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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: sean.martin@sickkids.caFax: 416-813-8209 Phone: 416 813-7654 ext. 28320
Mail: The Hospital for Sick ChildrenNew Immigrant Support NetworkRoom 635525 University AvenueToronto, Ontario M5G 2L3
Cultural Competence Train-the-Trainer Manual - 2011
Cultural Competence Train-the-Trainer Manual - 2011
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
Cultural Competence Train-the-Trainer Manual - 2011
Cultural Competence Train-the-Trainer Manual - 2011
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.
Cultural Competence Train-the-Trainer Manual - 2011
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
Cultural Competence Train-the-Trainer Manual Section 1 3
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.
Cultural Competence Train-the-Trainer Manual Section 1 4
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.
Cultural Competence Train-the-Trainer Manual Section 1 5
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
Cultural Competence Train-the-Trainer Manual Section 1 6
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.
Cultural Competence Train-the-Trainer Manual Section 1 7
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
Cultural Competence Train-the-Trainer Manual Section 1 9
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.
Cultural Competence Train-the-Trainer Manual Section 1 10
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
Cultural Competence Train-the-Trainer Manual Section 1 11
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
Cultural Competence Train-the-Trainer Manual Section 1 12
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
Cultural Competence Train-the-Trainer Manual Section 1 13
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
Cultural Competence Train-the-Trainer Manual Section 1 14
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
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
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
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
Cultural Competence Train-the-Trainer Manual Section 1 15
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
Cultural Competence Train-the-Trainer Manual Section 1 16
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
Cultural Competence Train-the-Trainer Manual Section 2 18
Cultural Competence Train-the-Trainer Manual Section 2 19
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.
Cultural Competence Train-the-Trainer Manual Section 2 20
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
Cultural Competence Train-the-Trainer Manual Section 2 21
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
Cultural Competence Train-the-Trainer Manual Section 2 22
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
Cultural Competence Train-the-Trainer Manual Section 2 23
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
Cultural Competence Train-the-Trainer Manual Section 2 24
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
Cultural Competence Train-the-Trainer Manual Section 2 25
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
Cultural Competence Train-the-Trainer Manual Section 2 26
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
Cultural Competence Train-the-Trainer Manual Section 2 27
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
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
28
Appendix 2.2
Thank you for your participation.
Cultural Competence for Healthcare Professionals Workshop B Evaluation
Profession:____________________________ Date:_______________
1. I felt this workshop was aworthwhile learning experiencefor my role at <<Organization>>.
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.
10. The presenter(s) met the outlinedlearning objectives.
Comments? Please use reverse.
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
29
Appendix 2.2
Thank you for your participation.
Cultural Competence for Healthcare Professionals Workshop C Evaluation
Profession:____________________________ Date:_______________
1. I felt this workshop was aworthwhile learning experiencefor my role at <<Organization>>.
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.
8. The presenter(s) met the outlinedlearning objectives.
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.
Comments? Please use reverse.
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
Agree Stronglyagree
1 2 3 4 5
Stronglydisagree
Disagree Neither agreeor disagree
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
Disagree Neither agreeor disagree
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 Train-the-Trainer Manual Section 2 31
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
Cultural Competence Train-the-Trainer Manual Section 2 32
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
Cultural Competence Train-the-Trainer Manual Section 2 33
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
Cultural Competence Train-the-Trainer Manual Section 2 34
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
Cultural Competence Train-the-Trainer Manual Section 2 35
Train-the-Trainer
Manual
2011
Section 3Cultural Competence Curriculum
Section 3.1Teaching Methodologies
Section 3.2Educational Content
Section 3.3Facilitation Strategies
Appendix 2.3
Cultural Competence Train-the-Trainer Manual Section 3 36
Cultural Competence Train-the-Trainer Manual Section 3 37
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.
Cultural Competence Train-the-Trainer Manual Section 3 38
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).
Cultural Competence Train-the-Trainer Manual Section 3 39
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.
Cultural Competence Train-the-Trainer Manual Section 3 40
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).
