultural Competence:What are you doing about it?

13

13

Facilitation Tips

Ask the learners;

otheir

New Immigrant Settlement Challenges include:

Skills & credential recognition as requirements for immigration approvalincrease, so too do the socio-economic setbacks for many newimmigrants (Quality of Life in Canadian Communities, 2009)

Language

Access to affordable housing

Access to appropriate community & settlement supports

Inconsistent public policy between levels of government the federalgovernment is involved in organizing immigration, however, upon arrivalin Canada new immigrants are faced with navigating provincial and/orprofessional governing bodies. For example, although the federalgovernment may credentials,provincial licensing bodies may not. This may act as a barrier toemployment and income generation.

Overview of Eligibilityfor Health Benefits

Immigration Status Healthcare Coverage

No status in Canada, and noapplications in progress No public health insurance

Refugee Claimant (Refugeeapplication in progress)

Interim Federal Health

Accepted Refugee OHIP(3 month waiting period may apply)

Permanent Resident (aka LandedImmigrant)

OHIP(3 month waiting period may apply)

14

Facilitation Tips

Ask the learners;

orefugees often arrive with almost nothing whereas immigrants often have more

New immigrants- must wait for 3 months to receive OHIP coverage.Health care can still be provided to those in the waiting period, althoughfees will be levied. Some immigrants may not be aware that they can stillaccess care during this period, while those that are aware may beprevented from doing so for economic reasons. Either way, barriers tohealth care access are created.

Refugees who have been granted protection - must wait 3 months forOHIP coverage, however, they may apply for the Interim Federal HealthProgram which can cover essential services (ie. Prenatal care,emergency care and medical exams necessary for immigration)

There are up to 200,000 uninsured non-status immigrants in Canada,roughly half in the Greater Toronto Area alone (Khandor et al.,2004).While these immigrants may access community health clinics free ofcharge, community health centres can only accommodate 12,000 patientsper year.

Immigrant Experience

15

Facilitation Tips

- Health Care

Minnesota; a primary care clinic that focuses on meeting the health care needs ofimmigrant and refugee communities. Although it is an American clinic, the discussion ofdifficult health care decisions is important for participants to consider.

http://video.google.com/videoplay?docid=-5106027191893998854#

-play from 3:11-5:05


What are some challenges you think new immigrants mayface during resettlement?

Skills and credential recognition

Racism/discrimination

Language


Access to appropriate community and settlement supports

Inconsistent public policy between levels of government

16

Facilitation Tips

None


Challenges directly related to healthcare include:

Healthcare coverage

Access to and navigation of the healthcare system

Lack of significant knowledge of and sensitivity to diversehealthcare needs

17

Facilitation Tips

Comment

Access to healthcare does not just mean the ability to physically attend health careappointments/find a family doctor etc. but also the quality of the health care provided.

Personal differences/biases among healthcare workers in regards to new immigrantsmay negatively impact health outcomes.

We all carry biases; they are an aspect of our own ethnocentrism that result fromour individual values and beliefs. What is important is that you recognize yourown views, from where they stem, and how they could influence health careinteractions. Awareness of your own biases, values and assumptions is the firststep in becoming culturally competent.

Sources of Health Disparities

A review of over 100 studies regarding healthcare servicequality among diverse racial and ethnic populationsfound three main areas that caused disparities:

1. Clinical appropriateness, need and patient preferences

2. How the healthcare system functions

3. Discrimination: Biases and prejudice, stereotyping, anduncertainty (Institute of Medicine, 2002)

18

Facilitation Tips

Comment

Examples in each area include:

1. Clinical Appropriateness-need and patient preferences- variance in health-seekingbehaviour, attitudes toward health care team (distrust), and personal preference (maychoose different treatment options)

2. The operation of the health care system- cultural/linguistic barriers, where minoritiesaccess care (less likely to receive care in a )

3. Discrimination-biases and prejudice, stereotyping, and uncertainty- uncertainty whenworking with minorities, or beliefs held by the provider about another culture

Case Study

19

Case Study

A 6 year old girl is admitted to your medical unit from the emergency department. Uponreviewing her chart you read that she and her family immigrated from China ten months ago,and two months ago she was diagnosed with leukemia. She and her mother speak someEnglish, but her father speaks none. A number of medical tests and procedures have beenordered, but due to the language barrier you are having difficulty explaining to the parents whatthe procedures are and why they are being done. The girl seems very frightened and resistantto have the procedure done ask a colleague forsome assistance, who rolls her eyes when you explain the situation.room and tells the girl and her parents that the procedure is important and to hold still while sheproceeds to conduct the medical test, then leaves. The girl begins to cry and the mother asksyoudistrusting and asks you to leave. You find the colleague who conducted the procedure anddescribe the reaction of the patient and her mother. Your colleague states; r ordered

country when

Questions:

1. What are the cultural aspects of this story that have the potential to impact patient care?

2. How do you think this situation may have been understood by the patient/family?

3. What could have been done differently to provide more culturally competent care?

Facilitation Tips for Case Study Debrief

Questions:

1. What are the cultural aspects of this story that have the potential to impact patientcare?

Hint (think about the patient/family culture and the professional culture)

- Understanding of illness and disease (causality, prognosis, treatment)- Role of hospital and healthcare providers- Language (understanding, word meanings, communication styles)- Family roles (who is the care provider?)- Decision-making

2. How do you think this situation may have been understood by the patient/family?

The parents may feel that you lied to them, as you communicated that the procedure

decisions regarding their daughter, as the colleague came in and simply did the procedurewithout any discussion; thus, asking questions is not tolerated. They may feel that they arebeing punished for not being able to speak English. They may feel discriminated against.

3. What could have been done differently to provide more culturally competent care?

The first care provider could have had a discussion with the patient and family, and uponrecognizing the language barrier, asked them how they felt about using an in-person ortelephone interpreter. With interpretation available, they could have asked the patient and theirfamily what they understood about leukemia and why she had been admitted. This would haveled to a discussion of the medical procedures and why they were important, what the risks were,and whatand a trusting relationship built. Upon hearing the comments of the colleague, a conversationcould be had about the discriminatory nature of their actions and words, how they could beperceived by the patient/family, and how they could act as a barrier to health care access anddelivery.

Social Determinantsof Health

20

SOCIAL DETERMINANTS OF HEALTH

Learning Objective 2

A key aspect of culturally competent care is the ability of care providers to recognize the impactof social influences on health status. Although illness is a biological state, too often the factorsthat contribute to illness are social in origin. According to the World Health Organization (2010),the social determinants of health are described as;

health system. These circumstances are shaped by the distribution of money,power and resources at global, national and local levels, which are themselvesinfluenced by policy choices. The social determinants of health are mostlyresponsible for health inequities - the unfair and avoidable differences in health

Evidence suggests that the current state of the global community has created a situation inwhich the gaps within and between countries, in income levels, opportunities, health status, lifeexpectancy and access to care, are greater than at any time in recent history (World HealthOrganization, 2010).

Identify how the social determinants of health affect immigrants and refugees

Social Determinants of Health

The term emerged from

underlying the different levels of health and incidence ofdisease experienced by individuals with differing socio-economic status

21

Facilitation Tips

Ask the learners:

Why are the social determinants of health relevant to healthcare providers?

Discuss answers with group (refer to slide 20 for further information)


Early life Aboriginal status

Education Employment & working conditions

Food security Gender

Health care services Housing

Social safety net Income & its distribution

Social exclusion Unemployment & employment security

22

Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.).Toronto: Canadian Scholars' Press Incorporated.

Facilitation Tips

Comment

While housing, education, employment, and income are often identified by learners as socialdeterminants of health, the less obvious determinants are no less significant. For example,social exclusion, social safety nets, food security and early life all exert influence on health.


Housing

Asthma incidence is higher among children who live incrowded homes/aging buildings (Gilbert et al., 2003)

Families are often unable to accommodate a child withspecial needs in an small apartment, particularly whenrenting (Chalmers & Rosso-Buckton, 2008)

23

Facilitation Tips

None


Income and Socioeconomic Status

Immigrant families are under-represented in upper middleclass and high income households and are less likely toreport very good health (Dunn and Dyck, 2000)

Socioeconomic status is a significant predictor of heartdisease, adult onset diabetes and some cancers (Raphael,2006)

24

Facilitation Tips

Comment

Evidence suggests that among the new immigrant population, the health-related effects

alcohol.

Culture

25

CULTURE AND CULTURAL COMPETENCE


Cultural competence educators may struggle with the variety of definitions of culturalcompetence. An exploration of these complex terms will help learners simplify their meaningsand understand their key components, which may be helpful in the delivery of culturallycompetent care.


Deepening awareness of personal cultural biases requires self-reflection. Thus, this learningobjective is best achieved through reflective activities that require learners to apply theknowledge they have gained up to this point to their own personal experiences.

Understand the meanings of culture, cultural competence and culturally competent care

Recognize how personal biases affect the patient/family-healthcare provider relationship

What is Culture?

Dynamic:Created through interactions with the world

Shared:Individuals agree on the way they name and understand reality

Symbolic:Often identified through symbols such as language, dress,music and behaviours

Learned:Passed on through generations, changing in response toexperiences and environmentIntegrated:

(Nova Scotia Department of Health, 2005)

What does culture mean to you?

26

Facilitation Tips

Ask the learners:


Comment

Definitions

It is important for learners to recognize that many definitions of culture, cultural competence,and culturally competent care exist, and that the complex nature of these terms leads toinherent ambiguity. Nonetheless, working definitions of these terms are necessary forindividuals to begin to identify with their own personal biases and assumptions.

Culture

particular group of people that guides an individual or group in their thinking, decisions, andactions in pat as cited in Srivastava, 2007, p. 14)

Culture is the attitudes, values and beliefs that define a group of people according totheir actions and thoughts.

Individuals are not born with culture; they are born into a culture through languageacquisition and socialization.

Common Assumptions

Everyone who looks & sounds the same...IS the same

BUT

Drawing distinctions can lead to stereotypingMaking conclusions based on cultural patterns can lead to desensitizationto differences within a given culture

(Garcia Coll et al., 1995; Greenfield, 1994; Harkness, 1992; Ogbu, 1994)27

Facilitation Tips

Comment

We all carry biases; they are an aspect of our own ethnocentrism that result from ourindividual values and beliefs. What is important is that you recognize your own views,from where they stem, and how they could influence health care interactions.Awareness of your own biases, values and assumptions is the first step in becomingculturally competent.

Assumptions and the evidence scientists often fail to consider individual differencesamong members of the same cultural group when generalizing research findings; thus,examining factors related to within cultural group variations becomes as equallyimportant as comparing between group differences (urban vs. rural, working class vs.middle class)

Organizational and ProfessionalCulture

What is the culture of (your organization)?

ValuesInsert here

What is the culture of your profession?

28

Facilitation Tips

Comment

Healthcare providers are socialized into professional cultures as they learn about, andtake on the norms, values, and expectations of the profession

Ask the Audience

What is the culture of your organization?

Some examples include beliefs around importance of appointment times, lifelong learningand education, teaching hospital, family-based care, evidence-based practice, etc.

Iceberg Concept of Culture

Like an iceberg, nine-tenths of culture is out of

29

Facilitation Tips

Comment

The iceberg metaphor is used very commonly to describe culture

Above Ice

Beliefs Values Unconscious Rules Assumptions Definition of Sin

Patterns of Superior-Subordinate Relations Ethics Leadership

Conceptions of Justice Ordering of Time Nature of Friendship Fairness

Competition vs Co-operation Notions of Family Decision-Making

Space Ways of Handling Emotion Money Group vs Individual

Festivals Clothing Music Food Literature Language Rituals

30


Facilitation Tips

Comment

Those aspects of culture that are above the surface are things that are explicit andvisible; these include tangible things such as clothing, food, language, etc.

The non-visible aspects are habits, assumptions, values and judgments - things weknow but oftenintense the emotion attached to it.

Visible and Non-VisibleAspects of Culture

31

Facilitation Tips

Comment

These two pictures were taken from a project in Time Magazine where American teenswere asked to describe what can be perceived immediately about them from their picture(i.e. the visible aspects of culture) and what things may be under the surface (i.e. thenon-visible aspects).

Ask the Audience (after showing each picture separately)

What are the visible aspects of their culture? What are the non-visible aspects?

What are the visible and non-visibleaspects of culture?

ChristopherI suppose something that would not be perceived immediatelywould be my having cancer. I don't have it anymore, I've beentreated for it, but nonetheless, my experience with it has alarge say in who I am. I am a humble person and I don't feelas if I love to share everything with everyone, just like myexperience with cancer, though I suppose now I am telling

frequently as either being very formal and polite or as beingcoldhearted. The real me, however, is very emotional andunderstanding. When I got chemotherapy I saw children noteven five years old with more severe cases of cancer orintestinal problems and I felt . . . I knew something was wrongwith this, with young, innocent children being sick in the waythey were, and I wished I could take their pain and sufferingfrom them. From then on, I look at people with a differentoutlook, and I see how ignorant many people are from eventslike that, and it lifts me to a new level of understanding.

32

Facilitation Tips

Comment

Typical

o Grumpy teenager (a typical teenager)

o Skateboarder

o Hates school, bad grades.

o Lives in a cold climate

People instantly draw assumptions based on appearance, however, most of whoChristopher is (what is important to him, and what may influence his health care

OmarI know that I shouldn't but sometimes I wonder howother people look at me. What do they see first? Mybrown-ness, my beard, my cap, my clothes, the colorof my eyes, the design of my T-shirt? I think thatpeople see my skin color first. They probably see meas a brown guy. Then, they might see my black beardand my white kufi (prayer cap) and figure out I amMuslim. They see my most earthly qualities first.Brown, that's the very color of the earth, the mud fromwhich God created us. Sometimes I wonder what colormy soul is. I hope that it's the color of heaven.


33

Facilitation Tips

Comment

Typical


o Muslim practicing

o Wealthy because of his dress shirt

o Good student


Activity

Ask the learners;

opatieassumptions influence patient care.

o If anyone of them has been stereotyped as the result of some aspect of theiridentity?

o Why we stereotype? Answer we do so owing to the amount of information we areconfronted with on a daily basis, and in order to move through our day we categorizeinformation. However, when we generalize about others (all Martians are green) weare often incorrect.

Culture and the PaediatricExperience

Things to consider:

want to feel connected with their peers(Chalmers and Rosso-Buckton, 2008):

May attempt to distance themselves from the visible aspects oftheir culture/heritage

belongingMay try to regain control by resisting treatment

34

Facilitation Tips

Comment

Children and teens have a strong desire to be accepted by their peers, which often times meanschanging outward appearance and attitude to conform to group expectations. This may meanhiding or not exhibiting unwanted cultural aspects and/or replacing them with aspects of thedesired culture. If a sick child cannot control these cultural aspects, resisting treatment may be

Cultural Competence

35

Facilitation Tips

Comment

We are now moving from the discussion of why there are health disparities in the new immigrantpopulation, to a discussion of what you can do in practice to reduce these disparities. Culturallycompetent care has been shown to be an effective strategy in reducing health disparities.Before we discuss how to be culturally competent, we must first understand what culturalcompetence means, and how it is of benefit in reducing health disparities in the new immigrantpopulation.

Definitions of CulturalCompetence

Cultural CompetenceA set of congruent behaviours, attitudes and policies that cometogether to enable a system, organization or professionals to workeffectively in cross-cultural situations.(Terry Cross, 1988)

Culturally Competent Care

and groups of people into specific clinical standards, skills and

(Hogg Foundation of Mental Health, 2001)(

36

Facilitation Tips

Comment

Although there is some disagreement regarding the definition of clinical culturalcompetence, there is agreement in regards to its core components and the fact thatculturally competence care reduces health disparities.

Cultural Competence

We would not accept substandard competencein other areas of clinical medicine, and cultural

Dr. Joseph Betancourt, 2006

37

37

Facilitation Tips

Comment

Although maybe less intuitive than other areas of clinical medicine, cultural competence is anaspect of every patient interaction, with research evidence to support it as a method of bestpractice.

Benefits of Cultural Competence

Higher cultural competency scores predicted higherquality of care for children with asthma (Lieu et al., 2004)

A group provided with a culturally competent smokingcessation intervention adapted for African Americanshad a significantly higher rate of smoking cessationthan the standard group (Orleans et al.,1998)

Physicians self-reporting more culturally competentbehaviours had patients who reported higher levels ofsatisfaction and were more likely to share medicalinformation (Paez et al., 2009)

38

Facilitation Tips

There is a wealth of literature available that provides direct examples of the benefits ofcultural competence. Select the evidence that is most applicable to your workplace andpatient populations.

CulturallyCompetent

Practice

39

Facilitation Tips

Comment

Cultural competence research is increasing

Understanding and providing culturally competent care is now seen as a strategy toreduce health disparities and enhance the health outcomes of many cultural groups.(CNA, 2004)

Reducing Health DisparitiesThrough Culturally Competent Care

DiversePopulations

CulturalCompetenceTechniques

Clinician/Patient

BehaviouralChange

AppropriateServices

ImprovedOutcomes

Reduction ofHealth

Disparities

(Brach & Fraser, 2002)

40

Facilitation Tips

This is simply a visual presentation of how cultural competence acts to reduce healthdisparities.

