33 Cultural Aspects of Healthcare PDF

Professionalism, Culture and Cultural Awareness in Healthcare Prof. Denis Harkin MB MD FRCSI FEBVS Consultant Vascular Surgeon Chair of Medical Professionalism, RCSI Learning Objectives By the end of the lecture, learners will be able to: 1. Define culture and organis...

Professionalism, Culture and Cultural Awareness in Healthcare Prof. Denis Harkin MB MD FRCSI FEBVS Consultant Vascular Surgeon Chair of Medical Professionalism, RCSI Learning Objectives By the end of the lecture, learners will be able to: 1. Define culture and organisational culture in healthcare 2. Define cultural awareness in healthcare (including diversity and discrimination) 3. Describe culturally safe and sensitive practice (ABCD, RESPECT, ACCESS Methods) 4. Discuss the impact of culture on healthcare outcomes 5. Discuss the impact of culture on medical insurance, medical indemnity and medical regulation Disclaimer & Fair Use Statement This talk may contain copyright material, the use of which may not have been specifically authorised by the copyright owner. This material is available in an effort to explain issues relevant to education or to illustrate the use and benefits of an educational tool. The material is distributed without profit for educational purposes. Only small proportions of the original work are being used and those could not-be-used easily to duplicate original work. This should constitute a “fair use” of any such copyrighted material (referenced and provided for in Irish Copyright and Related Rights Act 2000 and EU Directive 2001/29/EC). If you use any copyrighted material from this talk for the purposes of your own that go beyond “fair use”; you must obtain expressed permission from the copyright owner. Organisational Culture ‘Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations.’ Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity Mannion R, Davies H. Understanding organisational culture for healthcare quality improvement. BMJ. 2018 Nov 28;363:k4907. doi: 10.1136/bmj.k4907. PMID: 30487286; PMCID: PMC6260242. 3 Levels of Organisational Culture Visible manifestations of healthcare culture include the distribution of services and roles between service organisations (such as the long established divides between secondary and primary care and between health and social care), the physical layouts of facilities (receptionists behind desks and doctors in consulting rooms), the established pathways through care (including the ubiquitous outpatients appointment), demarcation between staff groups in activities performed (and the tussles that challenge or reinforce these), staffing practices and reporting arrangements, dress codes (such as different coloured scrubs for different staff groups in emergency departments), reward systems (pay and pensions, but also the less tangible rewards of autonomy and respect), and the local rituals and ceremonies that support approved practices. Shared ways of thinking include the values and beliefs used to justify and sustain the visible manifestations above and their associated behaviours, as well as the rationales put forward for doing things differently. This might include prevailing views on patient needs, autonomy, and dignity; ideas about evidence for action; and expectations about safety, quality, clinical performance, and service improvement. Deeper shared assumptions are the (largely unconscious and unexamined) underpinnings of day- to-day practice. (professional roles, hierarchy and delineations) Ferlie E, Montgomery K, Reff Pedersen AMannion R. Davies, H Cultures in Healthcare. In: Ferlie E, Montgomery K, Reff Pedersen A, eds. Oxford Handbook of Health Care Management. Oxford University Press, 2016. 400-1200 Excess Deaths Poor Care and High Mortality (2005-2009) Mid Stafford NHS Foundation Hospital Robert Francis QC (24 February 2010). Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust. House of Commons. ISBN 978-0-10-296439-4. Retrieved 15 October 2021 A Lack of Care and Compassion Robert Francis QC (24 February 2010). Robert Francis Inquiry report into Mid -Staffordshire NHS Foundation Trust. House of Commons. ISBN 978-0-10-296439-4. Retrieved 15 October 2021 A Negative Culture "cutbacks to staffing and services in order to make millions of pounds' worth of surplus… to gain Foundation status" Pressure Fear Bullying Tolerance Robert Francis QC (24 February 2010). Robert Francis Inquiry report into Mid -Staffordshire NHS Foundation Trust. House of Commons. ISBN 978-0-10-296439-4. Retrieved 15 October 2021  Unhappily, the word “hindsight” occurs at least 123 times in the transcript of the oral hearings of the Inquiry report, and “benefit of hindsight” 378 times. It is easier to recognise what should have been done at the time now that the enormity of what was occurring in the Trust is better known. Robert Francis QC (24 February 2010). Robert Francis Inquiry report into Mid -Staffordshire NHS Foundation Trust. House of Commons. ISBN 978-0-10-296439-4. Retrieved 15 October 2021 Recommendations Common values Fundamental standards Openness, transparency and candour Compassionate, caring, committed nursing Strong patient centred healthcare leadership Accurate, useful and relevant information Culture change not dependent on Government Robert Francis QC (24 February 2010). Robert Francis Inquiry report into Mid -Staffordshire NHS Foundation Trust. House of Commons. ISBN 978-0-10-296439-4. Retrieved 15 October 2021 Smith JA. The Francis Inquiry: from diagnosis to treatment. Journal of medical ethics. 