Cultural Competence Train-the-Trainer Manual Section 3 41
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.
Cultural Competence Train-the-Trainer Manual Section 3 42
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 Competence Train-the-Trainer Manual Section 3 43
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.
Cultural Competence Train-the-Trainer Manual Section 3 44
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.
Cultural Competence Train-the-Trainer Manual Section 3 45
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.
Cultural Competence Train-the-Trainer Manual Section 3 46
Cultural Competence Train-the-Trainer Manual Section 3 47
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:
Cultural Competence Train-the-Trainer Manual Section 3 48
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.
Cultural Competence Train-the-Trainer Manual Section 3 49
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.
Cultural Competence Train-the-Trainer Manual Section 3 50
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:
Cultural Competence Train-the-Trainer Manual Section 3 51
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
Cultural Competence Train-the-Trainer Manual Section 3 52
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.
Cultural Competence Train-the-Trainer Manual Section 3 53
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
Cultural Competence Train-the-Trainer Manual Section 3 54
Cultural Competence Train-the-Trainer Manual Section 3 55
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.
Cultural Competence Train-the-Trainer Manual Section 3 56
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.
Cultural Competence Train-the-Trainer Manual Section 3 57
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.
Cultural Competence Train-the-Trainer Manual Section 3 58
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.
Cultural Competence Train-the-Trainer Manual Section 3 59
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.
Cultural Competence Train-the-Trainer Manual Section 3 60
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
Slide 1
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.
Slide 2
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
Slide 3
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
Slide 4
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
Slide 5
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?
Slide 6
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?
Slide 7
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
Slide 8
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.
Slide 9
Health Equity Terminology
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
Slide 10
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.
Slide 11
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.
Slide 12
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.
Slide 12 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
Slide 13
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.
Slide 14
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.
Slide 15
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
Slide 16
Immigrant Experience
What are some challenges you think new immigrants mayface during resettlement?
Skills and credential recognition
Racism/discrimination
Language
Access to affordable housing
Access to appropriate community and settlement supports
Inconsistent public policy between levels of government
16
Facilitation Tips
None
Slide 17
Immigrant Experience
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.
Slide 18
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
Slide 19
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.
Slide 20
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
Slide 21
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)
Slide 22
Social Determinants of Health
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.
Slide 23
Social Determinants of 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
Slide 24
Social Determinants of Health
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.
Slide 25
Culture
25
CULTURE AND CULTURAL COMPETENCE
Learning Objective 3
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.
Learning Objective 4
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
Slide 26
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:
What does culture mean to you?
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.
Slide 27
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)
Slide 28
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.
Slide 29
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
Slide 30
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
Iceberg Concept of Culture
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.
Slide 31
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?
Slide 32
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
Slide 33
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.
What are the visible and non-visibleaspects of culture?
33
Facilitation Tips
Comment
Typical
o Grumpy teenager (a typical teenager)
o Muslim practicing
o Wealthy because of his dress shirt
o Good student
People instantly draw assumptions based on appearance, however, most of whoChristopher is (what is important to him, and what may influence his health care
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.
Slide 34
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
Slide 35
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.
Slide 36
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.
Slide 37
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.
Slide 38
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.
Slide 39
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)
Slide 40
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.
Slide 41
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
Slide 42
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
Slide 43
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.
Slide 44
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.
Slide 45
Clinical Cultural Competence andFamily-Centred Care
45
Insert photos here
Facilitation Tips
CULTURAL COMPETENCE AND FAMILY-CENTRED CARE
Learning Objective 5
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
Slide 46
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.
Slide 47
Cultural Assessment
47
Facilitation Tips
CULTURAL ASSESSMENT
Learning Objective 6
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
Slide 48
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?
Slide 49
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.
Slide 50
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
Slide 51
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.
Slide 52
Questions?
52
Facilitation Tips
None
Slide 53
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.
Slide 1
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.
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.
Slide 2
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:
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?
Slide 3
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
Slide 4
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
Slide 5
Cross-CulturalCommunication
5
CROSS-CULTURAL COMMUNICATION
Learning Objective 1
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)
Slide 6
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.
