HCL202 Cultural Competence Student Notes PDF

HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES DAY 1: CULTURAL COMPETENCE REFERENCE: “When Medicine and Culture Intersect.” Edited by Editor, CMPA, The Canadian Protective Medical Association, 2014, www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/when-medicine-and-culture- intersect. Culture and Canadian Health Care “Culture incorporates a mix of beliefs and behaviours that define the values of communities and social groups.” Health practitioners in Canada will have patients who are from various cultures. The Unintentional Result It is possible to accidentally offend someone by “missing clues or misunderstanding a cultural viewpoint.” There could be trouble understanding the health care provider because of a language barrier. Culture, Health, and Management of Illness Culture can impact care and a response to illness. Example: Beliefs about what causes disease, whether to engage in certain health promotion activities or seek advice regarding health concerns, as well as whether treatment options are followed. Culture can also impact a patient's approach to attending medical appointments in a timely manner. Some patients prefer not being informed of a terminal illness or the implications of not following through with treatment. First Nations patients may see a doctor and a traditional healer. Culture can also influence eating and fasting rituals, even when nourishment is vital to recovery and overall function. What is Culture? Bureau of Educational and Cultural Affairs: https://www.youtube.com/watch?v=57KW6RO8Rcs REFERENCE: “Cultural Competence for Child and Youth Health Professionals.” Edited by Dzung Vo Canadian Paediatric Society and Maureen Mayhew, Caring for Kids New to Canada, Canadian Paediatric Society, Apr. 2018, www.kidsnewtocanada.ca/culture/competence What is cultural competence? The Office of Minority Health in the United States defines cultural competence as, “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations”. 1 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Other terms used are: cultural effectiveness culturally effective health care cultural humility cultural safety Why is cultural competence important? Given Canada’s increasingly diverse population, it’s important for health care providers to be culturally competent. Culturally competent care reduces disparities and improves health outcomes in a diverse population by improving communication and managing cultural differences (e.g., beliefs about health and practices, as part of patient care). Culture, religion, and ethnicity may influence people’s beliefs and values about health and health care, and patients and providers bring cultural perspectives to each encounter. Areas where different perspectives can affect clinical care Birth and early infant care practices Nutrition and diet Bedsharing and Sudden Infant Death Syndrome Developmental disabilities Parenting and discipline Adolescent issues, including development, confidentiality, roles within the family and/or extended family, sexuality, substance use and other risky behaviours, identity development and acculturation Accessing health care systems, clinics, and emergency departments Using traditional medicines and treatments Cultural Competence Gregg Learning: https://www.youtube.com/watch?v=jlaCa8y-LiM Defining Cultural Safety Cultural Safety is the goal in a learning process, according to Irihapeti Ramsden, the Maori nurse and educator who developed the concept. It starts with awareness of a patient’s ethnicity or community and, in culturally safe practice, growing concerns with social justice... and nurses’ power, prejudice, and attitude. Cultural Safety Today Today, the term cultural safety is used mostly in academic studies and government reports, but it has also been adopted by some Aboriginal communities in Canada. 2 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The LEARN Model The LEARN model is one framework for teaching cultural competence that is action-oriented and focuses on what health care providers can do: Listen with understanding to the patient’s perception of a problem Explain your perceptions of a problem Acknowledge and discuss differences and similarities Recommend treatment Negotiate agreement REFERENCE: Ray, RN, PhD, CTN-A, FAAN. Colonel (Ret.), United States Air Force Nurse Corps, Marilyn (Dee). “Transcultural Caring Dynamics in Nursing and Health Care.” Nursology, Nursology, 8 Dec. 2018, https://nursology.net/nurse-theorists-and-their-work/transcultural-caring-dynamics-in-nursing-and-health-care/ The Power of Transcultural Nursing HCR Home Care: https://www.youtube.com/watch?v=6U3n4UF_XGg What is transcultural caring? 3 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Description of the model Transcultural Caring Model - An integral mode of being, thinking, and doing in the framework of caring, transcultural caring ethics, transcultural context (social-cultural phenomena), and universal sources (religions or spirituality). These are the creative transcultural forces (four dimensions of the theory) that constitute the foundation for personal awareness, understanding and choice-making. Description of the theory The fundamental assumptions of this theory are: Transcultural consciousness (awareness, seeking to understand, critical reflection) creates an appreciation of cultural diversity and the reality of sharing a common humanity. Sociocultural - social and cultural knowledge (personal, ethical, empirical, aesthetic). Caring is the essence of nursing, and integral with all ways of knowing. Complex caring dynamics (transcultural caring is integral with the sciences of complexity with a focus on self- reflection, relational transcultural caring complexity, relational self-organization, and transcultural caring knowledge-in-process). DAY 2: DIMENSIONS OF CULTURE REFERENCE: Editor, RNAO. Clinical Best Practice Guidelines: Person- and Family-Centred Care. Registered Nurses' Association of Ontario, 2015. https://rnao.ca/sites/rnao-ca/files/FINAL_Web_Version_1.pdf The Therapeutic Relationship The existence of a therapeutic relationship between the person and health-care providers is central to person- and family-centred care. For a person to be satisfied with health-care services, care must be organized with and around the person. Respectful and reflective of the person’s voice, needs, culture, values, beliefs, and changing health status and life circumstances. The importance of patient and family culture and care. Person- and family-centred care includes the philosophy of holism. Holism acknowledges that a human being comprises many components (biological, psychological, emotional, physical, personal, social, environmental, cultural, and spiritual). Through a partnership established within the therapeutic relationship, health-care providers know the whole person, their goals, beliefs and values, culture, experience of health and life circumstances, and care needs. Planning someone’s care… What they feel must be taken into consideration when planning, coordinating, and delivering their care (beliefs, values, culture, religion, spiritual preferences, sexual orientation, etc.). 4 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The importance of culture and documentation Documentation should include the person’s words on these aspects of health care and the delivery of services: The name they prefer to be addressed by. Their perceptions, knowledge, and understanding of their health history and current health and well-being (health literacy). Their strengths, concerns, and how they feel their illness has impacted them. Their perceptions, desires, preferences, and expectations for their care. Their priorities for care and services (what is most important to them right now). Documentation should include the person’s words on the following aspects of health care and the delivery of services: Their thoughts and feelings about their ability to manage their health, self-identified strengths and whether they feel they need assistance. Considerations for planning, coordinating, and implementing care (e.g., beliefs, culture, sexual orientation, religion, spirituality, etc.). Who they wish to have involved in their health care (circle of care) and the degree to which they wish them to be involved (roles and responsibilities for care)? What information they asked for about their health, how they would like to receive this information (e.g., written, verbal, visual, electronic, language levels, and other preferences), and when would they like to receive the information (timing). Benefits of documentation Effective documentation of this information will help inform members of the health-care team about the meaning of health to the person and assist with continuity of care, quality, and safety when delivering health services to meet care needs. Planning Care and Culture To enhance the person’s experience of health care and services, the person must be invited to participate in all care conferences and planning meetings. (Committee on Hospital Care & Institute for Patient- and Family-Centred Care, 2012; International Alliance of Patients’ Organizations, 2012; RNAO, 2002, 2006a; Saint Elizabeth, 2011.) A person- and family-centred-care approach to planning enables the person to be an active partner with health-care providers in determining the goals and plans for care. (National Voices, 2014a; RNAO, 2002, 2006a; Richmond PRA, 2013.) Research supports that including the person in care planning personalizes care by acknowledging the person’s strengths, hopes, and preferences for care based on individual beliefs, values, culture, and life context. (Dancet et al., 2010; Morgan & Yoder, 2012; Pelzang, 2010; Richards et al., 2007; Robinson et al., 2008; Thompson, 2009) The person’s perspective must be kept central during the planning process to ensure the plan of care is personalized, addresses the person’s unique needs and life circumstances, and consists of evidence-based strategies appropriate for the person’s health needs. 