2015 Dec 1;41(12):944-5. Cultural Awareness Cul.tur.al_A.ware.ness NOUN ‘Someone's cultural awareness is their understanding of the differences between themselves and people from other countries or other backgrounds, especially differences in attitudes and values.’ Hippocratic Oath Hippocratic Oath I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture. To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer’s oath, but to nobody else. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly, I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein. Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me. – Translation by W.H.S. Jones. Medical Professionalism Medical Professionalism in the new millennium: a Physician Charter The primacy of patient welfare This principle focuses on altruism, trust, and patient interest Patient autonomy This principle incorporates honesty with patients and the need to educate and empower patients to make appropriate medical decisions. Social justice This principle addresses physicians’ societal contract and distributive justice. That is, considering the available resources and the needs of all patients while taking care of an individual patient. American Board of Internal Medicine Foundation. American College of Physicians–American Society of Internal Medicine Foundation. European Federation of Internal Medicine Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243–246. Diversity in our Society Non-Irish citizens increasing, now 12% of the population. Non-Irish groups: Polish (15%), UK (13%), Indian (7%), Romanian (7%), Lithuanian (5%). Brazilian, Italian, Latvian and Spanish. When immigrants relocate, they don’t leave their culture behind https://www.cso.ie/en/releasesandpublications/ep/p-cpsr/censusofpopulation2022-summaryresults/migrationanddiversity/ Cultural Competency Cultural competency allows for the delivery of individualized health care services within the cultural context of the patient and the avoidance of stereotyping. Cultural Desire is the process of wanting to become culturally competent. Cultural awareness is the process of becoming more sensitive, respectful, and attentive to the patient’s cultural beliefs and practices. Cultural knowledge is the process of developing an understanding of the differences and similarities between and within cultural groups. Cultural skill is the process of cultural assessment, which obtains relevant information about the patient’s beliefs, values, and practices. Cultural collaboration is the process that requires a partnership approach between the health care provider, the patient, and the family. Cultural encounter is the process of obtaining cultural experience through active engagement and, if possible, immersion in another culture. Leininger, M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcultural Nursing, 10(1), 9. Cultural Awareness Cultural awareness (or cultural sensitivity, cross-cultural / intercultural awareness) refers to the awareness of our own cultural identity, values and beliefs and the knowledge and acceptance of other’s cultures. Cultural awareness helps break down cultural barriers and brings a better understanding of ourselves and a better appreciation of those who are different. This enhances our interpersonal skills, enables us to relate to people from other cultures and to build connections in a more meaningful way. https://www.medicalcouncil.ie/ Cultural Awareness Cultural awareness is a reflective process to identify and understand your own cultural and professional: Background Values Beliefs Biases Assumptions Cultural awareness helps you understand how culture impacts your communication with others. Institute of Medicine; Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academy Press; 2004. American Association of Colleges of Nursing. Toolkit of resources for cultural competent education for baccalaureate nurses. 2008 http://www. aacn.nc he.edu/education-resources/toolkit.pdf. Accessed March 22, 2016. Cross-cultural Communication Cross-cultural communication is the ability to successfully communicate with people from different cultures and with different languages than your own. The goal of cross-cultural communication in health care is to help improve quality and eliminate racial and ethnic health disparities. Institute of Medicine; Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academy Press; 2004. American Association of Colleges of Nursing. Toolkit of resources for cultural competent education for baccalaureate nurses. 