Slide 7
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?
Slide 8
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.
Slide 9
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
Context of Communication
- -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.
Slide 10
Context of Communication
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
Slide 11
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.
Slide 12
Collaborative Conversations
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
Collaborative Conversations
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.
Slide 13
Things to Consider
Power Dynamics
Experience and Expertise
Communication Styles
13
13
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,
Communication Styles
Different communication styles will impact the success of our collaborativeconversations and thus how effective we are when communicating across cultures
Slide 14
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:
1. What do you think is occurring in this situation?
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
1. What do you think is occurring in this situation?
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.
Slide 15
Health Literacy
15
15
Facilitation Tips
None
Slide 16
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)
16
16
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.
Slide 17
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
17
17
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
Slide 18
Interpreter Services andLanguage Line
18
Facilitation Tips
None
Slide 19
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)
19
19
Facilitation Tips
None
Slide 20
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)
20
20
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?
Slide 21
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
21
21
Facilitation Tips
Comment
Remember that stress may impactEnglish
Slide 22
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
22
22
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
Slide 23
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)
23
23
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
Slide 24
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
24
24
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
Slide 25
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)
25
25
Facilitation Tips
None
Slide 26
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
Slide 27
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
27
27
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.
Slide 28
Cultural Differencesin Parenting
28
PARENTING ACROSS CULTURES
Learning Objective 2
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.
Slide 29
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)
29
29
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?
Slide 30
Have you been surprised by acultural difference in parenting?
(Greenfield & Suzuki, 1998)
30
30
Facilitation Tips
Ask the Learners:
Why do you think these differences in parenting styles are occurring?
Slide 31
How Culture Affects Parenting
SleepFeedingDisciplineParenting styleRoutinesMediaPlayTalking to children
AttachmentEducationConflictsSafetyFamily typeAdolescenceRolesAdvice seeking
31
31
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
Slide 32
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)
32
32
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
Slide 33
Historical Perspective
Parent-child relationships amongracialized groups are often portrayedas deficient (Keller, Volker & Yovsi, 2005)
33
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.
Slide 34
Individualism andCollectivism in Parenting
34
Facilitation Tips
None
Slide 35
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)
35
35
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)
Slide 36
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)
36
Individualism Collectivism
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)
Slide 37
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)
37
Individualism Collectivism
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
Slide 38
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
38
Individualism Collectivism
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)
Slide 39
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)
39
Individualism Collectivism
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,
Slide 40
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)
40
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.
Slide 41
Immigrant Parenting Experience
PARENTING VIDEO
41
41
Facilitation Tips
Videoo Play DVD
o Time Codes: 16:21-18:11
Ask the Learners:
Do you think immigrant parents are judged?
Slide 42
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
Slide 43
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
Slide 44
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
44
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
Slide 45
When teaching about parenting it is important toremember that optimal child development canfollow many paths.
45
45
Facilitation Tips
None
Slide 46
Mental HealthSupporting Immigrant and Refugee
Families and their Mental Health Needs
46
CULTURE AND MENTAL HEALTH
Learning Objective 3
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.
Slide 47
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
47
47
Facilitation Tips
None
Slide 48
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
Slide 49
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)
49
49
Facilitation Tips
None
Slide 50
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)
50
50
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)
Slide 51
Determinants of New ImmigrantMental Health
Migration stress (before, during, after)
Personal resources
Socio-demographic characteristics
Social resources
51
51
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
Slide 52
A Refugee Experience
52
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
Slide 53
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
53
53
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
Slide 54
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
Slide 55
Access Alliance
Four Villages
Hong Fook Mental Health Association
Mt. Sinai Hospital
Across Boundaries
Support for ImmigrantMental Health in Toronto
55
55
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
Slide 56
Pain
56
56
PAIN ACROSS CULTURES
Learning Objective 4
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.
Slide 57
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)
57
57
Facilitation Tips
None
Slide 58
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.
Slide 59
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
Slide 60
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?
Slide 61
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.)