5 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The importance of collaborating with family During planning meetings, health-care providers must spend time with the person to come to know them and understand their life context from their perspective. This collaboration supports the identification of actual and potential health-care needs. Health-care providers must partner with the person to identify their priorities and goals for care; be empowering; and act as a resource, providing information on the available evidence-based care options that align with the person’s strengths, life circumstances, beliefs, needs, values, and preferences. (CNO, 2014b; Conway et al., 2006; Frampton et al., 2008; Grant et al., 2013; National Research Corporation Canada, 2014; NICE, 2012, 2014; RNAO, 2002, 2006a; Robinson et al., 2008) A narrative review of randomized controlled trials identified that using open-ended questions, providing information, and responding positively to the person is empowering and helps health-care providers assist the person to explore their experience, goals, and preferences for health care. (Smith, Dwamena, Grover, Coffey, & Frankel, 2011) Managing Health and Culture All people can struggle with the challenges of managing their health, so nurses have a role to play in ensuring the person gains the knowledge, skills, and behaviours (health literacy) necessary for self- management. Health Literacy Health literacy, which is related to a person’s ability to self-manage their care, means that the person can access, understand, appraise, and apply health information when making decisions, and has the ability or supports required to overcome relational, cognitive, affective, physical, psychological, and social barriers (language, cultural, spiritual, symbolic, and life experiences) that interfere with their ability to self-manage their care. Professional Development Healthcare providers should participate in professional development opportunities that support the development of their knowledge and ability to apply person- and family-centred-care attributes in practice. Professional Development and Understanding Culture Healthcare providers should participate in the following types of professional development opportunities: Establishing therapeutic relationships and empowering partnerships based on trust, sympathetic presence, and respect; Using effective verbal and non-verbal communication that is complete, unbiased, and affirming; Facilitating the timing and continuity of care; Addressing the whole person’s needs and priorities for care, not just their disease; Incorporating the person’s knowledge, values, beliefs, and cultural background into the planning and delivery of care; Collaborating with the person and promoting their involvement in care through shared decision making; and Providing free-flowing information 6 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Culture and Healthcare: When medicine and culture intersect The Canadian Medical Protective Association (CMPA): https://www.youtube.com/watch?v=c0TquroTHxo REFERENCE: Albougami, Abdulrhman Saad. “Comparison of Four Cultural Competence Models in Transcultural Nursing: A Discussion Paper.” International Archives of Nursing and Health Care, vol. 2, no. 4, 2016, doi:10.23937/2469-5823/1510053. https://clinmedjournals.org/articles/ianhc/international-archives-of- nursing-and-health-care-ianhc-2-053.php?jid=ianhc Transcultural Nursing Transcultural nursing has been integrated into modern nursing education due to the increased heterogeneity of patient populations. As more people from a variety of cultures and with a variety of ethnicities now utilize healthcare facilities, nurses need to be aware of their varying perceptions and levels of tolerance for healthcare. Introduction to Cultural Competence Models Nurses should have sufficient information about different cultural backgrounds and customs to be able to conduct holistic patient assessments. Researchers have developed models to help nurses overcome challenges when caring for culturally diverse patients. These models were designed to encourage culturally appropriate and culturally competent care, and the developers of the models emphasize how nurses can use this skill to work effectively with any population. The importance of culture in care planning Culture care emphasizes consideration of a patient’s beliefs and heritage when developing a healthcare plan. It requires nurses to acknowledge that individuals belong to different cultures and races and, therefore, necessitating treatment that respects the uniqueness of each individual. Transcultural nursing employs the concepts of ethnicity, race, and culture in order to understand individuals’ perceptions and behaviors. The influence of culture in care planning Culture refers to a set of beliefs, assumptions, values, and norms that a group of individuals largely observe and transfer across generations. Culture affects the beliefs, values, norms, and behaviors of individuals, and it is reflected in language, food, dress, and social institutions. Culture can significantly affect various aspects of human life, including health and preferences for managing health conditions. Cultural Competence Cultural competence refers to a set of culturally congruent practices, behaviors, and policies that allow nursing professionals to deliver high-quality services in a variety of cross-cultural scenarios. 7 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Expectations of Healthcare Professionals Healthcare professionals, especially nurses, should try to understand and learn about different cultures.” Understanding a patient's religious and cultural background can be highly beneficial in delivering healthcare. Introduction to the Leininger Sunrise Model Describes the relationship between anthropological and nursing beliefs and principles; Nurses use this model when making cultural evaluations of patients. The model encompasses numerous aspects of culture: religious, financial, social, technological, educational, legal, political, and philosophical dimensions. The nursing profession considers patients' physical, spiritual, and cultural needs. A thorough understanding of these needs facilitates the achievement of desired clinical outcomes. Leininger's model helps healthcare professionals to avoid the stereotyping of patients. 3 Culture Care Concepts Cultural Preservation refers to nurses' provision of support for cultural practices. Cultural Negotiation refers to the support provided to the patients and their family members in carrying out cultural activities that do not pose threats to the health of the patients or any other individual in the healthcare setting. Cultural Restructuring refers to nurses' efforts to deliver patient-centered care by helping patients modify or change their cultural activities. Cultural restructuring is suggested only when certain cultural practices may cause harm to the patient or those in the surrounding environment. Leininger Theory JMU - Heather Savage: https://www.youtube.com/watch?v=_kgShx2FTJ8 Giger & Davidhizar’s Transcultural Assessment Model This model emphasizes the importance of considering every person as unique in his or her culture. There are six dimensions common to every culture: Communication Space Social Organization Time Environmental Control Biological Orientation 8 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES 6 Common Culture Dimensions 1. Communication Holistic process of human interaction and conduct. The use and preservation of communication takes several forms—verbal, nonverbal, and written— and differs in terms of expression, language and dialect, voice tone and volume, context, emotional implication, facial expression, gestures, and body language. Language can become a barrier to quality healthcare due to simple misunderstandings and failure to communicate as intended. 2. Space The distance maintained between interacting individuals; this “personal space” differs according to individuals' cultural backgrounds. The concept of space involves three other behavioral patterns: attachment with objects in the environment, body posture, and movement in the setting. It is important to observe tact and to avoid overstepping boundaries with respect to these aspects of interaction, because doing so can cause patients unnecessary anxiety. 3. Social Organization How certain cultures group themselves in accordance with family, beliefs, and duties. This dimension requires nurses to remain aware that patient conduct can be influenced by factors like sexual orientation, acknowledgement and utilization of titles, and decision-making regulations. An awareness of this dimension can help nurses avoid being perceived as being derogatory or disrespectful. 4. Time Time is subdivided into whether the group is clock-oriented, like most Westerners, or socially oriented. The clock-oriented group is fixated on time itself, and individuals with this orientation seek to keep appointments so as not to be seen as ill-mannered or offensive. The behavior of socially oriented groups emphasizes the here and now. Such individuals understand time as a flexible spectrum defined by the duration of activities; an activity does not begin until the preceding event has ended. 5. Environmental Control Implicates how the person perceives society and its internal and external factors, such as beliefs and understandings regarding how illness occurs, how it should be treated, and how health is uplifted and maintained 6. Biological Orientation Races vary biologically due to differences in DNA, and some races are more prone to certain diseases than others. What is culturally competent healthcare? Towson University: https://www.youtube.com/watch?v=E4k8YWqkjqo 9 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Purnell Model for Cultural Competence Provides a foundation for understanding the various attributes of a different culture, allowing nurses to adequately view patient attributes, such as incitement, experiences, and notions about healthcare and illness. This model is presented in a diagram with parallel circles that represent aspects of global society as well as the community, family, and person. The Purnell model includes twelve domains: overview or heritage, communication, family roles and organization, workforce issues, bio-cultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, healthcare practices, and healthcare professionals. The 12 Domains 1. Culture and Heritage: Geographical influence of the original and present home, political affairs, economics, educational status, and profession. 2. Communication: Primary language and dialects, circumstantial effectiveness and convenience of the language, paralinguistic differences, and nonverbal communication. 3. Family Roles and Organization: Who heads the household. The organization of the family is affected by goals and priorities, developmental tasks, social status, and alternative lifestyles. 4. Workforce Issues: Autonomy, and the presence of language barriers. 5. Bio-cultural Ecology: Observable differences with respect to ethnic and racial origins. 6. High-risk Behaviors: Using tobacco, alcohol, or recreational drugs. 7. Nutrition: Certain foods have meaning in cultures. Food consumption associated with rituals may affect health. Some ethnic groups suffer from certain nutritional limitations and deficiencies. 8. Pregnancy: The act of birthing and the postpartum period involve certain practices that need to be taken into consideration when dealing with a particular ethno-cultural group. 9. Death Rituals: Perceptions of death differ from culture to culture in terms of how death is accepted, what rituals are performed, and how one should behave following a death. 10. Spirituality: Religious practice, use of prayer, individual strength, the meaning of life, and how spirituality relates to health. 