2008 http://www. aacn.nc he.edu/education-resources/toolkit.pdf. Accessed March 22, 2016. Cross-cultural Miscommunication Sources of Miscommunication Assumption of similarities (when one differs we take a negative view) Language differences (lack of understanding or misuse) Nonverbal misinterpretation (dress-code, gestures like nodding the head?) Preconceptions and Stereotypes (pre-defining characteristics of group) Tendency to evaluate (analyze behaviour by one’s own cultural norms) High anxiety (unfamiliarity with culture) Unconscious Bias Unconscious bias refers to a bias that we are unaware of and which happens outside of our control. It is a bias that happens automatically, triggered by our brain making quick judgements and assessments of people and situations, influenced by our background, cultural environment and personal experiences. Implicit bias questions the level to which these biases are unconscious especially as we are being made increasingly aware of them. Once we know that biases are not always explicit, we are responsible for them. We all need to recognise and acknowledge our biases and find ways to mitigate their impact on our behaviour and decisions. Protected Characteristics Equality legislation, it is against the law to discriminate against someone because of: age disability gender reassignment marriage and civil partnership pregnancy and maternity race (Irish Traveller) religion or belief sex sexual orientation These are called protected characteristics. https://www.equalityhumanrights.com/en/equality-act/protected-characteristics What is Discrimination? Direct discrimination occurs when you treat a person less favourably than you treat (or would treat) another person because of a protected characteristic. Indirect discrimination occurs when you apply a provision, criteria or practice in the same way for all people or a particular group, such as cancer patients, but this has the effect of putting people sharing a protected characteristic within the general population at a particular disadvantage. Discrimination arising from disability occurs when you treat a disabled person unfavourably because of something connected with their disability and cannot justify such treatment. What is Cross-Cultural Communication? Cross-Cultural Communication (or intercultural communication) is the study of how verbal and nonverbal communication takes place among individuals from different backgrounds, geographies, and cultures. Language: many find verbal communication challenging in a setting with people from different cultures. Cultural norms: communications styles may change depending on whether someone is from a high-context or low-context culture. Nonverbal communication: while some may easily communicate with eye contact or facial expressions, others may not. Also, certain hand gestures may have different meanings across cultural groups. Guidance on Cultural Awareness (5 Rules) 1. Establish clear communication: make sure you know your patient’s preferred method of communicating and arrange professional interpretation if necessary. 2. Be aware of non-verbal cues without jumping to conclusions: non-verbal communication conveys a lot of critical information—but it may differ dramatically across cultures. Don’t make any assumptions. 3. Ask openly about potentially relevant traditions and customs: this includes exploring potential spiritual/religious practices, dietary considerations, and cultural norms that may be important. 4. Use normalizing statements: a respectful way to ask about sensitive issues like cultural or religious customs is to first explain that they are very common. 5. Examine your own biases: we all have unconscious biases and prejudices that impact our relationships with patients. Examples of Cultural Differences Communication: e.g. level of eye contact; how to be polite; directly saying what is meant versus using indirect speech and taking the context into account; preferring written or face-to-face communication; body language; etc. Attitudes to hierarchy and respect for authority figures (including superiors at work or Lecturers) Dress code, Traditions and Customs Attitudes to time: i.e. some cultures value punctuality and others are more flexible towards time; some cultures are future-oriented and others are past- oriented Cultural Differences Collective decision-making is the norm in many cultures, but it often clashes with the Western value of autonomy and an individual’s right to make one’s own decisions about health and dying. Collectivism can cause a treatment dilemma for Filipino/Kamaaina Couple. Photo by Phyllis Coolen. the health care provider whose focus is on getting the patient involved in the treatment plan. In collective decision making, the family decisions