Actions and Strategies thatSupport Cultural Competence

1. Examine own values, beliefs and assumptions

2. Recognize conditions that exclude people such as stereotypes,prejudice, discrimination and racism

3. Reframe thinking to better understand other world views

4. Become familiar with core cultural elements of diverse communities

41

Facilitation Tips

None

Actions that SupportCultural Competence

5. Engage patients and families to share similarities and differences fromwhat you have learned about their core cultural elements

6. Learn from and engage clients to share how they define, name andunderstand disease and treatment

7. Develop a relationship of trust by interacting with openness,understanding and a willingness to hear different perceptions

8. Create a welcoming environment that reflects and respects the diversecommunities that you work with and that you serve

(Nova Scotia Department of Health, 2005)

42

Facilitation Tips

None

Cultural Competence Continuum

CulturalDestructiveness

CulturalIncapacity

CulturalBlindness

CulturalSensitivity

CulturalCompetence

CulturalProficiency

43

Cultural competence builds on the concepts of cultural sensitivity andcultural awareness and refers to the ability of healthcare providers toapply knowledge and skill appropriately in interactions with clients(Srivastava, 2007)

Facilitation Tips

Comment

Clinical cultural competence can be viewed as a continuum of knowledge and practice.Moving down the continuum:

Cultural Destructiveness attitudes, practices, and organizational policies that focus onthe superiority of one culture to the extent that other cultures are dehumanizedCultural Incapacity the inability of healthcare providers and institutions to help clients ofdifferent cultures. Healthcare providers see a need to do things differently but feel powerless

Cultural Blindness the existence of cultural differences is denied in a desire to beunbiased and treat all clients identicallyCultural Pre-competence the recognition of needs based on culture and somemovement towards meeting those needsCultural Competence the recognition of, and respect for, difference and an ongoing efforttoward self-assessment and working with diversityCultural Proficiency the ability of practitioners and organizations to value diversity andseek out the positive role that culture can play in health and health care

Ask the audience

Identify that all people can fall at different points along the continuum, at different times.Identify weaknesses of the model including: too linear, and unidirectionalWe will all make mistakes; the point is to move down the slide.

What would youdo in these cases?

1. You room to teach a family how to provide their child amedication/exercise/diet, however, the parents do not speak anyEnglish.

2. You are transporting a patient to their MRI appointment and just beforeentering one of the MRI units a staff member notices a metal bracelet

objects on the patient.

3. A patient is in need of an urgent procedure. The parents understand

spiritual healer has met with the child. The healer will not be on-site foranother 36 hours.

44

Facilitation Tips

Activity

Ask each table group to review the three case examples and generate a discussion as towhat they would do in each case.

If the case example does not pertain to their current clinical role, ask them to brainstormideas and advice that they would give a colleague who came a across this issue in theirpractice.

Clinical Cultural Competence andFamily-Centred Care

45

Insert photos here

Facilitation Tips

CULTURAL COMPETENCE AND FAMILY-CENTRED CARE


Where patient-centred care places the needs of the patient at the centre of health careinteractions, family-centred care views the family as the primary source of knowledge about

(Willis, 1999, as cited in Srivastava, 2007, p. 204).

Culturally competent family-centred care considers cultural beliefs, preferences and practices askey knowledge to be included in collaborative decisions impacting the plan of care. Culture isan integral component of family and is thus an integral component of family-centred care.

Facilitation Tips

Ask the learners:What are your thoughts on the relationship between cultural competence and family-centred care?

are they the same thing?is one more important than the other?where does patient safety fall in relation to these concepts?can you provide one without the other?

Understand the relationship between culturally competent care and family-centred care

Family-Centred Care

Recognizing family as

lifeFacilitating child/familyand professionalcollaborationSharing informationUnderstandingdevelopmental needsRecognizing familystrengths andindividuality

CulturallyCompetent Care

Understanding themeaning of culture

Knowing aboutdifferent culturesBeing aware of disparitiesand discrimination thataffect racialized groupsBeing aware of ownbiases andassumptions

Culturally CompetentFamily-Centred Care

Exploring and respectingchild and family beliefs,values, meaning of illness,preferences and needsRecognizing and honouringdiversityImplementing policies andprograms that supportmeeting the diverse healthneeds of familiesDesigning accessibleservice systems

Cultural Competence andFamily-Centred Care

46

Facilitation Tips

Comment

One of the most significant aspects of family-centred care involves the family in the care,and part of any family is their culture. Although culturally competent care and family-centred care have distinctive qualities, many key concepts overlap.

Culturally competent care is integral to family-centred care and should be embraced andincorporated into our practice as part of the culture.

, but is a necessary part ofproviding high-quality patient care at all times.

Cultural Assessment

47

Facilitation Tips

CULTURAL ASSESSMENT


Like other patient assessments, a cultural assessment can provide vital information with thepotential to impact healthcare decisions.

While several cultural assessment frameworks exist, the framework developed by Andrews andBoyle (2003) considers a wide range of dimensions impacted by culture with the potential toinfluence health decisions and outcomes with a specific focus on family-centred care.

Complete a cultural assessment

Cultural Assessment Tool

Potential topics to explore:

(Andrews & Boyle, 2003)

Bio-cultural Variations and CulturalAspects of the Incidence ofDisease

Health Related Beliefs andPractice

Communication Kinship and Social Network

Cultural Affiliation Nutrition

Cultural Sanctions andRestrictions

Religious Affiliation

Developmental Considerations Values Orientation

Educational Background

48

Facilitation Tips

Comment

There are several frameworks on cultural assessment. This framework considers theimpact of culture on several different dimensions.

Think about how these questions can be incorporated in your practice.

Individual migration experiences can vary greatly.

Try and get a sense for whether the immigration experience was what the family hadexpected.

Try and gain insight into the transitioning experience (for example, school andemployment integration post-migration).

In many countries individuals attach different meanings (including spiritual and social) toan illness experience.

Understanding more about the social determinants of health will enable you to developstrategies to support the patient and family during the hospital stay as well as whentransitioning to the community.

Ask the learners:

What do you think about asking patients and families about their illness experience?

Case Study

49

Case Study

You meet a family who immigrated to Canada three years ago from Lebanon. Six months agotheir son developed physical disabilities and is being seen in your outpatient clinic. The parentswere unable to afford the housing they wanted near resources and services that would behelpful to their son, and getting to hospital appointments is difficult due to time factors and theirlacking a car.

The son has trouble navigating their small apartment with his wheelchair. They tell you theyfound the homecare physiotherapist, who has begun weekly visits, to be very disrespectful.They are skeptical about the quality of care they are now receiving and seem reluctant to booknew appointments or accept instructions on how to proceed with their

Questions:

1. What do you think is occurring in this situation?

There may be financial concerns impacting housing, transportation and other resources for thechild. Potential miscommunication between the family and the physiotherapist need to beexplored in a respectful manner.

2. How might you elicit information from family members about their view of thissituation?

Ask the family what they think is needed to help their son. Explore with the family what theirdaily life is like now, compared to before they immigrated and before their son became ill. Try togain an understanding of what their expectations are and what role they and the healthcare

providers can play in the care of their child. Explore their understanding of the importance of themedical appointments. Provide the support necessary to help them.

3. Identify two actions that would demonstrate a respect and valuing of the

Listen to the family and together devise a care plan for the child. Link the family with anyappropriate support networks in the community and regularly devise a mechanism that allowsfor continuous follow-up in regards to family life at home in relation to the care of their child.

But still I am one.I cannot do everything,

But still I can do something;And because I cannot do everything

50

Facilitation Tips

None

Option 1:Reflect on the visible and non-visible aspects of yourown culture

Option 2:Choose a culture other than your own and explorethe perception of illness and health beliefs

Option 3:Using the cultural assessment guide as a tool, ask afamily a question that you have previously neverasked

Take Away Activity

51

Facilitation Tips

Activity

Prior to concluding the workshop, ask participants to write down three visible and threenon-visible aspects of their culture.

Ask participants to choose a culture that they work with and to research illness andhealth beliefs of this culture. Remind them that the knowledge gained from this activity isjust a starting point and that they must recognize that there is diversity within any givenculture; do not draw conclusions.

Questions?

52

Facilitation Tips

None

THANK YOU!!

53

Facilitation Tips

None

Session B

Cross-Cultural Communication and

Practical Applications

Central Themes

This workshop builds upon the concepts of health disparities, personal biases and assumptions,and the benefits of cultural competence as it introduces the learner to concepts regarding cross-cultural communication as well as strategies and resources which can be utilized by healthcareproviders to facilitate effective communication. The workshop also introduces the learner toconcepts associated with parenting practices, mental health, and the expression of pain acrosscultures.

Session B Learning Objectives

Following completion of Session B learners will be able to:

1. Describe strategies and resources which facilitate cross- cultural communication(collaborative conversations, health literacy, interpreters).

2. Recognize parenting differences across cultures.

3. Recognize differences across cultures in mental health perspectives and describestrategies for providing culturally competent care to those with mental healthsymptoms.

4. Recognize differences across cultures regarding the expression of pain anddescribe strategies for providing culturally competent care to patients experiencingpain.

Part B:Cross-CulturalCommunication andPractical Applications

1

Cultural Competence forHealthcare Professionals

1

Facilitation Tips

Comment

Housekeeping

Washrooms, breaks,

Acknowledge the experience and expertise of audience.






Workshops

Session AIntroduces health disparities, the immigrant experience, social determinants ofhealth (SDOH), and clinical cultural competence.

Session BDevelops knowledge and skills on collaborativecommunication, cross-cultural communication, andclinical cultural competence as it pertains to parenting,mental health and pain management.

Session CDevelops knowledge and skills on clinical cultural competence in the use ofcomplementary and alternative therapies, bereavement and grief. Participantswill have an opportunity to practice with Standardized Patients

2

Facilitation Tips

Comment

This slide illustrates the path that is taken throughout the course of the workshops.The path follows the general steps of:



Learning Objectives

Upon completion of Workshop B participants will be able to:

Apply collaborative conversation techniques in a clinical scenario

Describe strategies and resources to facilitate cross-culturalcommunication

Recognize cultural differences in parenting practices, mental healthperspectives, and the expression of pain

Describe strategies for providing culturally competent care tochildren experiencing pain and mental health problems

3

3

Facilitation Tips

None

Caveat

rather than categories and generalities, is

still the best way to cross lines of

(Bateson, 2000)

4

4

Facilitation Tips

Comment

Although we are present some culture specific information because it can be useful as amust always assess patients and families on an individual basis

them as strange

Cross-CulturalCommunication

5

CROSS-CULTURAL COMMUNICATION


stions directly or fail to make eyecontact, or why some patients never arrive on time or fail to follow medical advice? Is it anindividual choice or does culture play a role?

To provide culturally competent care, healthcare providers must be able to recognize whichbehaviours could be associated with a cultural group and which behaviours are specific to anindividual (Carteret, 2008).

While it may seem useful to memorize the beliefs, values and customs of other cultures, thismethod stereotypes those within a cultural group and ignores individual differences. Instead,when communicating across cultures one must apply the same methods utilized when

towards those differences (Carteret, 2008). But to recognize differences one must first have apoint of reference; in this case a clear understanding of own culture and the role it plays incommunication style.

Describe strategies and resources which facilitate cross-cultural communication(collaborative conversations, health literacy, interpreters)

Assigning Meaning

Discuss at your tables: What itmeans to me

What it mightmean toanother

Not making eye contact

Spending time on small talk

Arriving late for an appt./class/work

Needing to consult family

6

6

Facilitation Tips

Activity

Ask each table group to take a few minutes to answer what each of these things mean tothem, and then what they might mean to someone else

Once they are finished, each table will be asked to discuss their thoughts on one of theissues

Some potential examples include:

Not making eye contact- could mean to you that the individual is disinterested orbeing rude, while to another it could mean a sign of respect or be related tosocial anxiety

- could mean to you that the person understands, while toanother it could mean understand oragree; they are simply responding in the manner in which they perceive as beingacceptable.

Joy Luck Club7

Joy Luck Club, (1993)

7

Facilitation Tips

Video

Play video from 43:40-46:30

Ask the Learners:

What did you notice in terms of the ways in which the individuals in the film werecommunicating and the influence of culture on their interaction?

What was the influence of culture on their interactions?

Were some people communicating directly and others indirectly? How did this affectunderstanding and the relationship between those who were communicating?

Discussion

What did you notice about the ways in which theindividuals in the film were communicating?

How did culture influence their interactions?

8

Facilitation Tips

Comment

The Chinese family in the Joy Luck Club uses a high context communication style; themeaning of the message is much more about the context of communication rather thanthe actual words that were used.

Clinical example of different communication styles and impacts on perception.

If a healthcare provider communicating in a low-context manner might repeatinstructions more than once to emphasize the message and ensureunderstanding.

A parent who communicates in a high context manner might interpret the carepr inferring that they are less intelligent and therefore themessage must be repeated to ensure understanding.

Low ContextHigh Context

Context of Communication

Communication is lessexplicit; most of the messageis in the physical context orinternalized in the person

More emphasis on what isleft unspoken; more likely to

i.e. Asian and Latin Americancultures

Most of the information ismade verbally explicit

Information is often repeatedto ensure understanding(if it is relevant and importantit must be stated, if it is notstated it is not relevant)

i.e. North American culture

(Hall, 1976)

9

9

Facilitation Tips

Comment


- -conanother. They are different ways of communicating.

Although these communication styles predominate in certainnecessarily mean that low context communication is never utilized in a high-contextculture and vice versa. For instance, individuals from North America may still use ahigh-context communication style, although likely not as often as individuals from China.


More responsibility on thelistener to hear, to interpretand then to act

More need for silence; longerpauses(to reflect, understand thecontext and process themessage)

The responsibility forcommunication lies withthe speaker; it is better toover communicate andclarify, than to leave thingsunsaid

Silence and pauses oftenmisunderstood as signs ofagreement or a lack ofinterest

(Hall, 1976)

10

High Context Low Context

10

Facilitation Tips

None

Collaborative Conversation:A Communication Tool

11

Facilitation Tips

Comment

Collaborative Conversations

communicating with patients and their families. The collaborative conversationsframework applies to all patients and their families, not just new immigrants.


3 Steps 2 Ingredients Key phrases

Empathy -Understanding

Two concerns

Help me understand . .Tell me more . .

Can you explain that a bit more?What else are you thinking?

Define theProblem

Invitation toGenerateSolutions

Win/win solutions Would you be open to . . ..

Could we consider . . . .What can we do about this?

What about . . .

I wonder if there is a way . . . .

12

(Greene & Ablon, 2006)12

Facilitation Tips

Comment


It involves:

three steps (empathy, defining the problem, and inviting solutions)two concerns (concerns of the patient, family, colleague or HCP)and potentially key phrases to be utilized when communicating with patients and theirfamilies

A key point of the collaborative conversation is establishing the concerns of thepatient/family first, rather than the healthcare provider stating their concerns first. Theposition of power held by the care provider in this relationship may act to minimize the

n communicating their concerns if the family perceives their

by asking questions rather than stating concerns, as the information gained from thisinteraction may enable a more collaborative decision that facilitates family-centred care.

Things to Consider

Power Dynamics

Experience and Expertise

Communication Styles

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Facilitation Tips

Comment

Considerations When Communicating Across Cultures

Power Dynamics

Who has the power in a health care environment like your organization?

with the healthcare team?How does culture influence power relations between the healthcare provider and thepatient and family?Are the voices of immigrant families heard?How do we minimize cultural silencing?

Experience/Expertise

the professional,


Different communication styles will impact the success of our collaborativeconversations and thus how effective we are when communicating across cultures

Case Study

14

Case Study

You are the mentor for a new employee and observe her giving information about the cost ofmedical and nutritional supplies to a new immigrant mother and father for their son with specialneeds.

The new employee is sitting closest to the mother and is directing most of the instructions andinformation to her. She frequently attempts to make eye contact, even putting her hand on the

summarizes important information. You notice that the parents go from being engaged andinterested, to sitting back in their chairs away from your colleague, with their eyes cast down atthe table. Your colleague continues.

When your colleague has finished providing the parents the information she finds them bothsilent, without comments or questions. She wonders if they do not understand English as wellas they seemed to at first. She repeats her key points, more slowly and loudly, placing her handon the modetails from a lengthy handout which she will provide before they leave.

Questions to consider:


2. How do you think this situation may have been understood by this family?

3. How might you elicit information from family members about their view of this situation?

4. Identify two actions that would demonstrate a respect and valuing of the child/family s cultureand expectations.

5. What strategies might enhance the cultural competency of the care being provided in this andsimilar situations?

Facilitation Tips


There is a difference in communication styles between the employee and the parents. Whilethe employee has recognized that something is impacting her interaction with the parents, sheis unable to recognize how she may be contributing to the difficulty she is encountering. Ratherthan ask questions, her assumptions are causing her to reinforce her communication style.

2. How do you think this situation may have been understood by the parents?

The mother may feel that by directing the discussion to her that the employee is disrespectingthe father. The father may feel disrespected. By speaking loudly the parents may feel that theemployee feels they are of low intelligence, and by using physical contact she is invading theirprivacy and being disrespectful. They may feel that their ability to speak and understandEnglish is poor, thus the need for repetition and louder instructions, making them less confidentto speak English. They may interpret her actions as implying that the cost of the supplies will bedifficult to deal with, and thus they are of lower socioeconomic class.

3. How might you elicit information from family members about what they have understood?

You could ask the parents to repeat back what they have understood from the informationprovided, and ask open-ended questions that liemployee could ask the parents to demonstrate their understanding of the instructions throughsimulation or even drawing.

4. Identify two actions that would demonstrate a respect and valuing of the child/family s cultureand expectations.

Understand your own communication style and resulting communication tendencies. Pay closeattention to the parents communication style so that you may adjust yours appropriately. Silencedoes not necessarily reflect a lack of understand; ask questions and allow time for silence andalways reassess understanding. Attempt to understand the parents concerns.

5. What strategies might enhance the cultural competence of the care being provided in similarsituations?

Review cross cultural communication strategies with new employees beforehand, emphasizingthe importance of recognizing non-verbal communication and taking cues from the familyregarding preferred communication styles. Reinforce the importance of understanding your owncommunication style and how it can impact the effectiveness of cross cultural communication.Always ask questions and allow time for parents and patients to comprehend and respond.Gauge your next steps based upon both the response provided and your interpretation of theunderstanding demonstrated by the response. Do not simply enforce your will; collaborate toachieve win/win solutions.

Health Literacy

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Facilitation Tips

None

What is Health Literacy?

Health literacy involves the ability to obtain,process and understand basic health information(Ratzan & Parker, 2000)

Canadians with the lowest literacy scores are twoand a half times as likely to see themselves asbeing in fair or poor health (Rootman & Gordon-El-Bihbety, 2008)

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Facilitation Tips

Comment

Health Literacy

Health literacy is not just the ability to understand English; it also includes the ability toaccess information to make informed decisions. For example, an individual who knowshow to speak English but has no knowledge of community resources or how to use theinternet to access health information may still be considered at a low level of healthliteracy.