11. Healthcare Practices: Healthcare practices include traditional practices, religious practices, chronic-disease treatment and rehabilitation, mental-health practices, and the roles of the sick. 12. Healthcare Professionals: Perceptions and roles of traditional and folk healthcare practices. Purnell's Cultural Domains Shadwige: https://www.youtube.com/watch?v=We48h5Z8Jqk Campinha–Bacote Model of Cultural Competence Cultural competence is a process in which the nurse attempts to achieve greater efficiency and the ability to work in a culturally diverse environment while caring for the patient, whether an individual, a family, or a group. To achieve cultural competence, a nurse must undertake a process of developing the capacity to deliver efficient and high-quality care, a process that encompasses five components. 10 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The 5 Components 1. Cultural Awareness: Healthcare professionals consciously acknowledge their own cultural backgrounds, which helps them avoid biases toward other cultures. 2. Cultural Skill: Ability to obtain the necessary information from patients via culturally-appropriate conduct and physical assessment. 3. Cultural Knowledge: Healthcare professionals open their minds to understand variations in cultural and ethnic traits as they relate to patient attitudes toward illness and health. 4. Cultural Encounter: Stereotyping is avoided through the interaction between healthcare professionals and members of different cultures. During this process, overreliance on conventional views is discouraged. 5. Cultural Desire: The driving force for becoming educated, skilled, competent, and aware of culture. Cultural Competency at Rutgers University Behavioural Health Care University Behavioral Health Care - Rutgers Health: https://www.youtube.com/watch?v=c-h1ZuRXBpg REFERENCE: Wilmot, Stephen. “Cultural Rights and First Nations Health Care in Canada.” Health and human rights vol. 20,1 (2018): 283-293. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039741/ UN Universal Declaration of Human Rights The UN Universal Declaration of Human Rights states that everyone has the right to participate freely in the cultural life of the community. ICESCR The International Covenant on Economic, Social and Cultural Rights (ICESCR) identifies a right to take part in cultural life and notes the obligation of governments to promote this. This is elaborated in General Comment 14 and 21, where indigenous peoples right to culturally appropriate health care and to their specific cultural heritage, respectively, are identified. DRIPS Also, in the UN Declaration of the Rights of Indigenous Peoples (DRIPS), 15 of the 45 articles assert the right to retention, protection, and continued practice of indigenous cultures.4 Canada is a party to all these documents. 11 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES DAY 3: PERSONAL AND PROFESSIONAL BIASES REFERENCE: Aronson, Joshua et al. “Unhealthy interactions: the role of stereotype threat in health disparities.” American journal of public health vol. 103,1 (2013): 50-6. doi:10.2105/AJPH.2012.300828. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518353/ Stereotype Threat Interactions between patients and health care providers may induce stereotype threat, a phenomenon shown by extensive psychological research to generate negative effects in interpersonal contexts, including the classroom and the workplace. First identified by Steele and Aronson in 1995, stereotype threat can be defined as a disruptive psychological state that people experience when they feel at risk for confirming a negative stereotype associated with their social identity—their race, gender, ethnicity, social class, sexual orientation, and so on. Unintended Bias It is important to recognize that whether or not health care providers explicitly hold or endorse stereotypes about members of disadvantaged groups, they, like anyone in the culture, are aware of common negative stereotypes. Because of this, they are capable of unintended, nonverbal bias in their interactions with their patients that, for the patient, can be a cue that confirms the relevance of the stereotype. Research confirms that health care providers stereotype their patients and that patients sense this bias and, as a result, feel dissatisfied with the care they receive. Effects of Stereotype Threat The experience of stereotype threat has been shown to have direct negative effects on physiological, psychological, and self-regulatory processes that can contribute to ill health. For example, laboratory experiments find that stereotype threat elevates blood pressure, induces anxiety, and increases aggressive behavior, overeating, and a host of other failures of self- regulation. The importance of such direct effects is clear, but stereotype threat also poses risks that may be less obvious, by complicating social interactions and relationships between patients and their providers. Stereotype Threat as a Dangerous Obstacle To receive proper care, patients must seek it. Yet if stereotype threat creates an unpleasant social climate, patients may avoid their providers. Minority group members who perceive discrimination and report higher levels of mistrust are the patients most likely to miss medical appointments and delay needed or preventive medical care.” The implications are self-evident: if minority patients avoid interacting with health care providers, they place themselves at risk for failing to arrest medical conditions before they become serious, and they will be less likely to receive appropriate care. 12 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Communication Challenges in communicating may negatively impact the care of those that feel they are stereotyped. Providers need to know medical histories, habits, and symptoms to offer the most appropriate course of treatment. If a patient is experiencing stereotype threat, communication can be compromised in several ways. Discomfort can compromise a caregiver’s ability to provide and obtain information critical to the patient’s treatment. Stereotype threat reliably induces arousal and anxiety, which impair cognitive performance and working memory. This can compromise the communication process; minority patients may ineffectively communicate important information to providers or fail to understand and remember the content of important conversations. History Taking Stereotype threat may influence what patients share with their providers. Studies show that worries about confirming stereotypes significantly influence how individuals present themselves. One can well imagine that patients who feel at risk for devaluation might not truthfully disclose pertinent information, say, about exercise or dietary habits, if that information casts them in a negative, stereotype-confirming light. Stereotype threat may also help explain why clinical interactions appear to be of lower quality when they occur across racial lines—why they are of shorter duration, are less pleasant, and are characterized by less patient involvement and shared decision-making. Poor communication and less participation in decision-making predict a variety of negative outcomes, such as poor adherence to treatment, utilization of services, self-management, and recovery. The Vicious Cycle Although tensions may arise from situational forces such as stereotype threat, people are apt to lay the blame for unpleasant interactions on their interaction partners. Patients may characterize their providers as prejudiced, which will likely further erode trust and warmth and increase the likelihood of avoidance behaviors. For providers, unpleasant, strained interactions and their effects on patient behavior may reinforce unflattering racial stereotypes. Both of these effects can perpetuate a vicious cycle, whereby contact serves to degrade the quality of the patient–provider relationship. 13 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Impacts on the treatment plan Likely than others to adhere to prescribed treatment plans. First, if the patient fails to adequately process information because an interaction arouses anxiety, he or she may misunderstand the nature or the importance of recommendations, or, alternatively, have difficulty later recalling vital information. In addition to suffering impaired performance on tests, participants in experiments on stereotype threat exhibit significantly worse recall for words presented during a task if a stereotype was activated during a testing session, presumably because they were devoting cognitive resources to contending with stereotype threat. Second, because stereotype threat engenders mistrust, minority patients may hear, understand, and recall information and feedback, yet discount it because it is seen as biased or threatening. REFERENCE: Northon M.A., Lindsay. “Become Aware of Personal Bias, and You'll Improve Ethical Practice.” SHRM, Society for Human Resource Management, 16 Aug. 2019, www. https://www.shrm.org/resourcesandtools/hr- topics/behavioral-competencies/ethical-practice/pages/become-aware-of-personal-bias-and-improve-ethical- practice-.aspx. Personal Biases To have personal biases is to be human. We all hold our own subjective world views and are influenced and shaped by our experiences, beliefs, values, education, family, friends, peers, and others. Being aware of one's biases is vital to both personal well-being and professional success. The importance of self-awareness People with a high degree of self-awareness are likely to be more adept in one of the most critical competencies for HR professionals, Ethical Practice. When you realize what your personal triggers are—triggers that contribute to the creation of personal biases—you can actively manage, mitigate, or avoid them. In the workplace, developing self-awareness helps you navigate potential obstacles to career success. The ultimate goal is to achieve happiness through building and maintaining healthy relationships. Tips for assessing your personal bias Test yourself. There are several psychometric tests to choose from, including the Myers-Briggs Type Indicator, the Big Five, the Predictive Index or the Strengths Finder. These tests help you understand how you perceive people and situations. Get regular feedback from colleagues—formal or informal. Pause and reflect. Study yourself and your reactions. How do you react to change? What do you feel when something doesn't go the way you expected it to? Take notes. Expand your horizons. Proactively look for new experiences to discover more about yourself and your reactions to unfamiliar situations. Learn to know yourself. This may be the most challenging but find time for solitude and to relax. It's amazing what you learn about yourself when you sit with your thoughts. Meditate. 