will be family oriented; the power of collectivism is more important than an individual. Giger, J., Davidhizar, R., & Fordham, P. (2006). Multi-cultural and multi-ethnic considerations and advanced directives: developing cultural competen cy. Journal of Cultural Diversity, 13(1), 3-9. ABCD Cultural Assessment Model Kagawa-Singer and Blackhall developed a cultural assessment mnemonic (ABCD). Using this approach to assess the degree of cultural adherence can help avoid stereotyping and decrease the risk of miscommunication. Attitudes of parents and families Beliefs (religious or spiritual) Context (historical and political) Decision-making style Environment Kagawa-Singer, M., & Backhall, L. (2001). Negotiating cross-cultural issues at end of life. Journal of American Medical Association, 286(3001), 2993 - RESPECT Model Cross-Cultural Communication The RESPECT Model What is most important in considering the effectiveness of your cross-cultural communication, whether it is verbal, nonverbal, or written, is that you remain open and maintain a sense of respect for your patients. The RESPECT Model can help you remain effective and patient-centred. https://hclsig.thinkculturalhealth.hhs.gov/ProviderContent/PDFs/RESPECTModel.pdf. Mutha, S., Allen, C. & Welch, M. (2002). Toward culturally competent care: A toolbox for teaching communication strategies. San Francisco, CA: Center for Health Professions, University of California, San Francisco. The Wong-Baker FACES Pain Rating Scale The Wong-Baker FACES Pain Rating Scale has a series of 6 gender-neutral face circles that range from depicting a happy face of “no pain/no hurt’ to the “worst possible pain/hurt worst” depicting a crying face. Available in 13 different languages, including Spanish, French, Vietnamese, Chinese and Romanian. But not Irish? Fatalism as influenced by Buddhist and Confucian beliefs proposes that pain should be endured, as can lead to spiritual growth https://wongbakerfaces.org/faces-download/ Different Cultural Views on Death Buddhism Many Southeast Asians are Buddhist and believe in the cycle of life, karma, reincarnation, and that death is part of life. Aggressive treatment may be viewed as disturbing the natural ebb of life and a sign of a bad death. Patients and families may be more open to the discussion about and acceptance of advance directive planning. Jagaro, A. (2004). Death and Dying in Buddhism True Freedom. Bangkok: Buddhadhamma Foundation. Assisted Decision Making Capacity Act The Assisted Decision-Making (Capacity) Act (2015) Is about supporting decision-making and maximising a person’s capacity to make decisions. This Act applies to everyone and is relevant to all health and social care services. This new Act will assist in complying with human-rights obligations contained in the Constitution of Ireland, the European Convention on Human Rights, and the United Nations Convention on the Rights of Persons with Disabilities. Medical Practitioners Act 2007 http://www.irishstatutebook.ie/eli/2007/act/25/enacted/en/html Assisted Decision-Making (Capacity) Act 2015 http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-decision-making-capacity-act/ Capacity The 2015 (Capacity) Act formalises in law a four stage test for mental capacity. A patient will lack the capacity to make a decision if they are unable to: understand all of the information relevant to the decision retain the information for long enough to consider it use or weigh up that information in their decision-making process communicate their decision (by any means, including assistive technology) Medical Practitioners Act 2007 http://www.irishstatutebook.ie/eli/2007/act/25/enacted/en/html Assisted Decision-Making (Capacity) Act 2015 http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html Assisted Decision Making Capacity Act (2015) Means that every adult will be presumed to have capacity to make decisions, unless determined otherwise Provides for the individual’s right of autonomy and self-determination to be respected Introduces guiding principles interacting with a person who has difficulties with their decision-making capacity Establishes a tiered system of decision support arrangements for people who need help with making decisions Abolishes the current wardship system and requires all wards of court to be discharged within 3 years. Establishes the Decision Support Service Legal framework for decision making where a person lacks capacity and for advance healthcare directives Legally compliant decisions for a person who lacks capacity where matters of consent to treatment are at issue. Provides for legally recognised decision-makers to support a person to maximise their decision-making powers Moves to a flexible functional approach to the assessment of capacity – moving away from “all or nothing” status Puts the person at the centre of their healthcare treatment even where they lack decision-making capacity Provides improved oversight of Enduring Powers of Attorney process Medical Practitioners Act 2007 http://www.irishstatutebook.ie/eli/2007/act/25/enacted/en/html Assisted Decision-Making (Capacity) Act 2015 http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-decision-making-capacity-act/ Decision Support Arrangements (Act 2015) People who currently, or may shortly, face challenges when making certain decisions. 