Health Literacy

We should not assume people understandwords or their meaning.

Health literacy is more than:

giving a family a pamphlet in their own language(English or otherwise)

providing interpretation in the language of theirchoice

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Facilitation Tips

Ask the Learners:

How do you use written material with patients and families to help facilitateunderstanding?

Comment

Need to be cognizant of the fact that some families may not be literate in their ownlanguage

It is important to ensure that patients and families are able to decode, process and acton the information provided in a pamphlet

Interpreter Services andLanguage Line

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Facilitation Tips

None

Costs of Not ProvidingInterpretation in Healthcare

A literature review described inequitable care withregard to three specific factors:

Inappropriate tests and procedures

Increased adverse events

Lack of or inappropriate hospital utilization

(Access Alliance, 2009)

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Facilitation Tips

None

Availability of interpretersInterpreters are sometimes unavailable

Strategies are always needed to support effectivecommunication, even when interpreters are unavailable(ex. Language Line)

Trained versus untrained interpretersTrained interpreters were 70% less likely to make medicaltranslation errors than untrained interpreters (Gany et al.,2010)

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Facilitation Tips

Comment

We should refrain from using untrained interpreters including family members asimportant information may be lost. Only consider the use of family members asinterpreters when the information to be communicated is extremely basic, for example;

Are you hungry?

for an Interpreter

Ask the family what language they speak at home

Observe what language the family speaks amongthemselves

Explore with the family when having an interpretermay be helpful

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Facilitation Tips

Comment

Remember that stress may impactEnglish

for an Interpreter

Pay attention to non-verbal cues

Ask the family to tell you their understanding of whatwas discussed

Continue to assess the need for an interpreter on anongoing basis

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Facilitation Tips

Comment

Ask the family a simple question that requires more than a yes or no answer and listento how they respond

As interpreters are not always available, it is important that a communication plan bedeveloped for the daily care of patients, for example;

using non-verbal communication

using physical materials as communication tools (simulation, drawing, etc)

complex and important information including information related to medicationsand the health of the patient should always be communicated through aninterpreter

Barriers to the use of Interpreter Services:

Some families may be concerned about confidentialityif they are from a small ethnic community where theymay be known to the interpreter

Families may decline interpreter services out of fear ofbeing viewed as different or difficult

(Chalmers & Rocco-Buckton, 2008)

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Facilitation Tips

Comment

Remember that when talking to families about an interpreter, how the interpreter isoffered is extremely important. For example, explain to the client that medical languagecan be hard to understand even for people whose first language is English

If the patient/family declines, explain to them that you are also requesting the interpreterso that you can understand what they are saying

In order to work with the family, it is important to listen to and recognize their concernsregarding interpretation

Working Effectively withMedical Interpreters

Introduce yourself, the interpreter, and the parentand/or patient

Briefly provide background information to theinterpreter (purpose of the meeting)

Address the patient/family, not the interpreter

Ensure closure and debrief with the interpreter

Document the conversation

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Facilitation Tips

Comment

A recent study found that health care professionals introduce themselves to aninterpreter 72% of the time but they only introduce the patient to the interpreter 17% ofthe time (Lie et al, 2009)

When using an interpreter it is important to:

Explain the purpose of the meeting to the interpreter and explain the role of theinterpreter to the patient/family

Arrange seating in a manner conducive to interpretation; you should have adirect view of the patient

Closely observe the patient/family for non-verbal communication

Address the patient in the first person rather than he or she

Speak directly to the patient, not to the interpreter

Interpreter Services:SickKids Policy

Must be related to direct patient care

The request must be made by a healthcareprofessional

24-48 hours notice must be provided (duringbusiness hours)

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Facilitation Tips

None

26

Working Effectively withMedical Interpreters

26

Facilitation Tips

Videoo Play DVD

o Show: Part 1. Diabetes (unskilled interpreter- 10 mins)

Part 2. Diabetes (skilled interpreter- 7 mins)

Ask the Learners:

(after parts 1 and 2)

How do you feel or what did you notice about the quality of patient care that wasprovided in the first example (family member as interpreter), versus the second example(staff member as interpreter)?

Comment

Remind learners that although a care provider may be useful as an interpreter, youcannot assume that the care provider holds the same values and beliefs as thepatient/family simply because they speak the same language

Language Line:SickKids Policy

Recommendations for use of Language Line:Urgent or same day requests

Ideally, use a phone with a speaker or 3-way calling

Provides services in languages unavailable throughInterpreter Services

Requires the department cost centre code

Available 24/7

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Facilitation Tips

Ask the Learners:

Have you ever used interpreter services or language line before? Why or whynot?

What influenced your decision to utilize interpreter services for this particularfamily?

How accessible was the interpreter?

Describe the interaction between yourself, the interpreter, and the family.

Have you ever used language line before? Why or why not?

What influenced your decision to use language line over interpreter services?

Did you consult with anyone before using this service?

How accessible was language line for you to use?

Describe the interaction between yourself, the language line interpreter, and thefamily.

Cultural Differencesin Parenting

28

PARENTING ACROSS CULTURES


Content

function in their local community. Parents transmit values, rules, and standards about ways ofthinking and acting, and provide an interpretive lens through which children view socialrelationships and structures.

The meaning of family can differ between cultures; for example, in some cultures aunts anduncles may not be blood relatives, while in other cultures they must be blood relatives.Likewise, the roles of each family member may differ across cultures; for example, the fathermay be responsible for discipline while the mother may be responsible for the physical care ofthe children, or an adolescent may take on a greater amount of responsibility within ahousehold.

Culture affects values, beliefs and attitudes in regards to:

sleep, attachment, education, safety, family, extended family, adolescence, roles, feeding,discipline, play, advice-seeking and much more.

Collectivism and individualism are examples of cultural orientations which can affect howindividuals interact with each other and how they parent their children.

Recognize parenting differences across cultures.

Cross-Cultural Parenting

They openly laughed at me for

to walk. A child walks of itsaccord, they said. I would besaying next that trees had to beinstructed in how to bear fruit.(Hogbin, 1943)

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Facilitation Tips

Comment

This quote illustrates different beliefs around parenting;

one view is that you should encourage and teach your child to walk, whereas analternate view is that a child will walk on his/her own, so why teach him or her todo so?

Have you been surprised by acultural difference in parenting?

(Greenfield & Suzuki, 1998)

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Facilitation Tips

Ask the Learners:

Why do you think these differences in parenting styles are occurring?

How Culture Affects Parenting

SleepFeedingDisciplineParenting styleRoutinesMediaPlayTalking to children

AttachmentEducationConflictsSafetyFamily typeAdolescenceRolesAdvice seeking

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Facilitation Tips

Ask the Learners:

Can you think of a clinical/personal example where your belief around one of thesethings clashed with that of a family you were working with?

How did you work through this?

Comment

Culture will have a major influence on these aspects of parenting

While we recognize the importance of all of these areas, we will highlight a couple ofthese topics in the next slides

Parenting DifferencesAcross Cultures

Gusii mothers of Kenya holdtheir 9-10 month old infantsand engage in soothingphysical contact more thanmiddle class mothers fromBoston, but also look andtalk to them less

(Richman, Millar & Solomon, 1988)

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Facilitation Tips

Comment

In Kenya:

Infant mortality rates are high, holding and soothing provides a greater chance ofsurvival

There is a common belief that language is not understood until age of 2 and thatone should avoid eye contact with others

In Boston:

There is a common belief that language and learning should begin early and thatplacing infants in playpens where they can play by themselves begins the highlyvalued process of independence

Historical Perspective

Parent-child relationships amongracialized groups are often portrayedas deficient (Keller, Volker & Yovsi, 2005)

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33

Facilitation Tips

Ask the Learners:

How might the social determinants of health impact parenting?

The expectation that parents should be present at the hospital while their child isadmitted may be unfair if the parent is working two jobs and taking time off is notan option for financial reasons.

Co-sleeping may be the result of a family not being able to afford a crib, orhaving no room in the apartment for a crib.

Individualism andCollectivism in Parenting

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Facilitation Tips

None

Definitions

Goal of autonomyValues

Personal choiceEmphasize

Goals focus on the individualpreferences, rights andpleasure

Universalistic approachSame values are applied toall

Individualism Collectivism

Promote relatedness andinterdependenceValues

Connection to the familyRespect and obedience

EmphasizeGoals focus on the group

Pluralistic approachDifferent values andstandards are applied to

(Tamis-LeMonda, Way & Hughes,2008, Srivastiva, 2007)

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Facilitation Tips

Comment

A universal tasknecessary to function in their local community

Parents transmit values, rules, and standards about ways of thinking and acting, andprovide an interpretive lens through which children view social relationships andstructures

Collectivism and individualism are examples of cultural orientations which affect howindividuals interact with each other

Collectivism tends to be more common in Latin America, the Middle East and Asia

Individualism is more common in North America and northern Europe

Many studies illustrate the contrasting goals of parents from different collectivisticand individualistic cultures; however, boundaries between the two are oftenblurredIt is important to remember that these cultural orientations are dynamic and maychange depending on the situation, setting or context (Tamis-LeMonda, Way, &Hughes, 2008)

Communication

Communicate about thephysical world, such asusing objects, and othertopics that preparechildren for school

Emphasize outwardexpressions using wordsor gestures e.g. pointingto an object while sayingthe name to teach infantsnew words

Use communication to

knowledge, such as howobjects relate to one another

Use more non-verbal andsubtle expression such aslearning games throughobservation or using touch,gaze, posture, and facialexpressions to expressmeaning

(Srivastiva, 2007)

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36

Facilitation Tips

Comment

In an individualistic culture a parent may repeat the word they would like the child to say;say it: pot,

, 1943, pg. 303)

In a collectivistic culture there may be more use of non-verbal cues; for example, with aquick movement of eyes, a parent may tell a child to put the food into the pot (Mistry,1993)

Family Structure and Roles

The core family unit isusually the authority whenit comes to decisions,parenting and childrearing

The extended family unitplays a key role in childrearing

The family system is thehighest authority

(Srivastiva, 2007)

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37

Facilitation Tips

Comment

The meaning of family and who is considered family differs across cultures. Forexample, in some cultures aunts and uncles do not necessarily mean blood relatives.

Involving extended family can help parents feel supported and give children multiplesources of support

The roles of each family member may differ across cultures

The father may be responsible for discipline while the mother may be responsiblefor the physical care of the children

Adolescents may take on a greater amount of responsibility within the household

Sleep

Often believe that separatesleeping arrangementshelp children developindependence andmaintain parental privacy

Regularly co-sleep (as many as

Self-soothing less important

Help child-parent bond

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38

Facilitation Tips

Comment

updated July, 2010, all children under the age of 2 will be required to sleep in a crib

If parents are resistant, it is crucial to understand parental concerns FIRST, after whichwe may provide education as healthcare professionals (re: policy, and patient safety) orinvolve other team members if necessary (i.e. charge nurse, associate chief of nursingpractice, or risk manager)

Discipline

Value providing structureddiscipline while beingavailable, involved, warmand sensitive

Encourage thinking abouttheir behaviour andlearning about limits

May use strategies such asshaming

Encourage respect for eldersand authority figures

May use other relatives ornetworks for discipline

(Srivastiva, 2007)

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39

Facilitation Tips

Comment

Understanding the discipline practices of others can be challenging, however,considering parental goals for behaviour and discipline is important when developingstrategies

Because of differences in parenting across cultures, some investigators have advocatedfor a culturally sensitive approach which reviews the normal range of relationships withina given culture and how these relationships have been linked to child outcomes (Hughes& Seidman, 2002)

However,

Immigrant Parenting Experience

Other considerations:

Transitioning

Idea of transitioning from child to adult services is basedon Western values

The concept of encouraging a child to gain autonomy andmake decisions independently may not be appropriate insome cultures

Primary caregiver roles

(Chalmers & Rocco-Buckton, 2008)

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40

Facilitation Tips

Comment

Perceptions of adulthood and other developmental transitions are highly cultural. Forexample, some cultures may associate a certain age with the onset of adulthood,whereas others may require a religious or other practice to make this transition. Thus,transitioning from pediatric to adult care centres at the age of 18 may not be understoodand could contribute to feelings of stress or helplessness.

Who is the primary care provider? The most common answer to this question is theparents; however, in some cultures it is the norm for the grandmother to be the primarycaregiver during the . Do not make assumptions; alwaysask questions.

Immigrant Parenting Experience

PARENTING VIDEO

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41

Facilitation Tips

Videoo Play DVD

o Time Codes: 16:21-18:11

Ask the Learners:

Do you think immigrant parents are judged?

Foreign VisitorActivity

42

Facilitation Tips

Activity

Pass one of the four quotes to each group. Allow the groups to discuss them at theirtable and then review them with the entire class.

Go to the next slide

Foreign Visitor Activity

What is the issue?

Is the criticism true? Fair?

What underlies it? What is the logic behind it?

How could you explain or defend it?

43

43

Facilitation Tips

Ask the Learners:

How would you respond to the following questions in relation to the quote you weregiven?

Most people will be able to defend each of the parenting practices being judgedin each of the quotes

These defenses may be based on values around individualism vs. collectivism

Try to get the group to think about how we judge the parenting styles of others, and whatit feels like when we are judged

Comment

Like Canadian parents, immigrant parents also have reasons behind their parentingchoices

These statements are generalizations, recognizing thatsuch and such a country do this also an unfair generalization

Parenting: Key Considerations

Recognize how culture and the new immigrantexperience impacts parenting

Recognize cross-cultural implications for the teachingthat we do around parenting

Be aware of the strengths of individualistic andcollectivistic approaches to parenting

Understand that personal parenting styles may noteffectively cross cultures in the context of growth anddevelopment

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44

Facilitation Tips

Comment

Examples of the strengths of different approaches to parenting include;

a child from an individualistic culture might be more independent

a child from a collectivistic culture might be more open to sharing and have adeeper understanding of community

When assessing development, keep in mind the cultural/social context of the family; forexample, is it a fair assessment if you gauge development based on how many blocks achild can stack, taking into consideration that a child may not play with blocks because

When teaching about parenting it is important toremember that optimal child development canfollow many paths.

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Facilitation Tips

None

Mental HealthSupporting Immigrant and Refugee

Families and their Mental Health Needs

46

CULTURE AND MENTAL HEALTH


Content

As has been described thus far, culture affects how people label and communicate distress andillness, perceive the need for and actions of healthcare providers and the way in which healthcare is accessed. In issues of mental health this statement holds true.

While the immigration is a stressful process, immigration itself does not jeopardize mentalhealth. Rather it is the circumstances that surround the migration including stressful pre- andpost-migration experiences that determine the risk of developing mental health problems(Hyman, 2001). Stressors experienced by new immigrants include culture shock,intergenerational tension, social determinants of health, and language barriers.

Facilitation Tips

Ask the Learners:

What is your first thought

What is your first thought

Recognize differences across cultures in mental health perspectives and describe strategies forproviding culturally competent care to those exhibiting mental health symptoms.

Culture and Mental Health

Culture affects how people:Label and communicate distressExplain causes of mental health problemsPerceive mental health providersRespond to treatment

Culture influences who people seek helpfrom and how they access treatment

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Facilitation Tips

None

New Immigrant Experienceand Mental Health

Balancing/navigating two or more cultures

Intergenerational tension

Social determinants of health

Language barriers

48

48

Facilitation Tips

Comment

going out late at night, parties, and clothing, may be very different from their adolescentchild who has grown up in a North American culture

Immigration and Mental Health

Even though it is a stressful process, immigration itself

Rather, it is the

circumstances that surround the migration including

stressful pre and post-migration experiences that

determine the risk of developing a mental health

problem.(Hyman, 2001)

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Facilitation Tips

None

Immigrant Youth, Identity,and Mental Health

Immigrant children may experience cultural conflict as theyattempt to identify with new cultures

more than one culture and also to switch roles back and forth(Jambunathan, Burts, & Pierce, 2000)

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Facilitation Tips

Comment

Note that biculturalism is not the same as assimilation

Assimilation refers to: the process by which an outsider, immigrant, or subordinate

criticized for exaggerating the importance of the values of the dominant group, and forneglecting the ability of new or subordinate groups both to affect the values of thedominant group or else to live alongside it while adhering to its own values (Marshall,1998)

Determinants of New ImmigrantMental Health

Migration stress (before, during, after)

Personal resources

Socio-demographic characteristics

Social resources

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Facilitation Tips

Comment

Migration stress- Immigrants who have experienced traumatic events such as war, famine and

forced migration are at an increased risk of mental health problems, includingdepression, PTSD and suicide

- Post-migration, experiences of unemployment, underemployment , low-socioeconomic status, racism and discrimination are at increased risk ofdeveloping mental health problems

Personal resources- Fluency in English or French is a protective factor- Those who maintain their original cultural identity while integrating with the larger

societal framework have the best mental health outcomes

Social resources- Family love and support promotes mental health and well-being- Social support provided by the ethnic community and the host society is

associated with positive mental health outcomes, whereas social isolation is amental health risk factor

Socio-demographic characteristics- Those who immigrate during adolescence or after the age of 65 seem to be at

higher risk of developing mental health problems

A Refugee Experience

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52

Facilitation Tips

Video

o Play DVDo Time code: Chapter 11: 31:08-38:30

Comment:

This movie is based on the Lost Boys of the Sudan. A civil warbetween the Northern Muslims and Southern Christians forced these children and teensfrom their homes and country for fear of death. Some geestatus in the United States. The following clip covers the period of time immediatelyfollowing their arrival in the US.

***Warn the learners that the clip is powerful and can evoke strong emotions, especiallyfor those who may have been through similar experiences. Tell the group to think aboutthe immigrant/refugee experience as it relates to mental health as they view the clip.