14 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: Jada, Umamaheswararao, et al. “Emotional Intelligence, Diversity, and Organizational Performance: Linkages and Theoretical Approaches for an Emerging Field.” Jindal Journal of Business Research, vol. 3, no. 1-2, 2014, pp. 46–57., doi:10.1177/2278682115627240. https://www.researchgate.net/publication/293639896_Emotional_Intelligence_Diversity_and_Organizational_Per formance_Linkages_and_Theoretical_Approaches_for_an_Emerging_Field An Introduction to Diversity in the Workplace Workplace diversity is getting attention of scholars across the globe. Business organizations are going global to spread its presence through diversity to maximize its revenues. The term diversity may sound simple, but it is a combination of holding and managing the aspirations of people from different cultures, race, gender, age, skill, cognitive style, group, education, background etc. (Kenely, 2000; Perry, 1997). To confront this kind of challenges, understanding and appreciating each individual’s emotions is of paramount in work settings. The Role of Emotional Intelligence It is assumed that to manage the emotions of a diversified workforce a professional irrespective of position and hierarchy need to be emotionally intelligent. Studies have found that line managers with sound emotional intelligence (EI) skills encourage the workforce in the organization to create healthy environment such that organization can prosper and be able to withstand the competition in the global market. More About Emotional Intelligence Previously emotions were ignored while studying organization behavior but latter on it was found that employee’s emotions are playing significant role in the organization. Therefore, the term of “emotional intelligence” discovered by Salovey and Mayer (1990) has defined as a type of intelligence that provides capabilities to control or monitor others feeling as well as employee emotions. This facilitates the information gathered in order to guide one’s thinking and action. Therefore, EI is involved in the capacity to perceive emotions, assimilate emotion-related feelings, understand the information of those emotions, and manage them. It is often measured as EI quotient (EQ) which includes the ability to perceive emotions, to access and generate emotion so as to assist thought, to understand emotions and emotional knowledge and to reflectively regulate emotions so as to promote emotional and intellectual growth. Lack of EI use to open door to conflicts in the organization whereas organizations catering diverse workforce when a single conflict arises and if it cannot be controlled instantaneously number of other consequences will add up. In order to control impact of conflicts on organization, manager or leader should be focused on handling and it can be possible when a leader is having good EI skills. “EI skills have been divided into four categories: self-awareness, self-management, social awareness, and relationship management”. 15 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES 4 Categories of EI Skills 1. Self-Awareness When strong negative emotions are triggered, the limbic system within the brain is activated, obstructing functions of the brain and putting the individual in a potentially volatile, reactive state. High EQ people working in a diversified organization recognize this and learn to neutralize their internal, automatic reactions. They proceed with caution, keeping their reactions in check. Low EQ people, on the other hand, get externally focused on the person or situation due to which the problem has been caused and allow their reactions to hijack their behavior. Recognizing and identifying one’s own reactions is first set and is essential for enabling self- management skills. 2. Self-Management The skill set that enables one to exert conscious control over one’s behavior in a situation where the reactions could sabotage the outcome that one want to achieve. In a diversified environment, high EQ people have the ability to explore possible strategies to achieve whatever outcome they want. 3. Social Awareness Low EQ people tend to make false assumptions in the heat of emotion. They often assume that there is a negative intent behind the behavior of others. High EQ people turn it to others and are capable of establishing empathy and look for positive intentions behind negative behavior. 4. Relationship Management In a diversified environment low EQ people often lose their patience when they get to be emotionally charged up. They are likely to react in the heat of the moment, with destructive behavior that undermines their future relationship with that person. High EQ people remain aware of the fact that how they interact in the present time is going to determine the relationships in the future. 16 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: Asare, Janice Gassam. “Empathy: The Key To A Diverse And Inclusive Workplace.” Forbes, Forbes Magazine, 25 Sept. 2018, www.forbes.com/sites/janicegassam/2018/09/25/empathy-the-key-to-a-diverse-and- inclusive-workplace/?sh=6cd882707097. The Role of Empathy in an Inclusive and Diverse Workplace When trying to foster a workplace that is equitable and inclusive for all, it is imperative for leaders to be well-trained in inclusive strategies. Empathy is a foundational trait that great leaders are seen to possess. Empathy is our ability to put ourselves in the shoes of others and to understand what another person is experiencing. Leaders that are more empathetic may be more effective at fostering diverse and inclusive workplaces. The Importance of Empathy in the Workplace KnowledgeAccess: https://www.youtube.com/watch?v=qjxdU6nvsc4 DAY 4: Professional Obligations Editor. Culturally Sensitive Care, College of Nurses of Ontario, 13 Dec. 2018, www.cno.org/en/learn-about- standards-guidelines/educational-tools/ask-practice/culturally-sensitive-care/. Culturally Sensitive Care Providing culturally sensitive care is an important component of patient-centered care. Health care professionals must strive to enhance their ability to provide patient-centered care by reflecting on how their and the patient’s culture’s, values, and beliefs impact the nurse-patient relationship. It is imperative that the health care provider understand how bio-psychosocial needs and cultural background relate to health care needs. 17 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Scenario 1: Treatment by Spiritual Healer My patient decided on a treatment to be performed by his spiritual healer. I believe my patient’s choice of treatment poses a risk to his well-being. What is my role as a nurse in this situation and how do I facilitate patient choice? Considerations Values important in providing nursing care include patient well-being and patient choice. o Accountable to listen to, understand, and respect patients’ values, opinions, needs, and ethno-cultural beliefs. o By integrating these elements into the care plan, you are supporting patients’ by meeting their specific health goals. Accountable for obtaining informed consent for proposed treatment. o Responsibility to determine the patient’s understanding of the treatment, ensure that they have the necessary information to make an informed decision, and ensure that their questions about the proposed treatment are answered. When there are concerns that a patient’s care decision negatively affects the patient: o Work with the patient to explain the choice’s associated risks, enabling the patient to make an informed decision. Encouraged to consult with the broader health care team including colleagues, the leadership team, and the treatment provider about concerns related to a proposed treatment or care plan. o Establishing collaborative relationships with other health care providers assists in the provision of patient-centred care. Strategies to Reflect on cultural beliefs and values Encouraged to reflect continually on your and your patients’ cultural beliefs and values to determine if or how they impact the care you provide. Such reflection assists in providing patient-centred, culturally sensitive care. Reflective Questions How would you describe your culture? How would you rank the following in order of importance: ethnicity, family, work, the future, diet, and religion? Do you believe your patients have the same priorities? How do these values impact your relationships with patients? Consider possible areas where cultural variations in beliefs and values frequently occur. In your role as a nurse, would the choices you make be different for yourself or someone you care about? What does your body language say about you? How might a patient from another culture interpret your body language? Could your body language be communicating something different from your words? 18 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Scenario 2: Promoting Effective Communications I work in a large metropolitan hospital’s emergency department. We receive patients from multicultural and multilingual backgrounds. How can I promote effective communication with these patients and ensure they receive the best possible care? Considerations A therapeutic nurse-patient relationship is based on meaningful communication. When communication barriers exist, you are responsible for using communication strategies and skills, so the patient is an informed partner in the care provision. Interpreters are essential when a nurse-patient language barrier exists. When using interpreters to communicate with patients, you need to obtain patient consent, be sensitive to the issues surrounding interpretation and ascertain the interpreter’s appropriateness for the particular patient situation. You also are encouraged to consult with your employer regarding organizational policies on using interpreters and work with your employer to develop policies if none are in place. You are obliged to maintain confidentiality and protect personal health information as outlined in the practice standard Confidentiality and Privacy: Personal Health Information. Interpreters, by virtue of their role, gain access to personal health information and also are bound by confidentiality. To help the patient feel comfortable with the interpreter, you should inform the patient that confidential information is shared only within the health care team. Non-verbal communication can be useful in conveying and receiving information. Techniques such as demonstration, gestures, using pictures or symbols, and written translations of information assists in communicating with the patient. You must appear open, receptive, and interested in the patient. For example, speaking clearly, making eye contact, and paying attention when the patient is speaking demonstrates respect for the patient. Achieving a common understanding requires considering how the patient perceives you or the situation and making attempts to correct any misperceptions. Scenario 3: Indigenous Community I work in an Indigenous community in northern Ontario. How can I support my patients and what resources are available to address the unique health needs of the Indigenous community? Considerations Partnering with patients and providing culturally sensitive care are important components of patient-centered care. You are accountable for discussing with your patients, your and your patient’s roles in achieving the care plan’s desired goal. You also must ensure you are sharing nursing knowledge with patients and promoting the best care possible. How culture connects to healing and recovery Fayth Parks | TEDxAugusta – TEDx Talks: https://www.youtube.com/watch?v=q9Tkb879dsY 19 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 59.) 