1. Decision-making assistance agreement (the person makes their own decision with support from their decision- making assistant. Their decision-making assistant helps them to access and to understand information and to communicate their decision) 2. Co-decision-making agreement (the person makes specified decisions jointly with a co-decision-maker) 3. Decision-making representation order (the court appoints a decision-making representative to make certain decisions on the person’s behalf). People who wish to plan for a time in the future when they might lose capacity. A person can appoint one or more attorneys to make decisions on their behalf about their personal welfare, or property or money matters. This is written down in and enduring power of attorney. A person can record their wishes about healthcare and medical treatment decisions in advance healthcare directive. The person may appoint a designated healthcare representative to make sure their advance healthcare directive is complied with https://www.decisionsupportservice.ie/ Assisted Decision-Making (Capacity) Act 2015 http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-decision-making-capacity-act/ Advance Healthcare Directive (Act 2015) A person wishes to plan ahead in relation to their future healthcare, they can make an Advance Healthcare Directive (AHD). This lets them set out their wishes regarding treatment decisions in case they are unable to make these decisions in the future. Importantly, it lets them write down any treatment they do not want. A person will be able to appoint someone they know and trust as their designated healthcare representative to ensure their advance healthcare directive is followed. A person without capacity, a valid and applicable AHD, must be considered A person, with capacity, may revoke their own AHD An AHD treatment request is not legally binding, but if relevant, should be considered https://www.decisionsupportservice.ie/ Assisted Decision-Making (Capacity) Act 2015 http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-decision-making-capacity-act/ Health Equity or Inequity (WHO) Life expectancy and healthy life expectancy have increased, but unequally. Poorer populations systematically experience worse health than richer populations. There is a difference of 18 years of life expectancy between high- and low- income countries; In 2016, the majority of the 15 million premature deaths due to non- communicable diseases (NCDs) occurred in low- and middle-income countries; Relative gaps within countries between poorer and richer subgroups for diseases like cancer have increased in all regions across the world; The under-5 mortality rate is more than eight times higher in Africa than the European region. Such trends within and between countries are unfair, unjust and avoidable. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_3 Social Determinants of Health (WHO) The social determinants of health (SDH) are the non- medical factors that influence health outcomes. The conditions in which people are born, grow, work, live: Income and social protection Education Unemployment and job insecurity Working life conditions Food insecurity Housing, basic amenities and the environment Early childhood development Social inclusion and non-discrimination Structural conflict Access to affordable health services of decent quality https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 Racism and Health Racism or Racial Discrimination, in contrast to cultural protective factors, are associated with poorer physical and mental health. Colonisation is recognised as having impact on disadvantage and health among Indigenous peoples worldwide, through social systems that maintain disparities. Racism can be interpersonal (such as through exclusion, abuse, or stereotyping), or systemic (through policies, conditions, and practices). It can impact health through: reduced access to social resources, including employment, education, housing, health care, and other services psychological distress and increased likelihood of engaging in risk behaviours, such as substance use injury from assault Paradies Y 2016. Colonisation, racism and indigenous health. Journal of Population Research 33:83-96. Paradies Y, Truong M & Priest N 2014. A systematic review of the extent and measurement of healthcare provider racism. Journal of General Internal Medicine 29:364-87. Indigenous Health and Wellbeing The Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2018, found Indigenous Australians lost almost 240,000 years of