Ask the Learners:

Based on the clip, what did you observe that would impact mental health?Stressors of a new environment and nothing being familiar (grocery store)

Loss of friends from the refugee camp who became their family, and with whom theyshared a traumatic experience

needing to succeed to help family back homeAge 13 and in charge of a group of 1200 children younger and smaller than you, havingto learn to dig graves and bury bodies..PTSD?Racism and discrimination

Refugees and Immigrants:Mental Health Challenges

May be separated from family for lengthy periods

Moving from rural to urban settings or to entirely differentgeographical locations

Witness to wartime atrocities, refugee camp life, personal orfamily violence leading to Post-Traumatic Stress Disorder(PTSD)

Minority status and/or limited English proficiency

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Facilitation Tips

Comment

PTSD is defined as: a severe anxiety disorder that can develop after exposure to a

self or to someone else (American Psychiatric Association, 2000)

The symptoms of PTSD are the same in all cultures, but how it is defined and expressedchange from culture to culture

Culture of origin is it collectivistic or individualistic?

What are the differences in the way mental health isviewed, responded to in collectivistic vs. individualisticcultures?

Consider the impact of stigma in relation to mental health

Mental Health:Key Considerations

54

54

Facilitation Tips

Ask the Learners:

How might individualistic and collectivistic cultures view mental health issues?

Individualistic cultures promote people relying on their own resources; forexample, if you have a problem imedications

Collectivistic cultures tend to support interdependence; people have networks torely upon (extended family, community). It is the group s responsibility to supportthe individual.

Can anyone provide an example of cultural stigma around mental health?

One example of cultural specific stigma may be that some Asian families do notwant to reveal mental health issues as it might be a reflection on the entire familyif one person has mental health issues

Comment

People may be more open to talking about a broken arm then to reveal that they are onmedication for depression

However, in some circles, talking about seeing a therapist every week is normal or the

Access Alliance

Four Villages

Hong Fook Mental Health Association

Mt. Sinai Hospital

Across Boundaries

Support for ImmigrantMental Health in Toronto

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Facilitation Tips

Comment

There are a number of community groups that support the mental health of newimmigrants. These are just some in the Toronto area.

Access Alliance - provides primary health care, illness and disease prevention andhealth education services to newcomers and refugees of all ages in Toronto

Four Villages - promotes health and wellness through a wide range of primary careservices and programs with a focus on reaching individuals and groups in the communitywho face difficulty accessing the healthcare system

Hong Fook - promotes the mental health of people in the Cambodian, Chinese, Korean,and Vietnamese communities

Mt Sinai- provides consultation and treatment both to inpatients and outpatients withspecialty clinics including geriatric psychiatry, trauma, maternal/perinatal mental healthand HIV-related concerns

Across Boundaries- provides a range of supports and services that identify and honourthe strengths of individuals, families, and racialized communities - while recognizing andaddressing the negative impact of racism and discrimination on their mental health andwell being

Pain

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56

PAIN ACROSS CULTURES


Literature suggests that there are cultural differences in the perception, assessment andtreatment of pain. Research has shown that individuals have a propensity to react to pain inone of two manners; with a stoic response or an emotive response, and how theseresponses are understood by care providers may influence how pain is interpreted and howit is treated.

Ask the Learners:

Are there cultural differences in the way pain is expressed and understood? If so, can youdescribe one?

Recognize differences across cultures regarding the expression of pain and describestrategies for providing culturally competent care to patients experiencing pain.

Culture and Pain Management

59 74% of African-Americans and Hispanics receivedinadequate analgesic prescriptions in an outpatient setting(Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997)

Study of Mexican-American patients found patients rated

(Calvillo & Flaskerud, 1993)

Cancer patients belonging to minority groups are at agreater risk for inadequate pain management than non-minority groups(Bernabei et al., 1998; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997, as citedin Lasch, 2000)

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Facilitation Tips

None

Latino children received 30% less opioids than Caucasianchildren for peri-operative analgesia(Jimenez et al., 2010)

A Canadian study suggests that differences in painresponse in relation to culture may exist for infants as earlyas 2 months of age(Rosmus, Johnston, Chan-Yip, & Yang, 2000)

Studies report varying pain thresholds among differentcultural groups(Sawhney, 2007)

58

Culture and Pain Management

58

Facilitation Tips

Comment

The study by Rosmus et al. (2000) showed that Chinese babies displayed greaterbehavioural reactivity to pain than non-Chinese babies.

Pain: Cultural Considerations59

59

Facilitation Tips

Comment

Family Patterns

the way children deal with pain is affected by how parents treat them when they are in pain,and how parents themselves respond to painexpectations of and socialization by family and society affect the pain experiencefamily must be included in the assessment and treatment

Level of understanding

understanding varies with the developmental age and stage of the childchildren may have difficulty communicating their pain and needs and thus rely greatly ontheir families to advocate for them

Previous Experience with Pain

an r responses to pain (burn victims may associatesymptoms of pain with a previous traumatic experience, or oncology patients may associatepain with an initial diagnosis or relapse)it is also important to recognize the emotional impacts of pain (despair, depression)providing effective pain management for the first procedure is extremely important, as thisexperience will carry over with subsequent procedures

Cultural Experience of Pain

From The Spirit Catches You and You Fall Down

makes it better and what makes it worse? Is it sharp? Dull?

Piercing? Tearing? Stinging? Aching? Does it radiate from one

place to another? Can you rate its severity on a scale from one to

ten? Is it sudden? Is it intermittent? When did it start? How long

does it last? I would try to get an interpreter to ask a Hmong these

(Fadiman,1998)

60

60

Facilitation Tips

Ask the Learners:

What are some cultural considerations we need to acknowledge when assessing pain?

Do we ask does your pain radiate from one place to another; or do we ask, doesyour pain move up and down from one body part to another?

Cultural Responses to Pain

Stoic Patients Expressive Patients

Less expressive of their pain

Tend to withdraw socially

Lack of facial grimace doesNOT mean that there is no pain

Northern European, NorthAmerican, Asian cultures

More likely to verbalize theirexpressions of pain

They desire people aroundthem to react to their painand assist them with theirsuffering

Hispanic, Middle Eastern,and Mediterranean cultures

(Llewellyn, n.d.)

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61

Facilitation Tips

Ask the Learners:

What have been your experiences with stoic patients? Expressive patients?

Do you treat patients that are stoic differently from those who are expressive?

Are you more likely to provide more attentive and compassionate care to the stoicpatient compared to the expressive one?

Comment

It is also important to take into consideration gender influences on pain

In many cultures, males are expected to respond to pain in a different mannerthan females

Case Study

62

Case Study

Kaleem is a 4 year old boy whose family recently immigrated to Canada from Pakistan.Hesuffers from systemic arthritis. Upon his return from a trip to Pakistan, Kaleem has developed afever, swollen and painful joints, and is immobile and severely nutritionally compromised.Kaleem missed his last scheduled clinic visit. During this clinic visit you perceive that his parentshave become desensitized to his pain, and that they believe the side effects of the painmedications (occasional drowsiness, nausea, and constipation) to besymptoms.


1. How can we be an advocate for Kaleem as he deals with his pain?

expertise as healthcare professionals?

3. How would you incorporate the collaborative conversations framework in dialogue with thisparticular family?

FacilitationTipsActivity

Hand out one case study to each table group and ask them to answer the following questions:

1. How can we be an advocate for Kaleem as he deals with his pain?

You should use appropriate tools to assess his pain and use non-verbal communicationdepending on his understanding of English. Talk to the parents about your impressions ofKaleem pain and how it may be affecting him (ie. not eating). Consider the use of aninterpreter.

2. How can we be respectful of Kaleem parents while still sharing our experience andexpertise as healthcare professionals?

Explain to them that you can appreciate their concern about the side-effects and that this is alegitimate concern. Try to understand their concerns more deeply by asking questions. Didsomething happen in Pakistan? Did a friend or family member tell them something bad aboutthe medication? Were his medications available? Did they run out? If the only reason dealsdirectly with concerns about side effects, explain that you will try to keep Kaleem comfortableusing the minimum amount of medication to decrease the potential side-effects. Try to come toa win-win solution using a collaborative conversation.

Explore with the family whether there are any complementary or alternative therapies they usein their culture to manage pain.

3. How would you incorporate the collaborative conversations framework with this particularfamily?

Discuss your thoughts with the family while also taking time to explore their concerns. Makesure to include the family in the decision-making process and show that you value and respecttheir views.

What might be a response to the question:

63

63

Facilitation Tips

Comment

hy does your chphilosophical questions:

A response based on North American culture might be literal ( st had)

The concept of ethnocentrism as it relates to pain is important, as we are more likely to

A healthcare professional from a stoic background may not know how to react to apatient who responds to pain with loud verbal complaints

Possible Child/FamilyExpectations

May be varied amongst different families

The nurse will know that I have pain and bring my medication

I know I will have pain but it is just part of the process

I do not believe in pain medication

I should apologize when I ask for pain medication

64

64

Facilitation Tips

None

Pain Assessment and Management:Key Considerations

Utilize established assessment tools to assist inmeasuring pain

Appreciate variations in affective responses to pain

Be sensitive to variations in communication styles

Recognize communication of pain may not beacceptable within a culture

65

65

Facilitation Tips

Comment

Utilize assessment tools to assist in measuring pain

To increase accountability for pain assessment, some experts suggest pain should beviewed as the fifth vital sign

? a sufficient assessmentstrategy for some patients, in cultures where stoicism is valued it may not beadequate

Appreciate variations in affective responses to pain

Cultural values about the expression of pain may result in stoic or emotive responses

Be sensitive to variations in communication styles

An individual may feel that non-verbal symptoms or expressions are enough toconvey a painful experience and therefore verbalization is not needed

Some may assume that if pain medication is appropriate then care providers wouldgive it, therefore asking for it would be inappropriate

Recognize that communication of pain may not be acceptable within a culture

In some cultures, asking for assistance is considered a lack of respect or a sign ofweakness

Appreciate that the meaning of pain varies betweencultures

Utilize knowledge of biological variations (vitals) in theassessment and management of pain

Develop knowledge of cultural values and beliefs that mayaffect responses to pain

Incorporate culturally specific practices (e.g. CAMtherapies) desired by the patient into the pain managementplan

66

Pain Assessment and Management:Key Considerations

66

Facilitation Tips

Comment

Appreciate that the meaning of pain varies between cultures

Individuals may attribute religious meaning to their pain and turn to praying or seekinghelp from spiritual healers

Utilize knowledge of biological variations

Pharmacological research has determined that there are significant differences indrug metabolism, dosing requirements, therapeutic response, and side-effects indifferent racial and ethnic groupsIt is important to remember that a wide range of reactions is possible even within acultural group

Develop personal awareness of values and beliefs which may affect responses to pain

asfrom how they would express their own painA healthcare provider who is concerned with drug addiction may hesitate to provideadequate analgesicsAssumptions and biases about other cultural groups may influence the way that ahealthcare provider views and treats an individual presenting with pain

Take Away Activity

Option 1:Use a communication resource (Language Line or InterpreterServices) to communicate with a non-English speakingparent

Option 2:Utilize collaborative conversation communication tool with afamily

Option 3:Initiate a discussion about how parenting, pain or mentalhealth differs across cultures

67

67

Facilitation Tips

None

Questions?

68

THANK YOU!!

53

Session C

Complementary and Alternative Medicine,

Bereavement and Grief,

and Practical ApplicationsCentral Themes

This workshop introduces the learner to cross-cultural concepts regarding complementary andalternative medicine (CAM), as well as bereavement and grief. Building on Session B, furtherstrategies and resources are presented that can be utilized by healthcare providers to facilitateculturally competent care. Session C also includes an activity involving standardized patientsdesigned to reinforce the concepts presented in the sessions by putting them into practice in asimulated and safe environment. In effect, the standardized patients provide the opportunity forparticipants to apply the knowledge they have gained throughout the sessions to a scenario thatacts to develop culturally competent attitudes and communication skills.

Session C Learning Objectives

Slide 1

Following completion of Session C learners will be able to:

1. Describe strategies for integrating complementary and alternative therapies intopractice.

2. Recognize differences across cultures in grief and bereavement.

3. Describe strategies for providing culturally competent care to patients and familiesduring the bereavement and grief period.

4. Apply cross cultural competency skills in clinical situations (by interacting withstandardized patients).

Cultural Competencefor

Healthcare ProfessionalsPart C: Practical Applications Continued

Facilitation Tips

Comment

Housekeeping

Washrooms, breaks,

Acknowledge the experience and expertise of audience.






Workshops

Session AIntroduces health disparities, the immigrant experience, social determinants ofhealth (SDOH), and clinical cultural competence.

Session BDevelops knowledge and skills on collaborative communication, cross -culturalcommunication, and clinical cultural competence as it pertains to parenting,mental health and pain management.

Session CDevelops knowledge and skills on clinical cultural competence inthe use of complementary and alternative therapies, bereavementand grief. Participants will have an opportunity to practice withStandardized Patients

Facilitation Tips

Comment

This slide illustrates the path that is taken throughout the course of the workshops.The path follows the general steps of:



ed to simulate patient case scenarios.

can take the role of patients, family members or healthcare providers.

Standardized Patients Program will be participating ina group activity designed to help you put your cultural competence knowledge and skills intopractice.

Learning Objectives

Participants will be able to:

Recognize differences across cultures in regards to:bereavement and griefcomplementary and alternative medicine

Describe strategies for providing culturally competentcare to patients and families during the bereavementand grief period

Describe strategies for integrating complementary andalternative medicine into practice

Apply cross-cultural competency skills in clinicalsituations (by interacting with simulated patients)

Facilitation Tips

None

Complementary andAlternative Medicine

(CAM)

COMPLEMENTARY AND ALTERNATIVE MEDICINE


The mply a cultural connotation, as these therapiesare only complementary or alternative to the dominant medical culture, that being Westernbiomedicine in the case of North America.

Is it fair for a healthcardifferent? ulturally competent care includes an exploration of culturalapproaches to health, illness, and treatment. With 70% of Canadians using CAM, healthcareproviders must take into consideration the potential role of CAM in each and every patient.Maintaining openness to this reality may not only serve to better incorporate CAM in the serviceof public health, but also provide more effective and culturally competent care (Vincent andSelenzio, 2002).

Describe strategies for integrating complementary and alternative therapies into practice.

Health and Illness

We practice a Westernized, biomedical model in relationto health and illness

Patients and families may feel strongly about anecdotalevidence

Decisions are often based on cultural perceptions ofhealth and illness

Conflicts may arise when dealing with CAM therapies

5

Facilitation Tips

Comment

There are many models of health, illness and healthcare throughout the world. Westernmedicine is but one; however, it is the one with which we are most familiar, the mostaccepting, and the one in which we practice. Just like any model, when perceptions

dicine relies greatly on research evidence-

first reaction to treatment suggestions that are complimentary or alternative may bedismissal, this reaction is neither patient or family-centred, nor advantageous todeveloping a supportive and communicative patient-care provider relationship. We muststrive to understand what is important to each patient, and how we can practice in amanner that respects the individual, including their thoughts and desires in regards tocomplementary and alternative medicine.

Worlds Apart, 2007

Facilitation Tips

Video

Play -part series on cross-

Play entire clip

Ask the Learners:

the afterlife?

How does this affect the kind of care that they consent to?

Definition of CAM

systems, modalities and practices and their

accompanying theories and beliefs, other than those

intrinsic to the politically dominant health system of a

particular society or culture in a given historical period.

CAM includes all such practices and ideas self-defined by

their users as preventing or treating illness or promoting

health and well-

(National Institutes of Health, Institute of Medicine, 2005)

Facilitation Tips

None

(Your institution) Goal:Evidence-based Practice

use of CAM therapies

Facilitation Tips

Comment

Complementary used as an adjunct to conventional treatments.

Alternative considered a true replacement.

AcupunctureChiropracticHomeopathyNaturopathyAroma TherapyAyurvedaFaith HealingIridologyReiki

Common CAM Therapies

Native HealingOligotherapyOsteopathyReflexologyRolfingShiatsuTherapeutic TouchTraditional ChineseMedicine

Facilitation Tips

Comment- Describe up to 3 of the therapies (see this and next page).

Iridology curate and painless system of health analysis through the

2008), it is not regulated in Canada.

Native Healing cludes healing beliefs and

herbal medicine, and rituals that are used to treat people with medical and emotional conditions(American Cancer Society, 2008).

Osteopathic Medicine

an OsteopathicAssociation, 2010).

Reflexology:feet and ears corresponding via nerve pathways of the nervous system (Western Medicine)and/or meridians (Eastern Medicine) to eAssociation of Canada, 2009).

Rolfing: web-like complex of connective tissues to release, realign and(Rolf Institute, 2010).

Shiatsu: The Shiatsu therapist unblocks the flow of energy through the application ofcomfortable pressure to all parts of the clients body (Shiatsu School of Canada, 2010).

Therapeutic Touch: In Therapeutic Touch, the practitioner uses his/her hands in the client'senergy field to facilitate healing (The Therapeutic Touch Network of Ontario, 2008).

Traditional Chinese Medicine:

College of Traditional Chinese Medicine Practitioners and Acupuncturist of Ontario

Acupuncture:

Ontario, it can be performed by individuals licensed by the College of Traditional ChineseMedicine Practitioners and Acupuncturists of Ontario (CTCMPAO)

Homeopathyhighly dil

Chiropractic -invasive, hands-on health care discipline that focuses ontreatment and preventative care for disorders related to the spine, pelvis, nervous system and

tion, 2010), in Ontario, Chiropractors are licensed by theCollege of Chiropractors of Ontario

Naturopathy:root cause of illness or disease and promotes health and healing using natural(Ontario Association of Naturopathic doctors, 2010)

Aroma Therapyas therapy to improve physical, emotional, and spiritual well- Institute,2010)

Ayurveda Therapy

without the direction of a trained practitioner (NIH, 2009)

Utilization of CAM Therapies

In Canada, around $7.84 billion was spent on CAMproducts and services in 2005 (Fraser Institute, 2007)

More than 70% of Canadians use CAM therapies eachyear (Fraser Institute, 2007)

Demographics of CAM users= female, age 18-34 years,better educated, middle class, ethnically diverse (NCCAM,2007; Fraser Institute, 2007)

Facilitation Tips

None

Toronto CAM/Natural HealthProduct (NHP) Study

49% of those surveyed in the SickKids ER usedat least one type of NHP or CAM practice

Of the children using NHP/CAM:85% children used at least one NHP

5% children used at least one CAM practice10% used both

(Goldman & Vohra, 2004)

Facilitation Tips

Comment

NHP natural health product; vitamins and minerals, herbal products, homeopathicmedicines, etc.