4, Pursuing Organizational Cultural Competence. Available from: https://www.ncbi.nlm.nih.gov/books/NBK248430/ Cultural Competence at an Organizational Level A set of congruent behaviors, attitudes, and policies that enable a system, agency, or group of professionals to work effectively in multicultural environments. A dynamic, ongoing process; it is not something that is achieved once and is then complete. Organizational structures and components change. The commitment to increase cultural competence must also involve a commitment to maintain it through periodic reassessments and adjustments. Diversity is an Asset Cultural competence does not occur by accident. The organization must first view diversity as an asset. The organization must ensure that its process of developing cultural competence has the genuine, full, and lasting support of the organization's leadership. A strong mandate from the board or CEO, coupled with a commitment to provide resources, can be a good motivator for staff and committees to undertake major organizational change. Support of cultural competence must be made clear throughout the organization and community in meaningful ways, in words and actions. The Role of Leadership Leadership can make a difference in the implementation of culturally responsive practices by creating an organizational climate that encourages and supports such practices. Discuss the importance of cultural competence Try new practices or approaches Tolerate the uncertainty that accompanies transitional periods during which practices and procedures are evolving Respond to unforeseen barriers Revise innovations that are not working as intended. A strong commitment to improving organizational cultural competence should include the obligation to monitor procedures after they have been implemented, maintain, and re-evaluate new practices, and provide resources and opportunities for ongoing training and culturally competent supervision. Vision, Mission and Value Statements…Questions Are stakeholders involved in the development process? In what ways does the organization ensure that its values and mission reflect the community and populations that it serves? Does the organization see this task as a singular event, or has it planned for periodic review of its values and mission to ensure continued organizational responsiveness as needs, populations, or environments change? 20 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Vision, Mission and Value Statement The planning committee should determine how the culture of the organization as well as the surrounding community can support achievement of the mission and vision statements. Culturally responsive organizational statements cannot provide a tangible framework unless supported by community, referral, and client demographics; a needs assessment; and an implementation plan. Cultural Competence in the Strategic Planning Process The strategic planning process provides an opportunity to re-evaluate an agency's values, mission, and vision regarding cultural competence. A comprehensive process involves evaluating the organization's internal and external environments prior to holding planning meetings; this evaluation involves conducting staff, client, and community assessments. From assessing current needs to evaluating global factors that influence the direction and delivery of services (e.g., funding sources, treatment mandates, changes in health insurance), organizations can begin to gain insight into the demands and challenges of providing culturally responsive services. Moreover, strategic planning is an opportunity to explore and develop short- and long-term goals that focus on incorporating culturally responsive delivery systems while addressing issues of sustainability. Assign a Senior Manager A senior staff member with the authority to implement change should be assigned to oversee the developmental process of planning, evaluating, and implementing culturally responsive administrative and clinical services. Key responsibilities include the ongoing development and facilitation of cultural competence committees and advisory boards, management of evaluative processes, facilitation of the development of a cultural competence plan and its implementation, and oversight of policies and procedures to ensure cultural competence within the organization and among staff. Develop Culturally Competent Governing and Advisory Boards It is vital that executive staff members on governing and advisory boards and committees are educated about and invested in the organization's mission and plan. The organization should establish a community advisory board that includes stakeholders, specialists, and/or experts in multicultural behavioral health services along with key administrators and staff. This advisory board should consist of local community members from whom the organization can solicit valuable advice, input, and potential support for the development of culturally responsive treatment. Representation should include clients, alumni, family members, and community-based organizations and institutions. 21 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Establish a Cultural Competence Committee By creating a committee within the organization to guide the process of becoming culturally competent and responsive, the organization ensures that a core group will provide oversight and direction. Should draw from all levels of the organization. Representatives of the advisory board should also be included. Program administrators should provide direction to the cultural competence committee. The person assigned to take the lead on cultural competence should chair the committee, and the CEO should be noticeably involved. The cultural competence committee will oversee the organization's self-assessment process while also creating the demographic profile of the organization's community, developing a cultural competence plan, and formulating and monitoring procedures that evaluate the implementation and effectiveness of the organization's plan in developing culturally responsive services and practices. The committee should ensure that the organization's plans are continually updated. To succeed, this team must be empowered to influence, formulate, implement, and enforce initiatives on all levels and throughout every department of the organization. How Administrators are able to engage Communities Ask board members to help recruit key members of the local community. Create a community advisory group to complement the governing boards in assessing and recommending culturally responsive policies, procedures, and practices. Facilitate local community focus groups to discuss key treatment needs, health beliefs, and attitudes and behaviors related to substance use and mental illness. Develop a policy that supports the use of culturally congruent communication modalities and technologies for sharing information with communities. Provide professional development activities that focus on strengthening skills for collaboration with culturally and linguistically diverse communities. Develop policies and procedures to support community involvement in the treatment setting. Develop local outreach and educational programs in multiple languages. Participate in community events to raise awareness of services, develop trust and gain knowledge of cultural groups and community practices. Regularly analyze demographic trends and populations served by the treatment organization. Clients, Staff and Community: Planning, Development, and Implementation Clients and the community should have an opportunity to provide input on how services are delivered and the types of services that are needed. Staff members are likely to have specific knowledge of client needs and to be able to identify potential obstacles or challenges in how an organization attempts to implement culturally responsive policies and procedures. A parallel process that can influence the potential success of staff involvement and commitment to the development of cultural competence is the organizational culture. The organizational climate sets the stage for staff responsiveness and motivation in developing cultural competence and in implementing culturally responsive services. 22 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Develop a Cultural Competence Plan Using demographic data and an organizational self-assessment, the organization's cultural competence committee can begin writing an organizational plan for improving cultural competence. The committee will need to assign staff members to research and write each component of the plan, which should outline specific objectives, means of achieving these objectives, and recommend timelines and processes for evaluation. A Cultural Competence Plan Should Include… Methods to enhance professional development in culturally responsive treatment services. Mechanisms for community involvement: the development of a community advisory board and cultural competence committee. Approaches to amending facility design and operations to present a culturally congruent atmosphere. Guidelines for implementation that describe roles, responsibilities, timeframes, and specific activities for each step. When developing a plan, an Administrator should: Develop a thorough knowledge and understanding of the social, cultural, and historical experiences of the community of people your agency is serving. Document, track, and evaluate/assess the reasons why clients are not accepted for services. Policies and Procedures to Ensure a Culturally Responsive Organization In essence, policies and procedures are the backbone of an organization's implementation of culturally responsive services. Monitoring and Evaluation Information must be gathered from all levels of the organization, from clients and community, and from other stakeholders. Gather demographic data from the populations that are or could be served by the agency and extending to soliciting feedback from various stakeholders, gathering information prior to plan development helps the organization provide direction and determine priorities. This evaluation and monitoring will identify effectiveness and areas where there are gaps. Create a Demographic Profile of the Community, Clientele, Staff, and Board Intake, admission, and discharge data provide a good starting point for determining the demographics of current populations. Programs would likely benefit from developing a demographic summary for each population served, consisting of age, gender, race, ethnic and cultural heritage, religion, socioeconomic status, spoken and written language preferences and capabilities, employment rates, treatment level, and health status. Gather information on the community through census data and national centers. Community demographics can provide a quick benchmark on how well an agency serves the local community and how the community is represented at all levels of the organization. 