healthy life due to ill-health and premature death – equivalent to 289 years for every 1,000 people. The leading 5 diseases: 1. mental & substance use disorders (anxiety, depression, and drug use) 2. injuries (falls, road traffic injuries, and suicide) 3. cardiovascular diseases (coronary heart disease and rheumatic heart disease) 4. cancer and other neoplasms (lung cancer and breast cancer) and 5. musculoskeletal conditions (back pain & problems and osteoarthritis) Indigenous burden 2.3 times non-Indigenous Australians https://www.aihw.gov.au/reports/burden-of-disease/illness-death-indigenous-2018/summary Cultural Safety in Healthcare Cultural Safety, as a concept was originally defined and applied in the cultural context of New Zealand, in response to the harmful effects of colonisation and the ongoing legacy of colonisation on the health and healthcare of Maori people. The definition of cultural safety from the Nursing Council of New Zealand is the: ‘effective nursing practice of a person or family from another culture and is determined by that person or family. Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual.’ The emphasis is on the provision of culturally safe health care services as defined by the end users of those services, the Maori people of Aotearoa New Zealand, not by the [non-Maori] providers of care. Cultural safety, the Treaty of Waitangi and Maori health are aspects of nursing practice that are reflected in the Council’s standards and competencies. https://www.ngamanukura.nz/sites/default/files/basic_page_pdfs/Guidelines%20for%20cultural%20safety%2C%20the%20Treaty%20of%20 Waitangi%2C%20and%20Maori%20health%20in %20nursing%20education%20and%20practice%282%29_0.pdf Cultural Safety, Treaty of Waitangi and Maori Health Cultural Safety education is delivered according to the Council’s definition and extends beyond ethnic groups to include age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability. The Treaty of Waitangi understanding of the Treaty and its principles within the contexts of Aotearoa/New Zealand and nursing practice, and its practical application within nursing. Treaty of Waitangi and cultural safety, informs students about Maori health and nursing practice. Kawa whakaruruhau (cultural safety within the Maori context) is an inherent component of Maori health and nursing, especially in its contribution to the achievement of positive health outcomes. Cultural safety, the Treaty of Waitangi and Maori health are aspects of nursing practice that are reflected in the Council’s standards and competencies. https://www.ngamanukura.nz/sites/default/files/basic_page_pdfs/Guidelines%20for%20cultural%20safety%2C%20the%20Treaty%20of%20 Waitangi%2C%20and%20Maori%20health%20in %20nursing%20education%20and%20practice%282%29_0.pdf Indigenous Australians Indigenous Australians have poorer access to health services than non- Indigenous Australians, barriers such as availability, cost and a lack of culturally appropriate health services. For Indigenous Australians, cultural identity, family and kinship, country and caring for country, knowledge and beliefs, language and participation in cultural activities and access to traditional lands are also key Census estimates 984,000 Aboriginal and Torres determinants of health and wellbeing. Strait Islander people in 2021 https://www.indigenoushpf.gov.au/Report-overview/Overview/Summary-Report/2-Demographic-and-social-context Culture in Healthcare National Collaboration Centre for Indigenous Health in Canada (2013) notes that culturally safe health care systems and environments are established by a continuum of building blocks: Cultural Cultural Cultural Cultural Awareness Sensitivity Competence Safety Cultural Safety ‘…requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause clients to feel accepted and safe, or rejected and unsafe.’ https://www.nccih.ca/en/ Irish Traveller Health Inequality The All Ireland Traveller Health Study (2010) highlights health inequalities that lead to such poor health status, these include: Traveller women live on average 11.5 years less than women general population; Traveller men live on average 15 years less; and the number of deaths among Traveller infants is estimated at 14.1 for every 1,000 live births compared to 3.9 for every 1,000 live births in general population; The study also showed that deaths from respiratory and cardiovascular diseases and suicides increased in Travellers compared to the general population. Primary Health Care for Travellers Projects (PHCTPs) a model for developing health services based on the Traveller community’s own values and perceptions. https://www.hse.ie/eng/about/who/primarycare/socialinclusion/travellers-and-roma/irish- travellers/#:~:text=The%20health%20inequalities%20that%20lead%20to%20such%20poor,men%20live%20on%20average%2015%20years%20les s%3B%20and Cultural Safety Cultural safety aims to improve health care for Indigenous and Marginalized