61
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
Slide 62
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.
Questions to consider:
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.
Slide 63
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
Slide 64
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
Slide 65
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
Slide 66
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
Slide 67
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
Slide 68
Questions?
68
Slide 69
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).
Slide 1
Cultural Competencefor
Healthcare ProfessionalsPart C: Practical Applications Continued
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.
Slide 2
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:
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?
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.
Slide 3
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
Slide 4
Complementary andAlternative Medicine
(CAM)
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Learning Objective 1
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.
Slide 5
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.
Slide 6
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?
Slide 7
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
Slide 8
(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.
Slide 9
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)
Slide 10
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
Slide 11
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
Slide 12
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?
Slide 13
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?
Slide 14
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.
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
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. .
Questions to consider:
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.
Slide 20
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.
Slide 21
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.
Slide 22
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)
Slide 23
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?
Slide 24
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.).
Slide 25
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.
Slide 26
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.
Slide 27
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.
Slide 28
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
Slide 29
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.
Slide 30
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.
Slide 31
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?
Slide 32
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
Slide 33
(Your institution) Policies
-of-lifecare
Facilitation Tips
None
Slide 34
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
Slide 35
Standardized Patients
Learning Objective 4
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
Slide 36
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
Slide 37
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
Slide 38
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
Slide 39
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.
Slide 1
Cultural Competencefor Non-Clinicians
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.
Slide 2
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.
2
Facilitation Tips
None
Slide 3
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
3
Facilitation Tips
None
Slide 4
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
4
Facilitation Tips
None
Slide 5
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.
Slide 6
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.
6
Facilitation Tips
None
Slide 7
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
7
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?
Slide 8
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?
8
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?
Slide 9
Walk around and review the posted data and statementclusters.
that is of most interest to you.
Walkabout Activity
9
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
Slide 10
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
10
Facilitation Tips
Comment:
Social equity in health
Refers to an absence of unjust health disparities between social groups, withinand between c
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.
Slide 11
Cultural Competence:What are you doing about it?
13
13
Facilitation Tips
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 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 federal
provincial licensing bodies may not. This may act as a barrier toemployment and income generation.
Slide 12
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.
12
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.
Slide 13
Immigrant Experience
What are some challenges you think new immigrants mayface during resettlement?
Skills and credential recognition
Racism/discrimination
Language
Access to affordable housing
Access to appropriate community and settlement supports
13
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.
Slide 14
Immigrant Experience
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
14
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
Slide 15
Immigrant Experience
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
15
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.
Slide 16
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)
16
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
Slide 17
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.
17
Facilitation Tips
None
Slide 18
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.
Slide 18 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
Slide 19
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
21
Facilitation Tips
Comment
Canadian Immigration
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)
Slide 20
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
Slide 21
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).
Slide 22
Health Equity Terminology
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
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.
Slide 23
Social Determinants of Health
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)
Slide 24
Social Determinants of Health
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.
Slide 25
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.
Slide 26
Key Questions
What is culture?
What is cultural competence?
Why is cultural competence important at SickKids?
Who does cultural competence help?
27
Facilitation Tips
None
Slide 27
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)
What does culture mean to you?
28
Facilitation Tips
Ask the learners:
What does culture mean to you?
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.
Slide 28
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)
Slide 29
Iceberg Concept of Culture
Like an iceberg, nine-tenths of culture is out of
30
Facilitation Tips
Comment
The iceberg metaphor is used very commonly to describe culture
Slide 30
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.
Slide 31
Visible and Non-VisibleAspects of Culture
31
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?
Slide 32
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
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
Slide 33
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.
What are the visible and non-visibleaspects of culture?
33
Facilitation Tips
Comment
o Grumpy teenager (a typical teenager)
o Muslim practicing
o Wealthy because of his dress shirt
o Good student
People instantly draw assumptions based on appearance, however, most of whoChristopher is (what is important to him, and what may influence his health care
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.
Slide 34
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
35
Facilitation Tips
None
Slide 35
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.