23 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The Importance of a Cultural Organizational Self-Assessment An organization must have an awareness of how it functions within the context of a multicultural environment, evaluating operational aspects of the agency as well as staff ability and competence in providing culturally congruent services to racially and ethnically diverse populations. Thorough, reliable, valid evaluations can gauge the effectiveness of an agency's services, structure, and practices (e.g., clinical services, governing practices, policy development, staff composition, and professional development) with culturally and racially diverse clients, staff, and communities. More and more, public, and private funding sources—as well as accrediting bodies—use an organization's self-assessment as a means of measuring compliance, effectiveness, or quality improvement practices. Day 5: HEALTHCARE AND DIVERSITY REFERENCE: Gaiser, Melanie Doupe, et al. “Improving Quality and Performance: Cultural Competence and Workforce Diversity Strategies.” The Institute on Assets and Social Policy, Bradeis University, Jan. 2016. https://heller.brandeis.edu/iasp/pdfs/jobs/improving-quality.pdf The Cost of Health Care and Diversity Healthcare disparities raise the overall cost of health care. If not actively addressed, a significant area of potential cost-savings will remain unchanged, impacting the healthcare system and broadly impacting community health. Example Minority women in New Hampshire are three times as likely as non-Hispanic Caucasian women to be diagnosed with cardiovascular disease. The cancer-related death rate in New Hampshire is almost twice as high for non-Hispanic Black women as it is for Caucasian women: 294 per 100,000 non-Hispanic Black women and 150 per 100,000 Caucasian women. To address variation in treatment and outcomes, government, private payers, and healthcare accrediting bodies are emphasizing the importance of cultural effectiveness. Culturally effective organizations enable, cultivate, and support the delivery of high-quality health care for all groups of people. Work in this area is already underway to address gaps in health equity in New Hampshire. Performance Measures and Cultural Competency Ambulatory care-sensitive readmissions - Avoidable emergency room visits - Length of stay measured in hours - Inappropriate test ordering Patient satisfaction scores - Number of patient complaints - Diverse employee satisfaction scores - Employee discrimination complaints Pre/post staff cultural competence training knowledge assessment scores Chart review documenting clinician behavior change Waiting time for new clinical appointments for those requiring interpreters Cost of contract interpretation services Number of in-person vs. telephone interpreter contacts 24 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Staff hiring, retention, and advancement rates Staff absenteeism Lessons from Leadership Engaging linguistically appropriate services is the best first step toward cultural effectiveness. Performance assessment during and after the implementation of cultural competence and workforce diversity interventions should be part of any planned effort. The start to a Performance Assessment Develop a common understanding of how the organization defines cultural competence, workforce diversity and inclusion, and disparity. Delineate specific desired changes, such as clinical process, clinical outcomes, employee behavior change, reduction in adverse health events, return on investment, etc. Determine process and/or outcome variables that will measure the desired changes. Design an intervention drawing on existing evidence linking cause and effect. Include culturally and linguistically diverse staff and/or external stakeholders in the planning and implementation of the intervention. REFERENCE: Embracing Cultural Diversity in Health Care: Developing Cultural Competence, https://rnao.ca/sites/rnao-ca/files/Embracing_Cultural_Diversity_in_Health_Care_- _Developing_Cultural_Competence.pdf Measuring Diversity – Concerns Measuring diversity in populations as a way to reach out to under-represented groups arouse passionate responses. Concern: belief that information collected will be used against diverse populations. Concern: information will be misused has become a default excuse for not measuring these important variables about cultural diversity. Result: these concerns have weakened the very programs intended to reach out to under-represented groups, and in turn, to develop programs that would help such groups succeed and advance in the health care system. Much of what we know about the Canadian nursing workforce (beyond age, gender, education, and employment status) is purely anecdotal in nature and based on shared experiences. Equity census within sectors such as health care is important, because unless this kind of information is collected, measures to develop and support a culturally diverse workforce could be inadequate based upon poor evidence. The most common misconception… It is illegal to ask Canadians questions about their cultural demographics, such as race, religion, physical abilities, or sexual orientation. 25 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES The facts… It is illegal for employers or universities, for example, to require that Canadians declare characteristics such as race or sexual orientation in a job application, or in an application to a school of nursing. It is completely within the rights of governments, employers, regulators, and schools to ask if nurses or nursing students wish to voluntarily declare the way they identify themselves (or not) on a range of demographic measures. Researchers are able to survey samples of citizens and ask them if they wish to declare any identifying cultural characteristics. It must be clear to those asking the questions and being asked, that refusing to answer cannot carry with it negative implications. This guideline therefore recommends that health care employers ask staff and schools of nursing ask students to provide demographic data on a voluntary basis. It similarly asks regulators to do the same for the larger nursing workforce and for employers to pay attention to the cultural make-up of its workforce. The purpose of soliciting, monitoring, and evaluating these data is to determine more correctly the actual (not presumed) cultural make-up of the nursing profession. Information will allow the identification of gaps and weaknesses (including under-represented cultural groups) and facilitate the development of appropriate recruitment and retention strategies. REFERENCE: LEADERSHIP AND INFLUENCING CHANGE IN NURSING: Diversity in Health Care Organizations, Sonia Udod and Louise Racine, https://leadershipandinfluencingchangeinnursing.pressbooks.com/chapter/chapter-2- diversity-in-health-care-organizations/ Adapting Nursing to Meet Cultural Needs Health organizations must strive to adapt nursing and health care delivery to meet the needs of a culturally diverse population. Knowing that inequities affect health outcomes, both nurses and health organizations should strive to provide quality care that will consider cultural diversity. Organizational Culture in Nursing Organizational cultural competence involves characteristics shared within an organization. Organizations must have principles and policies that will sustain nurses and other health care professionals to work effectively in diversity contexts. These organizations will value diversity, conduct self-assessment, manage dynamics of differences, acquire, and institutionalize cultural knowledge, and adapt to diversity within hiring and staffing processes. 26 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Guidelines that Support Cultural Competency at the Instructional Level knowledge of cultures education and training in culturally competent care critical reflection cross-cultural communication culturally competent practice cultural competence in health care systems and organizations patient advocacy and empowerment multicultural workforce cross-cultural leadership evidence-based practice and research About the Guidelines The guidelines delineate the critical role played by nurse managers and administrators in creating a positive and open environment for managing cultural diversity. Health care organizations must provide the tools and context for nurse leaders to support cultural competency. Need for training and education in cross-cultural communication, as well as access to linguistically adapted tools and to interpreters who can also act as cultural brokers, enabling the understanding of behaviours, attitudes, and norms about experiences of health and illness. Cultural competency also implies that organizations will be mindful of cultural diversity within their organizations. Why Culturally Competent Nursing Matters Providing culturally competent nursing care is an ethical and respectful way to acknowledge that one’s clients, families, and communities see health and illness in ways that may differ from oneself. Cultural competency is about demonstrating attitudes of openness and flexibility to enter into a meaningful dialogue with clients or families. Respect and ethical practice are the hallmarks of cultural competency. REFERENVE: Jongen, Crystal et al. “Health workforce cultural competency interventions: a systematic scoping review.” BMC health services research vol. 18,1 232. 2 Apr. 2018, doi:10.1186/s12913-018-3001-5, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879833/ Training and Development Training and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. 