1800 patients were surveyed in this study

Toronto CAM Study

Children using NHP who take prescribedmedications at the same time:

30.5%

Facilitation Tips

Ask the Learners (before showing the answer)

What percent of children do you think are taking prescribed medicine and NHPs at thesame time?

Did you tell your family physician/pediatricianthat your child was on NHP therapy?

YES 45%

Toronto CAM Study

Facilitation Tips

Ask the Learners: (before showing the answer)

What percent of parents do you think told their doctors that their child was on CAMtherapy?

13%

3.5%

2.1%

No need to tell the doctor 1.5%

.80%

Asked pharmacist about interactions before buying .34%

Because another family member uses it .34%

(Goldman & Vohra, 2004)

Facilitation Tips

Comment

information regarding the use of NHPs was not communicated to the physician.

It is important to ask questions about CAM use with all patients, remembering that ourown personal beliefs about CAM can influence how and what questions we ask. This

other and the cardiologist, the doctorwas clearly laughing when she said that they would give it some time after the ceremonyto see if it worked. This may have given the mother the impression that the doctorthought it was ridiculous to think that the ceremony would actually close the hole in

It is crucial to use medication reconciliation forms; however, keep in mind that the formwould not explore non-medicinal CAM therapies (i.e. acupuncture).

These comments illustrate the importance of asking questions regarding the use of CAMtherapies in every patient-care provider interaction.

Ethical Values and Principlesat Stake

Choice

Respect

Trust

Safety (protection from harm)

Justice

Best Interests

Facilitation Tips

CommentChoice-Families/patients/parents may pursue options consistent with their values and beliefs-The choice of treatment should be informed and free of coercion-Choice promotes autonomy and self-determination

Respect-Reciprocal respect is foundational to the therapeutic relationship and establishment of trust

Trust-Is necessary for creating an atmosphere of information sharing and a willingness for eachperson to believe the other

Safety- s of care may require decisions about compromise/non-

fety-Consideration of whether a to thisdecision

Justice-Who has access to CAM services and practitioners?-To what extent should CAM be part of the public system (e.g. funding, training of practitioners,support for research)?

Best Interests- is more challenging when considering CAM- the healthcare team

CAM: Key Considerations

care providers and substitute decision makers

We should presume parents are motivated by doingwhat is best for their children, and treat the familyrespectfully

Collaboration with the family is the ideal; in conflictsituations parents wishes should prevail unless thereis likely to be identifiable harm to the child

In some cases, health care providers have a legal andmoral duty to the child to contact child protectionauthorities

Facilitation Tips

Comment

The Best interest standard is a legal standard of caregiving for incompetent patients,d decide in the same

situation

A consideration of best interests should attempt to weigh the burdens and benefits oftreatment to the patient. Decisions must meet a minimum threshold of acceptable care;what is at least good enough is usually judged in relation to what a reasonable andinformed person of good will regards to be acceptable if they werecircumstances

Strategies for Prevention andManagement of Conflict

Meet with the team and the familyOffer collaboration with CAM practitionersAttempt a shared understanding of thefollowing:

Medical factsRationale and/or medical necessity oftreatmentConsistency with belief or value system

Identify and utilize all available conflictresolution methods

Facilitation Tips

Ask the Learners:

What teams can we consult before having to make the decision to report to theauthorities?

Bioethics

SCAN

Patient advocates

Take Home Messages

Involving children in decision-making can increasetheir feelings of control

However, culture may have an impact on when parentswish to involve children in decision-making

Preservation of relationships is an important value(i.e. parent-child, healthcare professional family,healthcare professional child)

Encourages disclosure of CAM useAllows ongoing monitoring of the childIncreases levels of trustAvoids causing distress to the child

Facilitation Tips

None

Case Study

Case Study Western Chinese Medicine

The patient is a 15 year old Chinese boy whose parents do not speak any English. He has anosteosarcoma in his right tibia. He has been receiving conventional therapy involving threemonths of chemotherapy, followed by either a limb salvage procedure or amputation. Last weekit was discovered that the tumour has continued to grow despite chemotherapy. The medicalrecommendation is to discontinue the chemotherapy, and amputate the leg as soon as possibleas a limb salvage operation is no longer a viable option.

The child mother has found a Traditional Chinese Medicine (TCM) practitioner who promises a90% success rate for his treatments, but so far he has not treated children or osteosarcoma.The patient is willing to try the TCM. The parents request a one month trial of TCM, however,the oncologist believes that this will be too great of a delay to amputate and that the cancer willhave spread by the end of the trial. .


should the team proceed?

2. What strategies might the team implement to persuade the family to accept therecommended treatment plan? Use the word persuade as a catch to see if the learnersrecognize the potentially negative impact of this approach as it relates to culturally competentpractice.

3. How might the team demonstrate respect for the family wishes while acting in the bestinterests of the child?

4. How would the team assess the

Facilitation Tips

Activity

In their table groups, ask participants to work through the CAM scenario.

After the participants have completed the questions, ask them to discuss their responseswith the whole group.

Traditionally, parents make health care decisions for their children. Ideally, these

interests of the child.

Bereavement and Grief

BEREAVEMENT AND GRIEF

Learning Objectives 2 and 3

Facilitation Tips

by personal experience and culture. Attitudes about end-of-life care are more greatlymily than by education or socio-economic status. Key areas for

cultural exploration in the provision of end-of-life care can be described by feelings, faith,family and finality.

Recognize differences across cultures in grief and bereavement.

Describe strategies for providing culturally competent care to patients and families during thebereavement and grief period.

Bereavement and Grief

The vocabulary and expressions of bereavement andgrief are determined by culture

The definitions of dying, death, and life vary betweencultures

(Rosenblatt, 1993)

Facilitation Tips

Comment

In some cultures, individuals we would consider to be alive would be considered deadand vice versa.

In Papua New Guinea, when an individual loses consciousness they areconsidered to be dead.

Grief Across Cultures

How do you think grief varies across cultures?

Facilitation Tips

Ask the Learners:

How do you think grief varies across cultures?

Muted Grief: In Bali the gods will not heed onEmotional control in bereavement is highly prized.

Excessive Grief: In the slums of Cairo, it is expected that a major loss (loss ofyoung adult child) will cause years of muted depression, constant suffering andcontinuous bereavement.

Somatization: In some Asian cultures, physical expression of grief is common(i.e. nausea, shaking)

Emotive Grief: In some cultures, expression of grief tends to be very visible (i.e.wailing, pounding fists)

Grief and Loss

Different reasons why parents grieve:

The diagnosis itself

Loss of normalcy

Loss of dreams and goals for their child

Anticipatory lossPreparing for and grieving the potential death ordisability of a child

Facilitation Tips

Comment

Not all areas of the hospital deal with bereavement issues often, however, many familiesare grieving some sort of loss.

Ask the Learners:

Can you think of examples of situations in your unit which may lead to parentalexperience of grief and/or loss?

Grief and Loss

Parents may feel:

Concerned about not meeting the needsof siblings when caring for a sick child

Stressed about the loss of their ownroles/routines

Relationship strains (between partnersand extended family)

Financial loss

Facilitation Tips

Comment

Siblings- following a loss or when caring for a sick child, parents have expressed aninability to meet the needs of siblings including their questions, fears, and worries thatadd to the grief of the entire family.

Loss of their own routines/roles- sometimes family members will ask questions after adeath such as; do I still say I have 3 children; am I still a big sister?

Loss of their relationship - research shows that parental relationships suffer due to thechronic illness or death of child, even if they are trying to support each other. During the

so many strainsand stressors that it changes; some cope well and are able to adjust but many do not.

Financial loss- many families choose to stay home so that they can bewith their sick child. This causes great financial stress as well as a sense of loss (of theirabilities, confidence, livelihood, ability to support family, etc.).

Disclosure:Cultural Considerations

Disclosure desired because:Speaking candidly is an established tradition inWestern medicineIndividual rights and autonomy are underlying values

Disclosure NOT desired because:Individuals may exercise autonomy by choosing "not

Many new Canadians feel it is bad luck to talk aboutdeath as a there may be a view that what will happen

Facilitation Tips

Comment

Depending on the values of the patient and family, full disclosure of the diagnosis orprognosis of the illness may or may not be desired.

Decision-Making

are seen as necessary.

In some cultures, the soul is what gives life and thusthere is difficulty in understanding brain death and

Decision-Making:Cultural Considerations

Facilitation Tips

Comment

Culture influences the understanding of death and when it occurs.

Families that consider the soul to give life may not wish to learn about or consent toadvanced directives or withdrawing life support.

Decisions to withdraw life support may not rest with the parents but with theextended family, community or faith elders.

Hospice Care

Many cultures feel it is the duty of the family to takecare of its own members, others believe it is too hardfor the dying to let go in the presence of loved ones.

Cultures may believe that certain things need to be inplace at the time of death (i.e. a suit with no buttons toenable the soul to slip out easily).

Hospice Care:Cultural Considerations

Facilitation Tips

Comment

The moment an individual makes the transition between life and death is significant inmany cultures, and beliefs about who should be present may influence views towardshospice care.

Organ Donation

Some cultures resist organ donation because the familydoes not want the person to be born in the next life withthe donated organ missing (Braun & Nichols, 1997)

Other cultures may interpret organ donation as a methodof helping others

Organ Donation:Cultural Considerations

Facilitation Tips

Comment

Difficult topics can be introduced in an indirect manner; for example, one might say,

.

Most religions have rules regarding what can be done with the body after death, butindividuals will have their own fears and beliefs.

Never assume that people will agree or disagree - always explore with the family.

Also note that circumstances around death will influence organ donation and autopsydecisions

The 4-Fs

Cultural exploration inend of life care involves:

1.Feelings

2.Family

3.Faith

4.Finality

(Pottinger, Perivolaris & Howes, 2007)

Facilitation Tips

Comment

Feelings: Death and diagnosis, as well as the process of dying bring strong feelings tofamilies and healthcare providers.

Family: It is important to acknowledge who the patient and familyErrors in acknowledging family members are more likely to occur if the family does not fita conventional definition of a family.

Faith: In many cultures, faith influences the dying experience as well as the rituals andpractices related to death and dying. Also note that spirituality (believing in something)may not encompass faith (belonging to a group of people that share the same belief).

Finality: Includes the closure of life as known and lived by the patient. Finality needs tobe done with dignity and greatly affects the grieving process.

Bereavement and Grief:Key Considerations

What are the cultural and religious practices for coping with

and honouring the death?

death?

How does the family express grief and loss?

What are the roles of family members in handling the death?

Who is involved in decision-making?

Facilitation Tips

Comment

You may not actually ask these questions, but they are important issues to consider.

When we ask these questions sometimes the families have not begun to think about theanswers, thus acting to open up the discussion within the family.

These questions may be used in addition to those in the cultural assessment guide.

Case Study

Facilitation Tips

Activity

In their table groups, ask participants to work through the bereavement and grief casestudy.

After the participants have completed the questions ask them to discuss their responseswith the whole group.

Case Study

Case Study

Your team has been caring for a 12 year old boy from Jordan, for one month on an inpatientunit. Two weeks ago, a poor prognosis was revealed to his parents.the team is not discuss the details of the illness and prognosis with the boy until the parentshave done so first. Until then, the team is not to mention the future or death to the boy. Theparents have declined counseling, though they appear grief-stricken when they arrive on theunit and every time they exit the to help, they are wavedoff and told everythingthe boy. Your colleague asked the parents some question regarding their lack of disclosure

.; however, when you are alone with her she manages to tell you that

although it is a difficult time, she knows that her son will get better because she has beenpraying.

Weeks pass and it becomes clear that the patient is unaware that his illness is terminal, andthe likely course of the disease. He responds to everyone with his usual cheery demeanor,though physically he is weakening and experiencing more pain. He does not understandwhy he cannot go home. Staff are becoming increasingly uncomfortable and critical of this

1. What actions would you take to ensure that parents will make an informed decision?

2. What resources would you access to ensure this family receives culturally competentcare?

3.you encourage staff to manage their personal beliefs that could affect the care of thispatient and family?

Resources

Facilitation Tips

Comment

What are resources for STAFF when dealing with these situations, recognizing theimportance of care of the caregiver?

Colleagues

Bioethics

Insert other institutional resources

(Your institution) Policies

-of-lifecare

Facilitation Tips

None

Helping family members deal with the loss of aloved one often means showing respect for theirparticular cultural heritage and encouragingthem to actively determine how they willcommemorate those they have lost.

Facilitation Tips

None

Standardized Patients


Facilitation Tips

Activity

Standardized Patients see next page

Apply cross cultural competence skills in clinical situations (by interacting with standardizedpatients).

Standardized Patients Activity

Set-up

Provide the table groups with the case information for the simulated patient exercise.

Place four chairs in the front of the room; two sets facing each other but facing towardthe Learners (V shaped).

Participant Instructions

Explain that the participants are to treat the simulated patients as they would any family.

Give the groups about 10 minutes to read the case and brainstorm questions that maybe important to ask the family.

Use the cultural assessment guide, collaborative conversations and otherquestions from the modules

Stress that this is a safe environment where the goal is not to be perfect but to practicethe different strategies.

Comment on the fact that although not all participants will encounter this specificscenario in their day-to-day work, the skills in communication which can be used hereare universal to all departments/specialties.

Participants may time in or out at any time if they are unsure or uncomfortable.

Facilitator Instructions

The facilitator may time in or out at any time to generate discussion about a pointthat was just made, or a question that was asked.

It is important for the facilitator to encourage participation but not to participatethemselves; the goal is to allow the participants to practically apply their skills.

Once all groups have taken part in the scenario, the simulated patients and participantsshould be given an opportunity to provide their feedback.

Cases

See end of this Workshop Guide for case material

Standardized Patients

Standardized patients are trained healthyindividuals that simulate a health care scenarioincluding physical symptoms, emotional responseand personal histories.

Standardized patients are trained to provideconstructive feedback from the perspective of apatient.

Facilitation Tips

Comment

See previous page

Cultural competence includes:

Awareness of personal cultural and family values

Awareness of personal biases and assumptions

Awareness and respect for cultural differences

Understanding how the dynamics of differences impactinteractions

Embracing diversity

Summary of CulturalCompetence Workshops

Facilitation Tips

None

Summary of CulturalCompetence Workshops

Key strategies:Apply collaborative communication techniques andcross-cultural assessment framework

Use resources known to be effective in cross-culturalcommunication (i.e. Language Line/InterpreterServices)

Recognize how culture and the new immigrantexperience impact parenting, pain management, use ofCAM therapies, mental health and bereavement andgrief

Facilitation Tips

None

Facilitation Tips

None

Script for Standardized PatientsFAMILY MEMBERS

Father: AlbertoMother: CarmenGrandmother: VictoriaSon: RafaelDaughter: GracielaLast Name: Ruiz

BACKGROUND

Alberto and Carmen are the parents of two children, Rafael and Graciela. The familyemigrated from Columbia one year ago. They came to Canada as skilled workers hoping toprovide a better life for their children (including safety). The family arrived in Canada with$15,000 in savings from Columbia. The family finished spending this money 3 months ago.Graciela is 9 years of age and in grade 4. She has recently been diagnosed with asthma. Priorto coming to Canada she was a gymnast who competed at the national level. Since coming toCanada, she has not been able to compete as a gymnast, but she hopes to begin after hermother completes ESL classes and finds a job. Her parents have noticed that she seems sadsince coming to Canada as her grades have dropped. Alberto and Carmen attribute thissadness to her inability to participate in activities (such as gymnastics) and also the loss of

mother, Victoria, also migrated to Canada with the family and she has early-stage dementia.Alberto is an Engineer by profession (with a Bachelors degree in Engineering), but he

currently works in a juice factory (called Motz). He earns $10/hour and is able to communicateeasily in English. He works 12 hours a day, 5 days a week to provide for his family. Carmenwas a diploma educated accountant prior to migrating to Canada. Carmen is now taking anESL course and is able to understand basic English (at the level of a grade 6 student). The ESLcourse she is currently taking is a government sponsored LINC (Language Instruction forNewcomers to Canada) located in Scarborough. She is currently at the highest level of theprogram, LINC level 5. Rafael and Graciela were able to quickly learn English due to theirinteraction with other students in school. They are also fluent in Spanish. Alberto and Carmenare very busy with school and work. The grandmother, Victoria, stays at home and does notspeak English. The family experienced a great shock on arrival in Canada due to the non-recognition of their credentials.

They currently live in a 2 bedroom basement apartment in North York and there is a verysmall window (the size of a legal paper). While the parents sleep in one room, grandmother andGraciela live in another room and Rafael sleeps in the living room. There is only one door intothe apartment and dad smokes cigarettes inside the house. The window has been kept closedin the basement to keep the basement cool. The owner of the house lives in the apartmentabove with 3 dogs.

When the family first arrived in Canada, Alberto smoked 5-10 cigarettes a day. Over thelast 3 months, they have been experiencing increasing financial stress. As a result of thestress, Alberto now smokes 20-30 cigarettes a day; however he is open to free smoking

They have no knowledge of any other community resources, except the LINC program and theCatholic Church. Although, the family has OHIP coverage, they have no extended healthcoverage.