Slide 36
Actions that SupportCultural Competence
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
37
Facilitation Tips
None
Slide 37
Actions that SupportCultural Competence
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
Facilitation Tips
None
Slide 38
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
39
Facilitation Tips
None
Slide 39
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
Facilitation Tips
None
Slide 40
Cultural Competence
competence in other areas of clinical
medicine, and cultural competence
Dr. Joseph Betancourt, 2006
41
41
Facilitation Tips
None
Slide 41
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.
Slide 42
Service Excellence
44
Facilitation Tips
None
Slide 43
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.
Slide 44
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-
46
Facilitation Tips
None
Slide 45
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
None
Slide 46
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
48
Facilitation Tips
None
Slide 47
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)
49
Facilitation Tips
None
Slide 48
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.
Slide 49
Clinical Cultural Competence andFamily-Centred Care
51
Facilitation Tips
None
Slide 50
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.
Slide 51
Family-Centred Care
CulturallyCompetent
Care
53
Facilitation Tips
None
Slide 52
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.
Slide 53
Cross Cultural Communication
55
Facilitation Tips
None
Slide 54
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
56
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.
Slide 55
Joy Luck Club57
57
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.
Slide 56
Low ContextHigh Context
Context of Communication
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
Context of Communication
- -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.
Slide 57
Context of Communication
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
59
Facilitation Tips
None
Slide 58
Collaborative Conversations
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
Collaborative Conversations
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.
Slide 59
Collaborative Conversations
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:
Collaborative Conversations
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.
Slide 60
Things to Consider
How can having a collaborative conversation withsomeone contribute to Service Excellence?
Other points to consider:
Power Dynamics
Experience and Expertise
Communication Styles
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?
Communication Styles
Different communication styles will impact the success of our collaborative conversations andthus how effective we are when communicating across cultures.
Slide 61
Health Literacy
63
63
Facilitation Tips
None
Slide 62
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.
Slide 63
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
Slide 64
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)
66
66
Facilitation Tips
None
Slide 65
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?
Slide 67
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
Slide 68
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
70
Facilitation Tips
None
Slide 69
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
Facilitation Tips
None
Slide 70
EVALUATION ANDCOMMITMENT TO CHANGE
72
Facilitation Tips
None
Slide 71
Questions?
73
Slide 72
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.
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White, and C. Lutz (Eds.), New directions in psychological anthropology (pp. 102-122).
New York: Cambridge University Press.
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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.
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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
http://www.miniature-earth.com/me_english.htm
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professionals in Nova Scotia. Retrieved November 12, 2010 from
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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.
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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.
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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.
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service in Canada. Healthcare Policy,1(2), 103-119.
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and Inequalities in Health and Social Care, 1(1), 27-33.
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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.
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York: Random House.
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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.
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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.
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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
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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.
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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
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Rootman, I., & Gordon-El-Bihbety, D. (2008). A vision for a health literate Canada: Report of
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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.
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(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,
e247.
Goldman, R.D., Vohra, S., & Rogovik, A.L. (2009). Potential vitamin-drug interactions in children
at a pediatric emergency department. Paediatric Drugs, 11(4), 251-257
Hospital for Sick Children. (2001). Possible use of complementary and alternative therapies.
Toronto, Ontario: Author.
Institute of Medicine. (2005). Complementary and Alternative Medicine in the United States.
Washington, DC: National Academies Press.
Pottinger, A., Perivolaris, A., & Howes, D. (2007). The end of life. In Rani Srivastava, The
inical Cultural Competence. Toronto, Ontario:
Elsevier.
Rosenblatt, P. C. (1993). Cross-cultural variation in the experience, expression, and
understanding of grief. In D. P. Irish, K. F. Lundquist, V. J. Nelsen, (Eds.) Ethnic
variations in dying, death and grief: Diversity in universality (pp. 13-19), Washington. D.
C.: Taylor & Francis.
Film
Grainger-Monsen, M. (Producer) & Haslett, J. (Producer). (2003).
Series on Cross-Cultural Healthcare. Fanlight Productions. For more info email
info@fanlight.com
E-Learning References
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