27 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES What we know… Health professionals play a key role in determining the nature of interactions and patient experiences when accessing health care. Cultural and linguistic differences between healthcare providers and health service users can results in significant miscommunication, as well as service user mistrust, decreased satisfaction and disempowerment. Practitioners’ increased cultural competence has been linked to increased patient satisfaction, treatment adherence and information seeking and sharing. Education and Training The general focus of cultural competence workforce interventions has been on educating and training the health workforce in the requisite and relevant knowledge, attitudes, and skills needed to effectively respond to sociocultural issues arising in clinical encounters. Cultural competence training can include understanding the central role of culture in all lives and how it shapes behaviour; respect and acceptance of cultural differences; learning to effectively utilise culturally adapted and culturally specific practices; and continuous development of ones awareness of personal cultural influences and prejudices or biases. Cultural competence training has mostly focused on developing knowledge, attitudes, awareness, and sensitivity of those working in healthcare. Cross-Cultural Approach to Education and Training Focused on teaching general knowledge, attitudes, and skills relevant to navigating any cross- cultural situation. Some of these skills … include eliciting patients’ explanatory models of health issues and their causes; strategies for negotiating shared understanding and facilitating participatory decision- making in creating treatment plans; and understanding health and illness in its biopsychosocial context. As well as being applicable in clinical encounters with patients from varied cultural and ethnic backgrounds, such approaches have the advantage of being focused on specific skills that can be applied in healthcare encounters. Positive Outcomes on the Health Workforce Positive outcomes have been reported from cultural competency interventions targeting the health workforce, particularly for practitioner outcomes. Researchers have found excellent evidence of improved practitioner knowledge and good evidence of improved practitioner attitudes and skills. Nurturing Cultural Competence in Nursing: Promising Practices for Education and Healthcare Oregon Center for Nursing: https://www.youtube.com/watch?v=JpzLzgeL2sA 28 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES DAY 6: ORGANIZATIONAL CULTURE REFERENCE: Brownlee, Kim, and Kien Lee. “Section 7. Building Culturally Competent Organizations.” Chapter 27. Working Together for Racial Justice and Inclusion | Section 7. Building Culturally Competent Organizations | Main Section | Community Tool Box, The Community Tool Box Is a Service of the Center for Community Health and Development at the University of Kansas, 2020, https://ctb.ku.edu/en/table-of-contents/culture/cultural- competence/culturally-competent-organizations/main. Role of Policies in Organizational Culture Organizations have a culture of policies, procedures, programs, and processes, and incorporate certain values, beliefs, assumptions, and customs. A culturally competent organization brings together knowledge about different groups of people – and transforms it into standards, policies, and practices. Institutionalizing Cultural Knowledge Cultural knowledge should be integrated into every facet of an organization. Policies should be responsive to cultural diversity. Adapting to Diversity Values, behaviors, attitudes, practices, policies, and structures that make it possible for cross- cultural communication guide a culturally competent organization. When you recognize, respect, and value all cultures and integrate those values into the system, culturally competent organizations can meet the needs of diverse groups. Indicators of Cultural Competence Recognizing the power and influence of culture. Understanding how each of our backgrounds affects our responses to others. Not assuming that all members of cultural groups share the same beliefs and practices. Building on the strengths and resources of each culture in an organization. Allocating resources for leadership and staff development in cultural awareness. Actively eliminating prejudice in policies and practices. Evaluating the organization's cultural competence on a regular basis. Organizational Structure and Operating Procedures Create systems that ensure equity in voice, responsibility, and visibility for all groups. Create a decision-making structure in which all cultural groups have a voice at all levels. Develop operational policies and programs that confront and challenge racism, sexism, and other forms of intolerance. 29 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: LEADERSHIP IN HEALTH CARE AND PUBLIC HEALTH: Leadership and The Promotion of Diversity in the Work Force and Beyond, Emily Feyes, https://ohiostate.pressbooks.pub/pubhhmp6615/chapter/leadership- and-the-promotion-of-diversity-in-the-work-force-and-beyond/ Diversity in the Workplace Increasing diversity is a complex issue dealing with deep seated beliefs and both implicit and explicit biases. Enhanced diversity will not be accomplished easily and requires time, planning, and a willingness to be uncomfortable. The Benefits of a diverse workplace The desire to increase diversity stems from the benefits that come along with approaching problems from different perspectives instead of through a single homogeneous lens. For health care organizations, the benefits of diversity extend into the communities in which they serve. Better health care outcomes in Minority Population Diversity in the work force has been shown to result in better healthcare outcomes in minority populations. A literature review done by The U.S. Department of Health and Human Services in 2006 found that minorities and non-English speaking patients received better healthcare when treated by workers of a similar background. The evidence reviewed attributed this to patients having a better understanding of health information discussed, increased likelihood of follow-up visits, and better interpersonal relationships with the health care provider. This study showed that increased diversity in the healthcare work force resulted in increased access to quality health care and an overall improvement in public health. The role of cultural competence In a health care setting, cultural competency is best defined as the knowledge, skills, attitudes, and behaviors required of a practitioner to provide optimal healthcare services to persons from a wide range of cultural and ethnic backgrounds (Cohen et al., 2002). Cultural competence requires that health care providers can use a completely different approach than they would for someone with a similar cultural background as they themselves have. Demonstrating cultural competence is critical in a healthcare setting, as it can play a role in decreasing health inequity. 30 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Promoting diversity through Transformational Leadership Leaders are working toward increasing the ethics and standards within themselves and their followers. Goals are clearly outlined, and leaders demonstrate the morals/values that they want to see promoted within the company. These leaders are often charismatic and able to inspire their followers to change and find their place within the new culture. Transformational leaders not only inspire their followers, but they also provide support and guidance, which is important during culture shifts. REFERENCE: “How Culture Influences Health.” Edited by Maureen Mayhew, MD Canadian Paediatric Society and Maureen Mayhew, Caring for Kids New to Canada, Canadian Paediatric Society, March 2018, https://www.kidsnewtocanada.ca/culture/influence. Culture is… Dynamic and Evolving Learned and passed on through generations Shared among those with similar beliefs Identified through language, dress, music, and practices Integrated into all aspects of an individual’s life Elements of Culture Source: “How Culture Influences Health.” Edited by Maureen Mayhew, MD Canadian Paediatric Society and Maureen Mayhew, Caring for Kids New to Canada, Canadian Paediatric Society, March 2018, https://www.kidsnewtocanada.ca/culture/influence. 31 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Impact of culture on Health Health is a cultural concept because culture frames and shapes how we perceive the world and our experiences. Along with other determinants of health and disease, culture helps to define how patients and health care providers view health and illness. Culture also helps to define… What patients and health care providers believe about the causes of disease. o For example, some patients are unaware of germ theory and may instead believe in fatalism, a djinn (in rural Afghanistan, an evil spirit that seizes infants and is responsible for tetanus-like illness), the 'evil eye', or a demon. o They may not accept a diagnosis and may even believe they cannot change the course of events. Instead, they can only accept circumstances as they unfold. Which diseases or conditions are stigmatized and why. What types of health promotion activities are practiced, recommended, or insured. In some cultures, being strong (or what Canadians would consider overweight) means having a store of energy against famine, and strong women are desirable and healthy. How illness and pain are experienced and expressed. In some cultures, stoicism is the norm, even in the face of severe pain. In other cultures, people openly express moderately painful feelings. The degree to which pain should be investigated or treated may differ. Where patients seek help, how they ask for help and, perhaps, when they make their first approach. Patient interaction with health care providers. For example, not making direct eye contact is a sign of respect in many cultures, but a care provider may wonder if the same behaviour means her patient is depressed. The degree of understanding and compliance with treatment options recommended by health care providers who do not share their cultural beliefs. Culture impacts Acceptance Acceptance of a diagnosis, including who should be told, when and how. Acceptance of preventive or health promotion measures (e.g., vaccines, prenatal care, birth control). Culture impacts Perceptions Perception of the amount of control individuals have in preventing and controlling disease. Perceptions of death, dying and who should be involved. Perceptions of youth and aging. Culture impacts Communication Use of direct versus indirect communication. Eye contact gives various messages in different cultures. Willingness to discuss symptoms with a health care provider, or with an interpreter being present. Culture impacts Family Dynamics Influence of family dynamics, including traditional gender roles, responsibilities, and family support. 