Meaning of nonverbal communication, eye contact, unwillingness to challengehealthcare provider directly, role of Grandmother in the family, decision making styleThe grandmother, Victoria, is the matriarch of the family and makes decisions regardinghealthcare. The grandmother does not understand English or how to get around Toronto;Rafael helps take care of her at home. Rafael has also been responsible for taking his sister toschool and appointments. The parents appreciate the fact that Rafael takes care of his sisterand helps with his grandmother; this level of responsibility is appropriate in their opinion.In their culture, it is inappropriate to look at individuals who are in a position of power directly asit is considered disrespectful. There is a great respect for healthcare professionals andhealthcare professionals are considered to have higher knowledge and authority. Therefore,Alberto and Carmen (parents) would not look at health care professionals directly in the eye, oropenly disagree with them. Instead of disagreeing, Alberto and Carmen would nod or say yes.Saying yes is a sign of respect butinstructed by the healthcare professional.

HEALTHCARE PROBLEM

Healthcare Problem(daughter gets taken to hospital with difficulty breathing and is admitted for three days)

Graciela was a previously healthy girl before coming to Canada. Three months ago, shestarted developing an occasional cough (2-3 times a day) which Alberto and Carmen thinkresolves independently. One week ago, she developed increasing shortness of breath and acough. Her parents became concerned and took her to Sick Kids emergency four days ago.She was then admitted to the unit where she remained for 3 days. While on the unit, sherequired ventolin treatment (by mask).

Her asthma crisis has resolved, she is no longer experiencing shortness of breath, heroxygen saturation has been within normal limits and her lungs are clear to auscultation. She isto be discharged home with her parents and healthcare professionals are concluding dischargeteaching. She is being discharged home with Flovent (twice a day) and Salbutamol (ventolin, asneeded) puffers. Her parents have bought the medication and are aware of how to use it. Shehas a clinic follow up appointment booked for next week Friday at 2pm and parents are aware ofthe appointment. Parents are expecting Rafael to take Graciela to this and future appointments.

while at home. They are concerned that the diagnosis will affect them in various ways. Her

diagnosis and they are concerned this will negatively affect her self esteem. They are alsoworried that the illness will be a financial burden to the family. The financial burden includes thecost of medication, and traveling to the hospital. While in the hospital, dad was unable to taketime from work due to the financial costs of doing so. The combination of 12 hours a day workwith taking care of his child has resulted in dad being sleep deprived. Also, both parents haveeaten once today (for afternoon session, not eaten for morning session).

ens in the hospital; can the parents visit, taketime from work or not; what do the parents understand the problem is; what does the familywant to do about the problem; what they think will happen after they go home, what theirresponsibilities are regarding follow-up appointments). Grandmother understands the illness tobe caused by an imbalance between emotional, physical and social arenas. In Columbia, theyview certain illnesses to be caused by hot and cold properties. Hence, asthma would be causedby cold. To counteract this effect, a child would be given warm fluids such as meat broth orherbal tea.

The family comes from a collectivistic culture where there is a strong focus on family.Grandparents and elders are highly regarded to provide advice. They are not accustomed tothe profession of social work and rely on family, friends and networks for support. The onlyinformation they have heard about social workers is that they can take your child away inCanada if you beat your child or if you are not capable of taking care of your child.

INTERACTION WITH THE HEALTHCARE TEAM

Interaction with Healthcare Team: the story starts at discharge after 3 days in the hospital; thehealthcare team wants to prepare the child to go home. This will involve medication, follow-upappointments, asking about the physical home environment and whether it may be harmful tothe asthma)

As the health care professionals conduct the assessment, the parents are looking downand they nod their heads and say yes any time healthcare professionals ask if they understandwhat is being said. When spoken to in Spanish, the parents replied they would prefer to bespoken to in English to practice their English skills. They also feel comfortable and understandthe present conversation. However, if the conversation involves many medical words (such asin-depth teaching about medications), they would like an interpreter.

They are happy about being discharged home, but are concerned about the diagnosis ofasthma and its associated stress. During the discussion, Carmen uses largely non-verbalcommunication to try to communicate with Alberto about a deeply felt concern (aboutcomplementary therapy) but Alberto communicates to her that it is not safe for her to verbalizeher thoughts.

They are communicating about whether or not they should tell the health careprofessional that they are planning to use other forms of therapy at home (including herbal tea).Their grandmother has recently suggested a visit to an Espiritista, a spiritual healer, who canassist them in prayer and also provide herbs to cure the asthma. The Espiritista communicateswith spirits in the gathering of like minded believers. There is a belief that good and evil spiritscan affect health and luck. They would like to consult the grandmother prior to making anydecisions regarding treatment and medication.

They would also like to learn more about drug side-effects, as they have heard negativecomments about steroids, especially its contribution to weight gain.

PREFERED RESPONSE FROM HEALTHCARE PROFESSIONALS

Interaction with Healthcare Team:Tprepare the child to go home. This will involve medication, follow-up appointments,communication with the school, checking about the physical home environment and whether itmay be harmful to the asthma)

We want the Healthcare Providers to do the following when interacting with the SPs:Ask questions from the cultural assessment guideSuggest medication instruction in SpanishAsk about complementary therapiesInvolve grandmother in decision makingAsk about the need for interpreterAsk about issues related to social determinants of health e.g. finances, housingPut measures in place to bridge gaps such as connecting with community social workerReinforce teaching: Medication, smoking, discharge appointmentUse plain language when talking to the parents, no medical terminology or jargonUse collaborative conversation framework to discuss the issue of Alberto smokingcigarettes in the home

Case Information for Healthcare Professionals

FAMILY MEMBERS

Father: AlbertoMother: CarmenGrandmother: VictoriaSon: RafaelDaughter: Graciella

Graciela was a previously healthy girl before coming to Canada. Three months ago, she starteddeveloping an occasional cough (2-3 times a day) which Alberto and Carmen think resolvesindependently. One week ago, she developed increasing shortness of breath and a cough. Herparents became concerned and took her to Sick Kids emergency four days ago. She was thenadmitted to the unit where she remained for 3 days. While on the unit, she required ventolintreatment (by mask).

Her asthma crisis has resolved, she is no longer experiencing shortness of breath, her oxygensaturation has been within normal limits and her lungs are clear to auscultation. She is to bedischarged home with her parents and healthcare professionals are concluding dischargeteaching. She is being discharged home with Flovent (twice a day) and Salbutamol (ventolin, asneeded) puffers. Her parents have bought the medication and are aware of how to use it. Shehas a clinic follow up appointment booked for next week Friday at 2pm and parents are aware of

while at home.

Non-Clinical Session

Central Themes

The non-clinical session is an adapted workshop for staff employed in non-clinical positions.While much of the material is borrowed from workshop A, specific material is included that linksthe concepts of cultural competence and service excellence. Activities are also designed withan emphasis on culturally competent service provision rather than clinical care.

Non-Clinical Session Learning Objectives

Following completion of the non-clinical session learners will be able to:

1. Recognize the different types of settlement stressors experienced by newimmigrant families and the negative impacts these have on health.

2. Identify how the social determinants of health affect immigrants and refugees.

3. Describe culture, cultural competence, and the benefits of cultural competence.

4. Recognize the impact of personal biases, prejudice, and discrimination on theability to deliver excellent service to patients, families and colleagues.

5. Describe the relationship between cultural competence and service excellence.

Cultural Competencefor Non-Clinicians

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Facilitation Tips

Comment

Housekeeping

Washrooms, breaks,

Acknowledge the experience and expertise of audience






Learning ObjectivesAt the conclusion of this workshop participants will be able to:

Recognize the settlement stressors experienced by new immigrantfamilies and the negative impact these have on health.

Identify what health disparities are

Describe the Social Determinants of Health

Describe culture, cultural competence, and the benefits of culturalcompetence

Recognize the impact of personal biases, prejudice, anddiscrimination on the ability to deliver excellent service topatients, families and colleagues.

Describe the relationship between cultural competence andservice excellence.

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None

New Immigrant Support Network

Key aim is to improve access to quality health care and health informationfor new immigrant children and their families

Year 1: internal focus on providing cultural competence education tohealthcare providers and other staff, will continue through February 2011

Champion initiative

Train-the-Trainer Workshops

Research and evaluation are ongoing

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Translation

300 health-related patient education resources and othermaterials, e.g. consent to treatment form, into 5-9 languages

Audio files created into all of these languages

AboutKidsHealth.ca website translated into French andChinese

--Languages include: French, simplified Chinese, traditionalChinese, Arabic, Spanish, Tamil, Urdu, Portuguese, Punjabi

*CIC provided input into languages to choose for translation

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So why are you here today?

Facilitation Tips

Comment:

Further examine your own cultural values and beliefs

Explore your awareness of and sensitivity to other cultural values and beliefs

Begin to consider how we can effectively span cultural differences to addresshealth care inequities and achieve the best possible health care outcomes forchildren and their families

To contribute to (insert your organization here) efforts to increase positive healthoutcomes for the new immigrant population.

Health Disparitiesand the

New Immigrant Population

Disparities are differences in health outcomes.

Health disparities prevalent in new immigrant population,regardless of language, culture, race, health, disease beliefs.

affect the new immigrant population, and how you cancontribute to cultural competence initiatives, including serviceexcellence.

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Miniature Earth

If we could turn the population of the earth into a smallcommunity of 100 people keeping the same proportions we havetoday, it would be something like this.

Miniature Earth Video

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Facilitation Tips

Miniature Earth

This short, web-based video clip presents the global community if it could be reduced toa total population of 100 people. Themes presented include privilege, poverty, diversity,and disparity among others.


Comment

It is human nature to see and interpret the world from the perspective of our ownworldview

This short video encourages us to open ourselves to new perspectives on thedistribution of resources that affect the health and well-being of humans around theglobe

Ask the Learners (after the video)

How do you feel about what you have just watched and what part of the video was mostsurprising/distressing?

How might this relate to where you live, work?

The Health of New Immigrants

How would you describe the health status of new immigrants uponarrival in Canada?

New immigrants arrive in Canada with better health scores and fiveyears later have lower health scores than average Canadians .

Why?

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Facilitation Tips

The Healthy Immigrant Effect

The goal of this activity is to identify and challenge stereotypes as they relate to thehealth of new immigrants. Ask the question, and have the learners raise their hands ifthey believe the health of new immigrants upon arrival is:

a. Worse on average

b. Better on average

c. The same on average

Typically, the majority of the learners will choose option A.

Ask the Learner:

Why do you think the Healthy Immigrant Effect exists in Canada?

After they answer this question, explain to the group that health is an immigrationscreening criteria, put simply, Canada wants a healthy population. The questionis:

What is contributing to the deterioration in health after a new immigrant arrives inCanada?

Walk around and review the posted data and statementclusters.

that is of most interest to you.

Walkabout Activity

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Facilitation Tips

Walkabout Activity

This activity acts to en -knowledge through the provision ofcultural, demographic, and evidence-based knowledge. To conduct this activity theeducator is required to collect and post on the walls of the training room demographicand evidence-based information relevant to the topics of poverty, disability, immigration,refugees, health disparity, socioeconomic status, racism, place of origin, gender,language, sexual orientation, religion, and marital/family status. Post the information inclusters of like-topics.

Ask the Learners

Ask the learners to review the posted data and after 10 minutes choose a cluster thatthey identify with, are surprised by, or interested in. Tell them to stand beside the cluster.

Choose people randomly to explain why they are standing in front of a specific group.

Comment

This exercise was intended to help us begin thinking about our own perspectives onsocial determinants of health, diversity and equity

**You may also take this opportunity to describe the differences between racializedgroups, marginalized groups and new immigrants

Definitions

Social Inequities in Health: Disparities judged to be unfair,unjust and avoidable that systemically burden certainpopulations.

Marginalized: Confined to an outer limit, or edge (the margins),based on identity, association, experience or environment.

Racialized Groups: Racial categories produced by dominantgroups in ways that entrench social inequalities andmarginalization. The term is replacing the former term known as

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Comment:


Refers to an absence of unjust health disparities between social groups, withinand between c




Cultural Competence:What are you doing about it?

13

13

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Video

Ask the learners;

o

New Immigrant Settlement Challenges include:

Skills & credential recognition as requirements for immigration approvalincrease, so too do the socio-economic setbacks for many newimmigrants (Quality of Life in Canadian Communities, 2009)

Language


Access to appropriate community & settlement supports

Inconsistent public policy between levels of government the federalgovernment is involved in organizing immigration, however, upon arrivalin Canada new immigrants are faced with navigating provincial and/orprofessional governing bodies. For example, although the federal

provincial licensing bodies may not. This may act as a barrier toemployment and income generation.

The Importance of CulturalCompetence at SickKids

Increasing Immigration

Toronto is the destination of choice for 45.7% of all newimmigrants to Canada (Stats Canada, 2006)

racialized groups (Stats Canada, 2010)

Culturally competent health care is one strategy foraddressing and ideally reversing health disparities.

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Facilitation Tips

Comment

The need for cultural competence education is not solely the result of an increasingproportion of non-Canadian born citizens, but also due to the documented healthdisparities in this population.

This slide illustrates a key point in terms of the need for this type of clinical culturalcompetence education.

All patients and families, regardless of their origins, deserve and benefit from culturallycompetent care.

Family-centred care and culturally competent care are integral to one another.


What are some challenges you think new immigrants mayface during resettlement?

Skills and credential recognition

Racism/discrimination

Language


Access to appropriate community and settlement supports

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Facilitation Tips

Comment

Unemployment, poverty, and lack of access to services are stressful, and immigrantsfrequently experience all three of these situations (Beiser, 2005).

Following arrival in Canada new immigrants are much more likely to live in poverty thantheir native-born counterparts, a fact that increases the likelihood of exposure to riskfactors for diseases, while also compromising access to treatment (Beiser, 2005).

Other stressors experienced by new immigrants that carry the potential to negatively affecthealth include:

lack of recognition of credentials and/or training,access to affordable housing,language barriersracism/racialization.

Content chosen to address this learning objective focuses on introducing the learners toCanada s immigration policy, the immigration experience, and health care challenges facedby new immigrants.


Resettlement Challenges

Underemployment/unemploymentLow socioeconomic statusLack of family/social supportLack of familiarity with the healthcare systemMental health (Post-traumatic stress disorder,depression)

Inconsistent public policy between levels of government

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Facilitation Tips

Comment

Resettlement Challenges:

Are impossible to prepare for

While individuals and families may plan to immigrate, there is no way to prepare foror predict some of the negative experiences they have after arrival


Resettlement Challenges

Challenges directly related to healthcare include:

Healthcare coverage

Access to and navigation of the healthcare system

Lack of significant knowledge of and sensitivity to diversehealthcare needs

Health Literacy

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Facilitation Tips

Comment:

Access to healthcare does not just mean the ability to physically attend healthcareappointments/find a family doctor, but also the quality of the health care.

Personal differences or biases among healthcare workers regarding new immigrantsmay negatively affect health outcomes.

Sources of Health Disparities

A review of over 100 studies regarding healthcare servicequality among diverse racial and ethnic populationsfound three main areas that caused disparities:

1. Clinical appropriateness, need and patient preferences

2. How the healthcare system functions

3. Discrimination: Biases and prejudice, stereotyping, anduncertainty (Institute of Medicine, 2002)

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Facilitation Tips

Comment

Examples in each area include:

1. Clinical Appropriateness-need and patient preferences- variance in health-seekingbehaviour, attitudes toward health care team (distrust), and personal preference (maychoose different treatment options)

2. The operation of the health care system- cultural/linguistic barriers, where minoritiesaccess care (less likely to receive care in a )

3. Discrimination-biases and prejudice, stereotyping, and uncertainty- uncertainty whenworking with minorities, or beliefs held by the provider about another culture

New ImmigrantHealth Disparities

During their first decade in Canada, immigrants are farmore likely than the native-born to develop tuberculosis.

Crisis and conflict create mental suffering for refugees,who constitute about 10% of the immigrant population.

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Facilitation Tips

None

Immigration

Why do families immigrate here?

What is culture shock?

What do hospital staff need to consider to provideservice excellence to new immigrant patients?

20

Facilitation Tips

Comment

is an economic policyarrival of skilled workers and professionals is a response to labour marketshortagesis in response to a low national birth rate

Why emigrate? Families immigrate to Canada because: Most often they are hoping togain something (i.e. opportunity, education, lifestyle, freedom, health care) and/or leavesomething behind.

Culture Shock: Arises when individuals suddenly find themselves in a culture in which

over which cultural practices to maintain or change. Culture shock can be decreased ifthe move is positive and planned and if cultural beliefs can be maintained whileintegrating into the new culture.

Considerations:

New immigrants experience challenges in knowing how to access health careand navigating new and complex healthcare systems

Health care disparities exist in Canada

Based on some of the challenges new immigrants face, reactive symptomsincluding anxiety and isolation are understandable and should be approachedwith understanding and sensitivity.

Background Information


o One of every six Canadian residents was born outside the country. Immigrationhas helped to make Canada a culturally rich, prosperous and progressive nation.(Citizenship and Immigration Canada, 2010)

o Net international migration continues to be the main engine of population growthin Canada, accounting for about two-thirds of the annual increase in 2005/2006(Statistics Canada, 2006).

o Between July 1, 2005 and July 1, 2006, Canada's population increased by324,000 of which 254,400 were immigrants, 9,800 more than in the previous year(Statistics Canada, 2006).

Regulations provide for the admission of new immigrants under 5 categories;

Skilled Workers andProfessionals

Skilled workers are selected as permanent residentsbased on their education, work experience, knowledgeof English and/or French, and other criteria that havebeen shown to help them become economicallyestablished in Canada.

Family Class A Canadian citizen or permanent resident may sponsorher or his spouse, common-law partner or conjugalpartner, or dependent children to come to Canada aspermanent residents.

Canadian Experience Class A temporary foreign worker or a foreign student whograduated in Canada often has the qualities to make asuccessful transition from temporary to permanentresidence. Familiarity with Canadian society and theability to contribute to the Canadian economy are keyconsiderations. Applicants should have knowledge ofEnglish or French and qualifying work experience.

Investors, entrepreneurs andself-employed persons

The Business Immigration Program seeks to attractexperienced business people to Canada who willsupport the development of a strong and prosperousCanadian economy. Business immigrants are expectedto make a C$400,000 investment or to own and managebusinesses in Canada

Refugee Refugees are individuals fleeing their homeland due tofears of persecution based on race, religion, nationality,membership in a particular social or political group, war,or massive human rights violations.