groups by addressing power imbalances, racism and discrimination in health services. ACCESS method is a tool to help health practitioners assess and improve their cultural safety skills. It stands for: Ask about the patient’s cultural background and preferences Communicate respectfully and effectively Consider the patient’s context and social determinants of health Engage with the patient’s family and community Support the patient’s self-determination and empowerment Share decision-making and care planning https://www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-framework/contents/background-material. Pirhofer, J., Bükki, J., Vaismoradi, M. et al. A qualitative exploration of cultural safety in nursing from the perspectives of Advanced Practice Nurses: meanin g, barriers, and prospects. BMC Nurs 21, 178 (2022). https://doi.org/10.1186/s12912-022-00960-9 GMC Ethnic Bias in Fitness to Practise Complaints and Training Doctors from ethnic minorities are twice as likely as white doctors to be referred to the GMC by their employers for fitness to practise concerns, and the referral rate for doctors qualifying outside the UK is three times higher than that for UK doctors. In education and training, exam pass rates show a 12 per cent difference between white and black and minority ethnic UK graduated trainees, rising to more than 30 per cent for overseas graduates. GMC ‘Fair to refer?’ Report 2019 ‘Fair to refer?’ Report (2019) GMC research into drivers for a greater proportion of ethnic minority doctors and international medical graduates referred by employers. Doctors in diverse groups do not always receive effective, honest or timely feedback Some doctors are provided with inadequate induction and/or ongoing support in transitioning to new social, cultural and professional environments Doctors working in isolated or segregated roles or locations lack exposure to learning experiences, senior mentors, support and resources Some leadership teams are remote and inaccessible Some organisational cultures respond to things going wrong by trying to identify who to blame rather than focusing on learning. In groups and out groups exist in medicine including relating to qualifications (including by country and within the UK by medical school) and ethnicity (including within BME populations). https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/fair-to-refer Stereotyping GMC ‘Fair to refer?’ Report 2019 ‘Fair to refer?’ Report (2019) GMC research into drivers for a greater proportion of ethnic minority doctors and international medical graduates referred by employers. Recommendations to address these issues: Improving induction, feedback and support for doctors new to the UK or the health service, or for doctors working in isolated roles. Addressing the systemic issues that prevent a focus on learning, rather than blame, when something goes wrong. Making sure that positive and inclusive leadership is more consistent across the health service. Developing a way to check that these recommendations are delivered. https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/fair-to-refer NMC ‘Ambitious for change’ Research ‘Ambitious for change’ Research by Nursing and Midwifery Council (NMC) 2020 into people’s protected characteristics (like gender, ethnicity or age) and how it affects their experience of NMC processes. The research examined NMC processes, including education, overseas registration, revalidation and fitness to practise, and has identified disparities in people’s experience and outcomes, depending on who they are. Key findings include: Nurses and midwives from a Black and minority ethnic background are more likely to be referred to fitness to practise by employers, while White professionals are more likely to be referred by the public Black practitioners are more likely to see their case go to the adjudication stage, although they’re not more likely to be removed from the register than White nurses and midwives Male nurses and midwives, and disabled nurses and midwives, are more likely to go to the adjudication stage of fitness to practise and be removed from our register Those living in the Channel Islands, Isle of Man, or whose region of the UK we don’t know are more likely to be referred than professionals living in other areas of the UK, the EU and outside of it https://www.nmc.org.uk/about-us/equality-diversity-and-inclusion/edi-research/ambitious-for-change-research-into-nmc-processes-and-peoples-protected-characteristics/ Thank you By the end of the lecture, learners will be able to: 1. Define culture and organisational culture in healthcare 2. Define cultural awareness in healthcare (including diversity and discrimination) 3. Describe culturally safe and sensitive practice (ABCD, RESPECT, ACCESS Methods) 4. Discuss the impact of culture on healthcare outcomes 5. Discuss the impact of culture on medical insurance, medical indemnity and medical regulation