32 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES What should health professionals do? Health care providers are more likely to have positive interactions with patients and provide better care if they understand what distinguishes their patients’ cultural values, beliefs, and practices from their own. Suggestions Consider how your own cultural beliefs, values and behaviours may affect interactions with patients. Respect, understand, and work with differing cultural perceptions of effective or appropriate treatment. Document how your patients like to receive health care. Where needed, arrange for an appropriate interpreter. Listen carefully to your patients and confirm that you have understood their messages. Make sure you understand how the patient understands his or her own health or illness. Recognize that families may use complementary and alternative therapies. Try to ‘locate’ the patient in the process of adapting to Canadian culture. Assess their support system. What are their language skills? Negotiate a treatment plan based on shared understanding and agreement. Providing health care to different cultural groups Health care providers should learn skills around cultural competence and patient-centred care. Such skills can be a compass for exploring, respecting, and using cultural similarities and differences to improve quality of care and patient outcomes. Cultures are dynamic. There is huge diversity within any culture. Even when you think you understand one culture, it will have evolved, or you will have identified exceptions. Cultural Sensitivity in Healthcare Brianne LaDuke: https://www.youtube.com/watch?v=VwLP4mD3qyI DAY 7: EVIDENCE AND DIVERSITY STRATEGIES What is the link between Patient Safety and Cultural Competence? Gaiser, Melanie Doupe, et al. “Improving Quality and Performance: Cultural Competence and Workforce Diversity Strategies.” The Institute on Assets and Social Policy, Bradeis University, Jan. 2016. https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety What are the stats? Disparities in healthcare extend to the patient safety arena. For example, a study that looked at hospitals across the country found that patients with limited English proficiency were more likely to be harmed than their English-proficient counterparts when they experienced adverse events, and that harm was more likely to be severe. 33 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES What are the safety events? diagnostics errors, missed screenings, unexpected negative responses to medication, harmful treatment interactions from simultaneous use of traditional medicines, healthcare-associated infections, adverse birth outcomes, inappropriate care transitions, and inadequate patient adherence to provider recommendations and follow-up visits. What about patient engagement? Cultural and linguistic competence strategies, such as provision of language assistance and the use of cultural brokers, can promote effective communication with diverse patients that is critical to engage them as collaborative partners in their care. We can improve patient safety by improving cultural competence in health care. Language Support A strategy to overcome language barriers Bilingual clinicians and staff and qualified foreign language and American Sign Language interpreters. Successful language assistance relies on the adequacy of the supply of interpreter services, policies on using them, and training on how to access and work with interpreters. What is the role of a Cultural Broker? Cultural brokerage is the mediation between the traditional health beliefs and practices of a patient’s culture and the healthcare system. Interpreters, community health workers, and patient navigators can play the role of a cultural broker by providing context and by serving as a partner for both the patient and provider. Cultural brokers must be knowledgeable about the cultural group they serve and be able to successfully navigate the healthcare system. An individual acting as a cultural broker should be a trusted and respected member of the community but does not need to be healthcare professionals. Cultural Competence Training Cultural competence training programs aim to increase cultural awareness, knowledge, and skills, leading to behavior change. Training has positive impacts on provider outcomes, but as a standalone strategy training may be insufficient to improve patient outcomes without concurrent systemic and organizational changes. 34 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: Vanderbroeck, Paul, and Jean-Blaise Wasserfallen. “Managing Gender Diversity in Healthcare: Getting It Right.” Leadership in Health Services, vol. 30, no. 1, 2017, pp. 92–100., doi:10.1108/lhs-01-2016-0002. https://www.researchgate.net/publication/313361762_Managing_gender_diversity_in_healthcare_getting_it_rig ht What does diversity look like in the workplace? Patient treatment and care are increasingly the result of work done in teams that bring together different professions, each with their own approach to care and decision-making and each with their own professional culture. Second, diversity is a result of external demographic developments, notably the rise in the number of women and immigrants in health care, as well as the entrance of the millennials (Generation Y), into the workforce. Each of these populations brings its own and different expectations, behaviors, and values to work. What does diversity look like? The degree to which there are differences between group members. Diversity in groups and organizations is complex. Diversity, therefore, is the experienced and perceived social identity of an individual in the workplace, resulting from individual differences. Foundation for a Diverse Team The key success factor appears to be group dynamics. Such dynamics in a team can be influenced positively and negatively by diversity. Diversity, by definition, leads to conflict. If it causes interpersonal conflict, such as. emotional, diversity has a negative impact on group dynamics, which brings down the performance in a team. Only if diversity causes a cognitive conflict, for example, competing ideas, it has the beneficial effect on team performance, by positively influencing group dynamics. Under these circumstances, the combination of higher creativity and positive collaboration makes a diverse team more productive than a non-diverse team. Example of the pros and cons of diversity German research shows that diversity in hospital boards makes communication more difficult and conflict more likely. On the other hand, diversity provides a stimulus for change and makes a board more open-minded. Key to developing a diverse team. Why do some diverse teams get into a negative spiral and others do not? The difference is leadership. Leadership is the critical factor to make multicultural or cross-functional teams more productive. The same applies to gender: gender-balanced teams are more productive than all male or all female teams, provided there is effective management. Highly productive teams are well led. Effective team leaders prevent and reduce emotional conflict and stimulate cognitive conflict. 35 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES REFERENCE: Richmond, C.A.M., Cook, C. Creating conditions for Canadian aboriginal health equity: the promise of healthy public policy. Public Health Rev 37, 2 (2016). https://doi.org/10.1186/s40985-016-0016-5 Aboriginal Health Equity In spite of the important conceptual development of healthy public policy at the global level, there is a distinct absence of Canadian public policy supporting Aboriginal health and well-being at the national and provincial levels. In the last half century there has been an increase in life expectancy for Canada’s Aboriginal population and a considerable reduction in infant mortality. There remains a high incidence of chronic and infectious disease paired with severely inadequate approaches for addressing the social determinants of Aboriginal health. The Indian Act of 1876 The only active national-level legislation specific to First Nations people is the Indian Act of 1876, which gave responsibility of health and health care for First Nations to the federal government. Many claim that the Indian Act has served to perpetuate health inequity, as well as racism and gender discrimination. A History of the Indian Act Prior to colonization, Indigenous societies could be described as subsistence cultures, meaning that their diet, daily nourishment, and medicines were provided by the resources of their local ecosystems. At the most basic level, it was these distinct knowledge systems – practiced by individuals, families, and communities over time immemorial – that seeded the roots for Indigenous societies to flourish in their social, political, cultural, economic, and spiritual systems. The Impact of Colonization During the colonization of Canada, clashing philosophical understandings about development, religion, and land ownership – among many other ways of knowing the world – between Indigenous people and new settlers created a number of challenges for the developmental agenda of the new nation. As early as 1867, the federal government of Canada was given constitutional responsibility for ‘Indian Affairs,’ under the Constitution Act. This mandated the federal government with the unilateral responsibility for all matters relating to Indians and Indian lands. From 1871 to 1921, several treaties were signed between Indian people and the Crown; in exchange for land for new settlers and the nation state, these treaties established the rights of Indians to a number of provisions including such things as reserve lands, farming equipment and animals, annual payments, ammunition, clothing, and certain rights to hunt and fish. 36 HCL202 Cultural Competence for Health Care Professionals—STUDENT NOTES Assumptions of the Indian Act In 1876 the Indian Act was legislated with goal of ‘civilizing the Indians,’ and created under the assumption that Aboriginal people and their ways of living were inferior, unequal, and uncivilized. The Indian Act included provisions that extended across the social, cultural, economic, political, gender and even spiritual dimensions of Indian life. It imposed religious and education systems, formal ownership of lands, and permanent settlement on lands reserved for Indians, foreign systems of government, mandated participation in foreign systems of wage labour and employment and encouraged Aboriginal people to relinquish their Aboriginal status and treaty rights. What about the speech in 1920? The measures enacted through the Indian Act were part of a coherent set of structures put in place to eliminate Aboriginal people as distinct peoples and to assimilate them into the Canadian mainstream against their will. Deputy Minister of Indian Affairs Duncan Campbell Scott outlined the goals of that policy in 1920, when he told a parliamentary committee that our objective is to continue until there is not a single Indian in Canada that has not been absorbed into the body politic. These colonial structures set the stage for a debilitating, systemic public policy that continues, in the modern day, to powerfully shape patterns of Aboriginal health, social inequity and access to health care and other services. Contemporary Patterns of Aboriginal Health Under the Constitution Act, 1982, the Aboriginal Population of Canada is composed of three legally identified groups: Indian, Inuit and Métis. Aboriginal Canada’s demographic profileFootnote3 reflects a young, quickly growing population, characterized by high birth rate and low life expectancy. Canada’s Aboriginal population is growing faster than the general

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