Source: Citizenship and Immigration Canada, 2007

Immigration

Immigrant: Someone who moves to another country

Refugee: An individual who flees their homeland due to fears ofpersecution based on race, religion, nationality, membership in aparticular social group, or political opinion or activity (CIC, 2009)

Permanent resident is an immigrant or refugee who has beengranted the right to live permanently in Canada

Refugee claimant is a person who has made a claim for protectionas a refugee. (Canadian Council for Refugees, 2004)

Non-status immigrants are individuals who have made their homein Canada but lack formal immigration status

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Comment


One of every six Canadian residents was born outside the country. Immigration hashelped to make Canada a culturally rich, prosperous and progressive nation.(Citizenship and Immigration Canada, 2010)

Net international migration continues to be the main engine of population growth inCanada, accounting for about two-thirds of the annual increase in 2005/2006 (StatisticsCanada, 2006).

Between July 1, 2005 and July 1, 2006, Canada's population increased by 324,000 ofwhich 254,400 were immigrants, 9,800 more than in the previous year (StatisticsCanada 2006)

IMMIGRANT EXPERIENCE

22

Facilitation Tips

The following link is - Health Care

Minnesota; a primary care clinic that focuses on meeting the health care needs ofimmigrant and refugee communities. Although it is an American clinic, the discussion ofdifficult health care decisions is important for participants to consider.

http://video.google.com/videoplay?docid=-5106027191893998854#

-play from 3:11-5:05

SOCIAL DETERMINANTS OF HEALTH

23

Facilitation Tips

Comment:

A key aspect of culturally competent care is the ability of care providers to recognize the impactof social influences on health status. Although illness is a biological state, too often the factorsthat contribute to illness are social in origin. According to the World Health Organization (2010),the social determinants of health are described as;

health system. These circumstances are shaped by the distribution of money,power and resources at global, national and local levels, which are themselvesinfluenced by policy choices. The social determinants of health are mostlyresponsible for health inequities - the unfair and avoidable differences in health

Evidence suggests that the current state of the global community has created a situation inwhich the gaps within and between countries, in income levels, opportunities, health status, lifeexpectancy and access to care, are greater than at any time in recent history (World HealthOrganization, 2010).


24

Equal means the same; to ignore differences

Equitable aims to produce the same opportunity forpositive outcomes

Disparities refers to differences I outcomes

Equitable Access refers to the ability or right to approach,enter, exit, communicate with or make use of healthservices

Facilitation Tips

Comment


Refers to an absence of unjust health disparities between social groups, within





25

The term

specific mechanisms underlying the different levelsof health and incidence of disease experienced byindividuals with differing socio-economic status.

Facilitation Tips

Ask the learners:

Why are the social determinants of health relevant to healthcare providers?

Discuss answers with group (refer to slide 20 for further information)


26

Early life Aboriginal status

Education Employment & working conditions

Food security Gender

Health care services Housing

Social safety net Income & its distribution

Social exclusion Unemployment & employment security

Raphael, D. (Ed). (2008) Social determinants of health: Canadian perspectives(2nd

Facilitation Tips

Comment

While housing, education, employment, and income are often identified by learners as socialdeterminants of health, the less obvious determinants are no less significant. For example,social exclusion, social safety nets, food security and early life all exert influence on health.

Culture and Cultural Competence

26

Facilitation Tips

Cultural competence educators may struggle with the variety of definitions of culturalcompetence. An exploration of these complex terms will help learners simplify theirmeanings and understand their key components, which may be helpful in the delivery ofculturally competent service.

Deepening awareness of personal cultural biases requires self-reflection. Thus, thislearning objective is best achieved through reflective activities that require learners toapply the knowledge they have gained up to this point to their own personalexperiences.

Key Questions

What is culture?

What is cultural competence?

Why is cultural competence important at SickKids?

Who does cultural competence help?

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None

What is Culture?

Dynamic: Created through interactions with the world

Shared: Individuals agree on the way they name andunderstand reality

Symbolic: Often identified through symbols such aslanguage, dress, music and behaviours

Learned: Passed on through generations, changing inresponse to experiences and environment

Integrated:Nova Scotia Department of Health (2005)


28

Facilitation Tips

Ask the learners:


Comment

Definitions

It is important for learners to recognize that many definitions of culture, cultural competence,and culturally competent care exist, and that the complex nature of these terms leads toinherent ambiguity. Nonetheless, working definitions of these terms are necessary forindividuals to begin to identify with their own personal biases and assumptions.

Culture

particular group of people that guides an individual or group in their thinking, decisions, andactions in pat as cited in Srivastava, 2007, p. 14)

Culture is the attitudes, values and beliefs that define a group of people according totheir actions and thoughts.

Individuals are not born with culture; they are born into a culture through languageacquisition and socialization.

Common Assumption

Everyone who looks & sounds the same...IS the same

Being aware of cultural commonalities is useful as a starting

BUT

Drawing distinctions can lead to stereotyping

Making conclusions based on cultural patterns can lead todesensitization to differences within a given culture

(Garcia Coll et al., 1995; Greenfield, 1994; Harkness, 1992; Long & Nelson, 1999; Ogbu, 1994)

29

Facilitation Tips

Comment

We all carry biases; they are an aspect of our own ethnocentrism that result from ourindividual values and beliefs. What is important is that you recognize your own views,from where they stem, and how they could influence health care interactions.Awareness of your own biases, values and assumptions is the first step in becomingculturally competent.

Assumptions and the evidence scientists often fail to consider individual differencesamong members of the same cultural group when generalizing research findings; thus,examining factors related to within cultural group variations becomes as equallyimportant as comparing between group differences (urban vs. rural, working class vs.middle class)


Like an iceberg, nine-tenths of culture is out of

30

Facilitation Tips

Comment

The iceberg metaphor is used very commonly to describe culture

Iceberg

Above Ice

Beliefs Values Unconscious Rules Assumptions Definition of Sin

Patterns of Superior-Subordinate Relations Ethics Leadership

Conceptions of Justice Ordering of Time Nature of Friendship Fairness

Competition vs Co-operation Notions of Family Decision-Making

Space Ways of Handling Emotion Money Group vs Individual

Festivals Clothing Music Food Literature LanguageRituals

31

Facilitation Tips

Comment

Those aspects of culture that are above the surface are things that are explicit andvisible; these include tangible things such as clothing, food, language, etc.

The non-visible aspects are habits, assumptions, values and judgments - things we

intense the emotion attached to it.

Visible and Non-VisibleAspects of Culture

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Facilitation Tips

Comment:

These two pictures were taken from a project in Time Magazine where American teens wereasked to describe either what can be perceived about them from their picture (i.e. the visibleaspects of culture) and what things may be under the surface (i.e. the non-visible aspects).

Ask the Audience (after showing each picture separately)

What are the visible aspects of their culture?

What are the non-visible aspects?


ChristopherI suppose something that would not be perceived immediatelywould be my having cancer. I don't have it anymore, I've beentreated for it, but nonetheless, my experience with it has alarge say in who I am. I am a humble person and I don't feelas if I love to share everything with everyone, just like myexperience with cancer, though I suppose now I am telling

frequently as either being very formal and polite or as beingcoldhearted. The real me, however, is very emotional andunderstanding. When I got chemotherapy I saw children noteven five years old with more severe cases of cancer orintestinal problems and I felt . . . I knew something was wrongwith this, with young, innocent children being sick in the waythey were, and I wished I could take their pain and sufferingfrom them. From then on, I look at people with a differentoutlook, and I see how ignorant many people are from eventslike that, and it lifts me to a new level of understanding.

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Facilitation Tips

Comment


o Skateboarder

o Hates school, bad grades.

o Lives in a cold climate


OmarI know that I shouldn't but sometimes I wonder howother people look at me. What do they see first? Mybrown-ness, my beard, my cap, my clothes, the colorof my eyes, the design of my T-shirt? I think thatpeople see my skin color first. They probably see meas a brown guy. Then, they might see my black beardand my white kufi (prayer cap) and figure out I amMuslim. They see my most earthly qualities first.Brown, that's the very color of the earth, the mud fromwhich God created us. Sometimes I wonder what colormy soul is. I hope that it's the color of heaven.


33

Facilitation Tips

Comment


o Muslim practicing

o Wealthy because of his dress shirt

o Good student


Activity

Ask the learners;

o nfluenced

assumptions influence patient care.

o If anyone of them has been stereotyped as the result of some aspect of theiridentity?

o Why we stereotype? Answer we do so owing to the amount of information we areconfronted with on a daily basis, and in order to move through our day we categorizeinformation. However, when we generalize about others (all Martians are green) weare often incorrect.

Reflect on a time when your own cultural biasesor assumptions influenced your interactions

(with family, friends, in the hospital, outside of the

Personal Reflection Sheet

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Facilitation Tips

None

What is Cultural Competence?

A set of congruent behaviours, attitudes andpolicies that come together to enable a system,organization or professionals to work effectively incross-culturalsituations.

(Terry Cross, 1988)

36

Facilitation Tips

Comment

We are now moving from the discussion of why there are health disparities in the new immigrantpopulation, to a discussion of what you can do in practice to reduce these disparities. Culturallycompetent care has been shown to be an effective strategy in reducing health disparities.Before we discuss how to be culturally competent, we must first understand what culturalcompetence means, and how it is of benefit in reducing health disparities in the new immigrantpopulation.


Examine own values, beliefs & assumptions

Recognize conditions that exclude peoplesuch as stereotypes, prejudice, discriminationand racism

Reframe thinking to better understand otherworld views

Become familiar with core cultural elementsof diverse communities

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Develop a relationship of trust by interactingwith openness, understanding and a willingnessto hear different perceptions

Create a welcoming environment that reflectsand respects the diverse communities that youwork with and that you serve

(A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia)

38

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Why is Cultural CompetenceImportant at SickKids?

Patient SafetyCultural competence in health care has a direct link topatient safety. When culturally competent care is absent,the risk of preventable adverse events can increase.

Adverse Events include:Unnecessary hospital admissionsMisdiagnosisOrdering of inappropriate,unnecessary tests or invasiveprocedures

Discrimination potentially leading to substandard quality of care

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Why is Cultural CompetenceImportant at SickKids?

Family-Centred CareCulture is an integral component of the family unit, and thus an integralcomponent of family-centred care.

EquityNew immigrants were almost two and half times more likely to reportdifficulties accessing immediate healthcare than were Canadian-bornresidents. (Sanmartin and Ross, 2006)

QualityA critical relationship exists between culture, language, and the safety andquality of care of patients from minority racial, ethno-cultural, and languagebackgrounds. (Johnstone and Kanitsaki, )

Growing DiversityGrowing cultural and linguistic diversity of population and patients/families

40

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Cultural Competence

competence in other areas of clinical

medicine, and cultural competence

Dr. Joseph Betancourt, 2006

41

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Benefits of Cultural Competence

Higher cultural competency scores predicted higherquality of care for children with asthma (Lieu et al., 2004)

A culturally competent smoking cessation interventionresulted in a higher rate of smoking cessation amongAfrican Americans (Orleans et al.,1998)

More culturally competent physician behaviourresulted in patients who reported higher levels ofsatisfaction and were more likely to share information(Paez et al., 2009)

42

Facilitation Tips

There is a wealth of literature available that provides direct examples of the benefits ofcultural competence. Select the evidence that is most applicable to your workplace andpatient populations.

Service Excellence

44

Facilitation Tips

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Service Excellence Icebreaker

Define what service excellence in your jobmeans.

Identify challenges you experience providingservice excellence at work.

Describe something you believe would help youdeliver service excellence

45

Facilitation Tips

Activity

Ask participants to work at their tables and come up with answers to these questions.

Ask them to choose a spokesperson to share with the group.

Service Excellence at SickKids

Strategic Objective : Lead in world class quality and serviceexcellence

accommodating and flexible to the needs of those who rely on us,including children and families who come to us for care, and staff

across both clinical and non-clinical areas and ensure that theseprinciples become ingrained in our culture and are evident in ourday-to-

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Success Factors for Service Excellence

An emphasis on formal corporate and strategic planning

A commitment to embrace and improve quality of care, involving:Asking patients and families what they wantListening to patients and familiesProviding excellent service in light of patients and families requirement.

A commitment to organizational flexibility and change, as well asimproved organization climate.

A focus on continuously reducing costs and improving productivitythrough ensuring patient safety, reducing length of stay

An uncompromising attitude toward improving information systems

(Brathwaite, 1993)47

Facilitation Tips

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Linking Service Excellenceand Cultural Competence

Cultural competence and service excellence involve:

Willingness to learn what patients/families need and want, and tomodify how you provide services to meet those needs

Sensitivity to differences and embracing the pluralism of ideas

Accepting and respecting patient/family differences

Respectful communication with patient /family

others and utilizing the patients preferred and most effective meansof communication

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Linking Service Excellenceand Cultural Competence

A commitment to flexibility in the provision of care and services

Recognizing healthcare access barriers, and helpingpatients/families overcome them

Commitment to achieving health equity

Demonstrating awareness, respect and sensitivity in elicitingsensitive information from patients and families

Accurate identification and documentation of population and clientslanguage preferences, level of proficiency and literacy

Continuously engaging in reflective practice by reflecting beforeaction, reflecting in action (during patient interactions) and reflectingon action (after patient interactions) (RNAO)

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Mini Cases What would you do?

You are having lunch with colleagues. A discussion of issues onthe unit begins and someone mentions the new employee, whois an immigrant. Three people begin talking about how hard it isto understand her and a discriminatory comment is made.

You have just finished coordinating a return visit for a patient andfamily who was having difficulty understanding your instructionsdue to a language barrier. After they leave, a colleague makes adiscriminatory comment regarding the family.

50

Facilitation Tips

Activity

Have participants discuss these cases and then share what they would do.

Clinical Cultural Competence andFamily-Centred Care

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Family-Centred Care

Recognizing family as

lifeFacilitating child/familyand professionalcollaborationSharing informationUnderstandingdevelopmental needsRecognizing familystrengths andindividuality

CulturallyCompetent Care

Understanding themeaning of culture

Knowing aboutdifferent culturesBeing aware of disparitiesand discrimination thataffect racialized groupsBeing aware of ownbiases andassumptions

Culturally CompetentFamily-Centred Care

Exploring and respectingchild and family beliefs,values, meaning of illness,preferences and needsRecognizing and honouringdiversityImplementing policies andprograms that supportmeeting the diverse healthneeds of familiesDesigning accessibleservice systems

(Adapted from Saha, Beach, & Cooper, 2008)

Cultural Competence andFamily-Centred Care

52

.

Facilitation Tips

Comment

One of the most significant aspects of family-centred care involves the family in the care,and part of any family is their culture. Although culturally competent care and family-centred care have distinctive qualities, many key concepts overlap.

Culturally competent care is integral to family-centred care and should be embraced andincorporated into our practice as part of the culture.

, but is a necessary part ofproviding high-quality patient care at all times.

Family-Centred Care

CulturallyCompetent

Care

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Cultural CompetenceCommunication Strategies

Facilitation Tips

or fail to make eyecontact, or why some patients never arrive on time or fail to follow medical advice? Is it anindividual choice or does culture play a role?

To provide culturally competent care, healthcare providers must be able to recognize whichbehaviours could be associated with a cultural group and which behaviours are specific to anindividual (Carteret, 2008).

While it may seem useful to memorize the beliefs, values and customs of other cultures, thismethod stereotypes those within a cultural group and ignores individual differences. Instead,when communicating across cultures one must apply the same methods utilized when

towards those differences (Carteret, 2008). But to recognize differences one must first have apoint of reference; in this case a clear understanding of own culture and the role it plays incommunication style.

Cross Cultural Communication

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Assigning Meaning

What itmeans tome

What itmightmean toanother

Not making eye contact

Spending time on small talk

Arriving late for anappt/class/work

Needing to consult family

56

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Facilitation Tips

Activity

Ask each table group to take a few minutes to answer what each of these things mean tothem, and then what they might mean to someone else

Once they are finished, each table will be asked to discuss their thoughts on one of theissues

Some potential examples include:

Not making eye contact- could mean to you that the individual is disinterested orbeing rude, while to another it could mean a sign of respect or be related tosocial anxiety

- could mean to you that the person understands, while toanother it could meanagree; they are simply responding in the manner in which they perceive as beingacceptable.

Joy Luck Club57

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Facilitation Tips

Video

Play video from 43:40-46:30

Ask the Learners:

What did you notice in terms of the ways in which the individuals in the film werecommunicating and the influence of culture on their interaction?

What was the influence of culture on their interactions?

Were some people communicating directly and others indirectly? How did this affectunderstanding and the relationship between those who were communicating?

Comment

The Chinese family in the Joy Luck Club uses a high context communication style; themeaning of the message is much more about the context of communication rather thanthe actual words that were used.

Example of different communication styles and impacts on perception.

If a service provider communicating in a low-context manner might repeatinstructions more than once to emphasize the message and ensureunderstanding.

A parent who communicates in a high context manner might interpret the serviceand therefore the

message must be repeated to ensure understanding.

Low ContextHigh Context


Asian and LatinAmerican cultures

Is less explicit, most ofthe message is in thephysical context orinternalized in theperson

More emphasis onwhat is left unspoken,

North American culture

Most of the information ismade explicit in languageused

Information is oftenrepeated for emphasis toensure understanding (if itis relevant and important itmust be stated, if it is notstated it is not relevant)

58

58

Facilitation Tips

Comment


- -another. They are different ways of communicating.

Although these communication styles predominate in certainnecessarily mean that low context communication is never utilized in a high-contextculture and vice versa. For instance, individuals from North America may still use ahigh-context communication style, although likely not as often as individuals from China.


