Demonstrating Cultural Competence:

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Demonstrating Cultural Competence
How can I demonstrate it if I dont know what it
looks like or why I need to?

• Jorge Orozco PT, NCS
• Rancho Los Amigos National Rehabilitation Center
• jorozco_at_dhs.co.la.ca.us

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What does it look like?Organizational,
Academic, Research, Clinical
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Cultural Competence

• Enigmatic
• Difficult to define

Politics, Religion
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Cultural Competence
a set of cultural behaviors and attitudes
integrated into the practice methods of a system,
agency, or its professionals, that enables them
to work effectively in cross cultural situations
DHHS 2001
e.g. clinical expertise
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Cultural Competence

• Progress from Cultural Awareness, Cultural
  Sensitivity- Knowledge based
• To Cultural Competence- Action Based
• Challenge remains to demystify and operationalize
  (action focused) cultural competence in PT.

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Current Physical Therapy Analysis
CLINICAL SKILLS EXPERTISE
CULTURAL COMPETENCE (conceptual)
QUALITY CLINICAL OUTCOMES
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(Vision) Physical Therapy Analysis
CLINICAL SKILLS EXPERTISE (includes
skills/operationalized cultural competence)
QUALITY CLINICAL OUTCOMES
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Examples Clinical Skills Related to Cultural
Competence
Accessing/integrating patient perspectives on
health, disease, rehabilitation, personal
preferences. Interview skills Integration of
patient perspectives into decision
making Bilingual / Skills in the use of
interpreters Knowledge of resources within an
individuals community Effective
educator Awareness of racial disparities in
health and their impact on access to PT
services
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Marginalization and Conceptualization of
Cultural Competence
Not fully operationalized as a clinical
skill Special Interest Not essential in expertise
e.g Clinical ed. Conference
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Marginalization in Physical Therapy
Professional Culture

• Training
• -medicocentric- Emphasis on a biomedical
  perspective (culturally specific and value
  laden)
• -relative importance of behavioral sciences
• -Indoctrination

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Marginalization in Physical Therapy
Demographics
Homogeneous profession relative to the
population we serve.
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Marginalization in Physical Therapy
APTA Membership by Race August 2001
100
89.32
80
60
40
20
4.45
2.39
1.45
1.28
0.62
0
Other
Am Ind,
Alask
Hisp/Lat
Am/Black
Asian Am,
Caucasian
Afri
Pac Isl
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Marginalization in Physical Therapy
Americans with Disability by Race Bradsher, J.E.
1995
100
80
60
40
21.9
19.7
20
20
15.3
9.9
0
Other
Am Ind,
Alask
Hisp/Lat
Am/Black
Asian Am,
Afri
Caucasian
Pac Isl
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Marginalization in Physical Therapy
Result (Training and PT Demographics)
Dominant Culture
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Marginalization in Physical Therapy
Dominant Culture standards of social behavior
are culturally derived, the closer one is to
ones original culture dominant culture, the
harder it is to recognize the culturally
specific, rather than universal, base of accepted
norms for behavior
Harry, 1992
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Therefore it is acceptable for discourse
regarding expertise in PT to be divorced from-
the cultural context of the patient- clinical
skills related to cultural competence
e.g. this case, patient firs,t exceptions
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Demarginalization of Clinical Skills Related to
Cultural Competence
Challenge is to mainstream Demonstrate that
these are skills and that they are essential to
quality/expert PT practice Behavior must
demonstrate this
e.g. bus, diversity lecture/day
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Progress towards Operationalization of Cultural
Competence in PT

• Research- qualitative vs quantitative
• Academic- comfort, priorities, competence of
  faculty (e.g. ortho)
• Clinical- interview, influence of patient on
  intervention decisions, bilingual/interpreter

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(Vision) Physical Therapy Analysis
CLINICAL SKILLS EXPERTISE (includes
skills/operationalized cultural competence)
QUALITY CLINICAL OUTCOMES
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APTA

• Advisory Panel on Minority Affairs (1982- 2001)
• Accomplishments Plan to Foster Minority
  Representation and Participation in Physical
  TherapyMinority Scholarship FundIncreased
  visibility components, conferences, publications
• Challenges Marginalized, advisory to the board

e.g. stadium
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APTA

• Committee on Cultural CompetenceGoalsIntegratio
  n Interfacing1. Strategic plan Cultural
  Competence2. Review core documents3. Impact
  APTA strategies and activities related to health
  policy, education, practice, and research

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Example of mainstream initiatives/activities
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Evidence Based Practice Model
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Evidence Based Practice Model
Clinical Experience
Scientific Literature
Patient/Family Perspective
Informed Shared Clinical Decision Making
Process Etiology, Prognosis, Evaluation, Treatment
Clinical Hypothesis Clinical Decision
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Patient/Family Perspectives

• About What?

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Evidence Based Practice Model

• Informed Shared Clinical Decision Making Process
  Etiology, Prognosis, Evaluation, Treatment

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Patient/Family Perspectives

• Practicing and therefore also learning EBP
  should begin and end with patients you have to
  add a mastery of the clinical skills of patient
  interviewing, history taking, and physical
  examination, without which you can neither begin
  the process of EBP by generating diagnostic
  hypothesis, nor end it (by integrating valid
  important evidence with your patients values and
  expectations) Sackett et. al. 2000

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Explanatory Models
Cultural constructs of clinical reality Kleinman,
1978
e.g. Bells Palsy
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Dominance of Explanatory Models
Biomedicine Disease Pathophysiology Scientific
Evidence Impairments
Cultural Norms Changes in social
function Personal Experiences Religion Quality of
Life Patient Preferences
Clinicians
Patients
Disability
Kleinman, 1978
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Accessing Patient Perspectives
Unfortunately, patients do not overtly express
their true concerns in up to 75 of acute care
visits When these concerns are explored, there
is improved satisfaction, adherence, and disease
outcomes in Lang et. al. 2000
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Clinical Skills Associated with EBP

• Access Patient Perspectives
• a. Language

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Clinical Skills Associated with EBP

• Access Patient Perspectives
• b. Interview skills(direct questioning,
  non-directed facilitation, active listening)

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Clinical Skills Associated with EBP

• Access Patient Perspectives
• b. Interview Skills
• Integrate the need to access diagnostic data and
  explanatory model

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Clinical Skills Associated with EBP

• Access Patient Perspectives
• b. Interview Skills
• Attend to both cognitive and affective dimensions

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Clinical Skills Associated with EBP

• Integration of Patient Perspectives
• a. Integration of patient perspectives into
  clinical decision making progess (integration
  with other sources of evidence)

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Patient Perspectives
Patient Explanatory Model
Clinician Explanatory Model (scientific and
clinical evidence)
Compromise Model
Informed Shared Decision Making
Clinical Decision
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Mainstreaming of Cultural Competence

• Government Affairs
• Upper Payment Limit Regulation (Aug
  2001)Federal regulation that would reduce
  Medicaid payment to safety net/public hospitals
• Impact Significantly cut funding and reduce
  access to health care services (including PT) for
  low income populations
• Potential integration

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Demonstrating Cultural Competence
How can I demonstrate it if I dont know what
it looks like or why I need to?
It looks like Clinical skills that are essential
to expert PT practice Recognition and action in
mainstream initiatives Sustained and explicit
commitment We need to because Effectiveness/Outco
mes Relevance as physical therapists in the
lives of the population we serve
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Thank you