More responsibility onthe listener to hear, tointerpret and then to act

More need for silence;longer pauses (to reflect,understand the contextand process themessage)

The responsibility forcommunication lies withthe speaker; it is betterto over communicateand be clear then toleave things unsaid

Silence and pausesoften misunderstood assigns of agreement orlack of interest

(Hall, 1976)

59

High Context Low Context

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3 Steps:

1. Empathy Attempt tounderstand the other

2. Define the ConcernExpress your concern

3. Invitation To generatesolutions that addressboth concerns

2 Key Ingredients:

1. Two concerns on thetable

2. Win/win solutions

(Greene, 2006)

60

60

Facilitation Tips

Comment


communicating with patients and their families. The collaborative conversationsframework applies to all patients and their families, not just new immigrants.

A key point of the collaborative conversation is establishing the concerns of thepatient/family first, rather than the staff member stating their concerns first. The position ofpower held by a hospital employee in this relationship may act to minimize the

asking questions rather than stating concerns, as the information gained from thisinteraction may enable a more collaborative decision that facilitates family-centred care.


3 2 Key phrases

Empathy -Understanding

Two concernsHelp me understand . .

Tell me more . .Can you explain that a bitmore?What else are you thinking?

Define theProblem

Invitation togeneratesolutions

Win/win solutions Would you be open to . . ..Could we consider . . . .What can we do about this?

What about . . .I wonder if there is a way . . . .

61

61

Facilitation Tips

Comment:


with patients and their families.

The collaborative conversations framework applies to all patients and their families, not just newimmigrants. It will also help you resolve problems and conflicts with colleagues.

It involves:

three steps (empathy, defining the problem, and inviting solutions)

two concerns (1. concerns of the patient/family, 2. Concerns of the employee or HCP)

and potentially key phrases to be utilized when communicating with patients and theirfamilies.

Things to Consider

How can having a collaborative conversation withsomeone contribute to Service Excellence?

Other points to consider:

Power Dynamics

Experience and Expertise


62

62

Facilitation Tips

Comment:

Considerations When Communicating Across Cultures

Power Dynamics

Who has the power in a health care environment?

conversations with the healthcare team?

How does culture influence power relations between the healthcareprovider and the patient and family?

Are the voices of immigrant families heard?

How do we minimize cultural silencing?


Different communication styles will impact the success of our collaborative conversations andthus how effective we are when communicating across cultures.

Health Literacy

63

63

Facilitation Tips

None

Health Literacy

(Canadian Public HealthAssociation)

(Ratzan and Parker,2000)

Canadians with the lowest literacy scores are twoand a half times as likely to see themselves asbeing in fair or poor health (Rootman & Gordon-El-Bihbety, 2008).

64

64

Facilitation Tips

Comment

Health Literacy

Health literacy is not just the ability to understand English; it also includes the ability toaccess information to make informed decisions. For example, an individual who knowshow to speak English but has no knowledge of community resources or how to use theinternet to access health information may still be considered at a low level of healthliteracy.

Health Literacy

It involves appropriate use of translatedmaterials and resources such as interpreterservices

It is not enough to give the family a pamphletin their own language

65

65

Facilitation Tips

Ask the Learners:

How do you use written material with patients and families to help facilitateunderstanding?

Comment

Need to be cognizant of the fact that some families may not be literate in their ownlanguage

It is important to ensure that patients and families are able to decode, process and acton the information provided in a pamphlet

Costs of Not ProvidingInterpretation in Health Care

A literature review described inequitable carewith regard to three specific areas:

Adverse eventsPatients who do not speak English are morelikely to experience serious medical errors

Inappropriate tests and procedures

Hospital Utilization(Access Alliance, 2009)

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Facilitation Tips

None

Need for an Interpreter

Pay attention to non-verbal cues

Ask the family to repeat back to youtheir understanding of whattold them

67

67

Facilitation Tips

Comment

English

Ask the family a simple question that requires more than a yes or no answer and listento how they respond

Avoi

As interpreters are not always available, it is important that a communication plan bedeveloped for the daily care of patients, for example;

using non-verbal communication

using physical materials as communication tools (simulation, drawing, etc)

complex and important information including information related to medicationsand the health of the patient should always be communicated through aninterpreter

Slides 66

Interpreter ServicesSickKids Policy

Interpreter Services

Request must be related to direct patient care, withthe focus on medical information

The request must be made by a healthcareprofessional

24-48 hours notice must be provided

68

68

Facilitation Tips

Comment

We should refrain from using untrained interpreters including family members asimportant information may be lost. Only consider the use of family members asinterpreters when the information to be communicated is extremely basic, for example;

Are you hungry?

Telephone InterpretationSickKids Policy

SickKids uses Language Line

Recommendations for use of Language Line:Urgent/stat or same day requests when informationis crucial and must be conveyed immediatelyLanguage assistance for less common languages

Requires the department cost centre code

69

69

Facilitation Tips

None

Cross-CulturalCommunication Strategies

Assume differences

Listen to stories

Share your intent, your purpose, your thinking

Ask for clarification

Be sincere and respectful

Acknowledge your own ethnocentrism

Take risks and be prepared to apologize

70

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None

Conclusion

Cultural Competence is an integral component of serviceexcellence as it acts to:

Create organizational flexibility and change and improveorganizational climate.

Continuously reduce costs and improve productivity by enhancingpatient safety.

Create an attitude toward improving information systems.

Improve the quality of care.

71

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EVALUATION ANDCOMMITMENT TO CHANGE

72

Facilitation Tips

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Questions?

73

THANK YOU!!

74

Train-the-Trainer

Manual

2011

Section 5Additional Resources

Session Slides

(A, B, C, Non-Clinical) - USB

Session Guides - USB

Train-the-Trainer Workshop Slides

References

Session Slides and Session Guides

(A-B-C, Non-Clinical)

Electronic Copies (USB)

Train-The-Trainer

Workshop Slides

ReferencesWe have endeavoured to acquire permission for any copyright material used inthese e-learning modules and to acknowledge sources correctly. Any mistakesor omissions called to our attention will be corrected.

Session References

Session A

Anderson, J. M., Blue, C., Holbrook, A., & Ng, M. (1993). On chronic illness: Immigrant women

a feminist perspective. Canadian Journal of Nursing Research,

25(2), 7-22.

Andrews, M. M., & Boyle, J. (1999). Transcultural concepts in nursing care. Philadelphia, United

States: Lippincott Williams and Wilkins.

Canadian Council for Refugees (2007). Refugee claimants in Canada: Some facts. Retrieved

May 18, 2010 from http://www.ccrweb.ca/documents/claimsfacts07.htm

Citizenship and Immigration Canada (2009). Refugee claims in Canada- Who can apply.

Retrieved May 18, 2010 from http://www.cic.gc.ca/english/refugees/inside/apply-who.asp

Chalmers, S., & Rosso-Buckton, A. (2008). Are you taking to me? Negotiating the Challenge of

Centre for Cultural Research, University of

West Sydney, Sydney: Australia.

Cross, T. (1988). Service to minority populations: Cultural competence continuum. Focal Point,

3, 1-4.

results from the National Population Health Survey. Social Science and Medicine.11

(1),1573-1593.

Free Country Media Production (n. d).Medicine Box: Healthcare and the New American.

Retrieved May 18, 2010 from http://video.google.com/videoplay?docid=-

5106027191893998854#

Greenfield, P. (1994). Independence and interdependence as developmental scripts:

Implications for theory, research, and practice. In P. Greenfield and R. Cocking (Eds.),

Cross-cultural roots of minority child development (pp.1-37). Mahwah, NJ: Lawrence

Erlbaum.

Harkness, S. (1992). Human development in psychological anthropology. In T. Schwartz, G.

White, and C. Lutz (Eds.), New directions in psychological anthropology (pp. 102-122).

New York: Cambridge University Press.

Hyman, S. E. (2001). Mood disorders in children and adolescent. Biological Psychiatry, 49(12),

962-969.

Institute of Medicine (2002). Unequal treatment: Confronting racial and ethnic disparities in

health care. B.D. Smedley, Stith, A.Y. & Nelson, A. Board on Health Science Policy.

Washington,DC: The national Academies Press

Kodjo, C. (2009). Cultural competence in clinical communication. Pediatrics in Review, 30, 57-

64.

Lien, T., Finkelstein, J., Lozano, P., Chi, F., & Quesenberry, C. (2004). Cultural competency and

other predictors of asthma care quality for medicaid insured children. Pediatrics,114(1),

102-110.

Meadows, D. (2001). The miniature earth project. Retrieved November 1, 2009 from


Nova Scotia Department of Health. (2002). A cultural competency guide for healthcare

professionals in Nova Scotia. Retrieved November 12, 2010 from

http://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_

for_Primary_Health_Care_Professionals.pdf

Orleans, C. T., Boyd, N. R., Binglar, R., Sutton, C., Fairclough, D., Heller, D., McClatchey, M.,

Ward, J. A., Graves, C., Flesisher, L., & Baum, S. (1998). A self help intervention for

African American smokers: tailoring cancer information service for a special population.

Preventive Medicine, 27(5), S61-S70.

Ogbu, J. (1994). Racial stratification and education in the United States: Why inequality persists.

Teachers College Record, 96(2), 264-298.

Paez, K., Allen, J., Beach, M. C., Carson, K., & Cooper, L. A. (2009). Physician cultural

competence and patient ratings of the patient- physician relationship. Journal of General

Internal Medicine, 24(4), 495-498.

Pollick, H. F., Rice, A. J., & Echenberg, D. (1987). Dental health of recent immigrant in the

newcomer schools, San Francisco. American Journal of Public Health, 77(6), 731-732.

Raphael, D. (2006). Social determinants of health: Present status, unanswered questions and

future directions. International Journal of Health Services. 36(4) 651-677.

Raphael, D.(Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.).

Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence and

healthcare quality. Journal of National Medical Association, 100(11), 1275-1285.

Sanmartin, C. and Ross, N. (2006). Experiencing difficulties in accessing first contact health

service in Canada. Healthcare Policy,1(2), 103-119.

Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity

and Inequalities in Health and Social Care, 1(1), 27-33.

Statistics Canada (2006). Community profiles: Toronto. Retrieved May 20, 2010 from

http://www12.statcan.ca/census-recensement/2006/dp-pd/prof/92-

591/details/page.cfm?Lang=EandGeo1=CMAandCode1=535__andGeo2=PRandCode2

=35andData=CountandSearchText=torontoandSearchType=BeginsandSearchPR=35an

dB1=AllandCustom=

Statistics Canada (2010). Projections of the diversity of Canadian population. Retrieved June 1,

2010 from http://www.statcan.gc.ca/daily-quotidien/100309/dq100309a-eng.htm

Time Magazine. (2010). Teens in America: Class pictures. Retrieved May 21, 2010 from

http://www.time.com/time/photogallery/0,29307,1698621_1509347,00.html#ixzz0lISMnQ

dm

Film

Cultural Competence: What are you doing about it?

Health Research & Educational Trust. (2006). Cultural Competence: What are you doing about

it? For more information visit www.hret.org

Session B

Abbe, M., Simon, C., Angiolillo, A., Ruccione, K., & Kodish, E. (2006). A survey of language

barriers from the perspective of pediatric oncologists, interpreters and parents. Pediatric

Blood Cancer, 47(6), 819-824.

Access Alliance Multicultural Community Health Centre. (2009). Literature review: Cost of not

providing interpretation in health care. Toronto, Ontario: Author.

Bateson, M. C. (2000). Full circles, overlapping lives: Culture and generation in transition. New

York: Random House.

Bernabei. R, Gambassi. G, Lapane. K, et al. (1998). Management of pain in elderly patients with

cancer. Journal of American Medical Association, 79(23):1877-1882.

Calvillo, E. R. ,& Flaskerud, J. H. (1993). Evaluation of the pain response by Mexican American

and Anglo American Women and their nurses. Journal of Advanced Nursing, 18(3), 451-

459.

Canadian Public Health Association. (2010). What is Health Literacy? Retrieved May 21, 2010

from http://www.cpha.ca/en/portals/h-l.aspx

Chalmers, S., & Rosso-Buckton, A. (2008). Are you taking to me? Negotiating the Challenge of

. Centre for Cultural Research, University of

West Sydney, Australia.

Cleeland, C. S., Gonin, R., Baez, L., Loehrer, P., & Pandya, K. J. (1997). Pain and treatment of

pain in minority patients with cancer. Annals of Internal Medicine, 127(9), 813-816.

Fadiman, A. (1998). The spirit catches you and you fall down. New York: Farrar, Straus, and

Giroux.

Ganv, F.M., Gonzalez, C. J., Basu, G., Hasan, A., Mukherjee, D., Datta, M., & Changrani, J.

(2010). Reducing clinical errors in cancer education: Interpreter training. Journal of

Cancer Education, 25: 560-564.

Greene, R., & Ablon, S. J. (2006). Treating explosive kids: The collaborative problem solving

approach. New York, New York: The Guildford Press.

Greenfield, P. (1994). Independence and interdependence as developmental scripts:

Implications for theory, research, and practice. In P.Greenfield & R. Cocking (Eds.),

Cross-cultural roots of minority child development (pp.1-37). Mahwah, NJ: Lawrence

Erlbaum.

Greenfield, P. M., & Suzuki, L. (1998). Culture and human development: Implications for

parenting, education, pediatrics and mental health. In I.E. Siegel & Renninger, K. A.

(Eds). Handbook of child psychology (Vol. 4, PP. 1059-1109). New York: Wiley.

Hall, E. T. (1976). Beyond Culture. New York: Doubleday

Hogbin (1943). A New Guinea Infancy: From Conception to Weaning in Wogeo. Oceana 13(4):

285-309

Hospital for Sick Children. (2003). Policies and Procedures: Interpreter Services. Toronto,

Ontario: Author.

Hyman, I. (2001). Immigration and Health. Health Policy Working Paper Series. Working Paper

01-05. Ottawa: Health Canada. Retrieved May 18, 2010 from http://www.hc-

sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/wpapers1.html.

Jambunathan, S., Burts, D., & Pierce, S. (2000). Comparisons of parenting attitudes among five

ethnic groups in the United States. Journal of Comparative Family Studies, 31(4), 395-

406.

Jimenez, N. Seidel, K., Martin, L., Rivara, F., Lynn, A. (2010). Perioperative analgesic treatment

in Latino and non-Latino pediatric patients. Journal of Health Care for the Poor and

Underserved, 21(1), 229-236.

Keller, H, Völker, S & Yovsi, R-D (2005). Conceptions of parenting in different cultural

communities. The case of West African Nso and Northern German women. Social

Development, 14(1), 158-180.

Lasch, K. (2000). Culture, pain, and culturally sensitive pain care. Pain Management Nursing,

1(3)(Suppl. 1),16-22.

Lie, D., Bereknyei, S., Braddock, C., Encinas, J., Ahearn, S., & Boker, J. R. (2009). Assessing

during patient encounters: A

validation study of the interpreter scale. Academic Medicine, 84(5), 643-650.

Marshall, G (1998) "assimilation." A Dictionary of Sociology. Retrieved September 24, 2010

from www.encyclopedia.com.

Ratzan S.C., & Parker, R.M. (2000). Introduction. In: National Library of Medicine Current

Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM,

Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S.

Department of Health and Human Services.

Richman, A. L., Miller, P. M. & Solomon, M. J. (1988). In R. A. LeVine, P. M. Miller and M. M

West (Eds), Parental Behavior in Diverse Societies. New Directions in Child

Development, No. 40 (pp. 65-74). San Francisco: Jossey-Bass.

Rootman, I., & Gordon-El-Bihbety, D. (2008). A vision for a health literate Canada: Report of

the expert panel on health literacy. Ottawa, Canada: Canadian Public Health

Association. Retrieved May 21, 2010 from http://www.cpha.ca/uploads/portals/h-

l/report_e.pdf

Rosmus, C., Johnston, C. C., Chan-Yip, A., & Yang, F. (2000). Pain response in Chinese and

non-Chinese Canadian infants: Is there a differences. Social Science and Medicine,

51(2), 175-184.

Ross-Sheriff, F. & Husain, A. (2004) South Asian Muslim children and families. In R. Fong.

(Ed.). Culturally competent practice with immigrant and refugee children and families

(163- 182). New York: Guilford.

Shawny, M. (2007). Pain Management. In Rani Srivastava (2007). The healthcare

professional guide to clinical cultural competence. Toronto, Ontario: Elsevier Canada.

Simon, C., Zyzanski, S. J., Eder, M., Raiz, P., Kodish, E. D., & Siminoff, L. A. (2003). Groups

potentially at risk for making poorly informed decisions about entry into clinical trials for

childhood cancer. Journal of Clinical Oncology, 21(11), 2173-2178.

Srivastava, R. (2007). The healthcare professionals guide to clinical cultural competence.

Toronto, Ontario: Elsevier Canada.

Tamis-LeMonda, C. S., Way, N., Hughes, D., Yoshikawa, H., Kalman, R. K., & Niwa, E.

Y. (2008). Parents' goals for children: The dynamic coexistence of individualism and

collectivism in cultures and individuals. Social Development,17,183-209.

T.V. Ontario (n.d). Parenting across cultures: The different ways we raise our children.

http://www.youtube.com/user/tvoparents#p/u/98/BJic9NrYk0Y

Film

The Joy Luck Club

Wang, W. (Producer), Wang, W. (Director). (1993).The Joy Luck Club [Motion Picture]. United

States: Hollywood Pictures Home Entertainment.

Interpreter Video

Kaiser Permanente; Kaise Foundation Health Plan Inc. (2005). Cultural Issues in The Clinical

Setting. United States: MultiMedia Communications.

Immigrant Parenting Video

TVO. (2010). Your Voice: Parenting Across Cultures. For more information contact

www.tvo.org/sales

God Grew Tired of US

Pace, M. (Producer), Quinn, C. (Producer), Walker, T. (Producer), Quinn, C. (Director). (2006).

God Grew Tired of Us [Motion Picture]. United States: Alliance Atlantis.

Session C

Fraser Institute. (2007). Complementary and alternative medicine in Canada: Trend in use and

public attitude, 1997-2006. Vancouver, British Columbia: Fraser Institute.

Goldman RD, Vohra S. (2004). Complementary and alternative medicine use by children visiting

a pediatric emergency department. Canadian Journal of Clinical Pharmacology, 11,

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