Culturally and Linguistically Appropriate Service Standards and the Training of Practicing Health Pr

1
Culturally and Linguistically Appropriate Service
Standards and the Training of Practicing Health
Professionals

• Marjory Bancroft, MA
• Nataly Kelly

2
The CLAS Standards

• The Culturally and Linguistically Appropriate
  Services (CLAS) Standards for health care are
  the first federal or national standards for
  cultural competence in the U.S.
• Published in 2000 by the U.S. Dept. of Health and
  Human Services, Office of Minority Health
• Based on years of preparation and
  information/input from groups across the U.S.
• 14 standards in all, widely disseminated
• See http//www.omhrc.gov/templates/browse.aspx?lvl
  2lvlID15

3
The CLAS Themes

• In the U.S. today, they remain a landmark and
  guidepost in the field.
• The 14 standards are organized by theme
• 1) Culturally Competent Care
• (Standards 1-3)
• 2) Language Access Services
• (Standards 4-7)
• 3) Organizational Supports for Cultural
  Competence (Standards 8-14).

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What Is Cultural Competence?

• Cultural and linguistic competence is 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.
• U.S. Office of Minority Health
• (definition from the CLAS standards)

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Summary of the Standards

• Standard 1 Provide effective, understandable,
  and respectful care in a manner compatible with
  cultural health beliefs and preferred language.
• Standard 2 Implement strategies to recruit,
  retain, and promote a diverse staff and
  leadership.
• Standard 3 Ensure that staff at all levels and
  across all disciplines receive ongoing education
  and training in CLAS service delivery.
• Standard 4 Offer and provide language
  assistance, e.g., bilingual staff and
  interpreters.

6
Standards Summary (continued)

• Standard 5 Inform patients orally and in
  writing of their right to receive language
  assistances.
• Standard 6 Assure the competence of language
  assistance provided. Family and friends should
  not be used to interpret.
• Standard 7 Make available materials and post
  signage in commonly used languages.
• Standard 8 Develop, implement, and promote a
  written strategic plan to provide CLAS services.

7
Summary (continued)

• Standard 9 Conduct ongoing organizational
  self-assessments of CLAS activities.
• Standard 10 Collect data on patients race,
  ethnicity, and spoken and written language.
• Standard 11 Maintain a current demographic,
  cultural, and epidemiological profile of the
  community and conduct needs assessment.

8
Summary (complete)

• Standard 12 Develop collaborative partnerships
  with communities. Facilitate community/patient
  involvement.
• Standard 13 Provide culturally sensitive
  conflict and grievance resolution processes.
• Standard 14 Make public information about the
  organizations progress in implementing the CLAS
  standards.

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Training Challenges

• CLAS Standards are not well understood
• Different groups need different types of
  training, e.g., management (at all levels),
  clinicians, front-line and support staff,
  bilingual staff, interpreters, patients.
• There is limited funding and TIME for training
• Language and culture are huge areas to coververy
  broad, abstract, hard to tackle

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How to Train Cultural and Linguistic Competence?

• A large body of research documents the need for
  training in the CLAS standards
• A growing body of research documents the
  effectiveness of such training, but the research
  is of uneven quality (see e.g., Beach M.C. et al
  (2005). Cultural competence A systematic review
  of health care provider educational
  interventions. Medical Care 43(4)356-373.)
• Relatively little research targets what
  constitutes effective trainingwhat works?

11
State of the Research

• Most studies of cultural competence training
  used self-administered tools that have not been
  validated. The results of cultural competence
  training could be interpreted more accurately if
  validated tools were used.
• Gozu, A. et al (2007). Self-administered
  instruments to measure cultural competence of
  health professionals a systematic review.
  Teaching and Learning in Medicine, 19(2)180-190.

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What are the results of training?

• Beach M.C. et al (2005). Cultural competence A
  systematic review of health care provider
  educational interventions. Medical Care
  43(4)356-373.

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How well does training work?

• Beach M.C. et al (2005). Cultural competence A
  systematic review of health care provider
  educational interventions. Medical Care
  43(4)356-373.

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Cultural Humility

• Existing measures of cultural competence
  embed highly problematic assumptions about what
  constitutes cultural competence. They ignore the
  power relations of social inequality and assume
  that individual knowledge and self-confidence are
  sufficient for change. Developing measures that
  assess cultural humility and/or assess actual
  practice are needed if educators are to move
  forward in efforts to understand, teach,
  practice, and evaluate cultural competence.
• Kumas-Tan, Z. et al (2007). Measures of
  cultural competence examining hidden
  assumptions. Academic Medicine, 82(6)548-57.

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De Facto National Standards

• To support effective training, a landmark
  document was published in the U.S.
• Gilbert, J. (ed) (2003). Principles and
  Recommended Standards for Cultural Competence
  Trainings of Health Care Professionals. Los
  Angeles, CA California Endowment.
• This work laid down clear, effective standards
  for the education and training of health care
  professionals and health care staff in general.
• The document addresses both what such training
  should include and how to present it.

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Goals of Cultural Competence Training

• GOALS
• 1) Increased self awareness and receptivity to
  diverse patient populations
• 2) Clinical excellence and strong therapeutic
  alliances with patients
• 3) Reduction of health care disparities
  through improved quality and cost-effective care.
  
• Gilbert, J. (ed) (2003). Principles and
  Recommended Standards for Cultural Competence
  Trainings of Health Care Professionals. Los
  Angeles, CA California Endowment.

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Principles

• Cultural competence training should be organized
  around
• KNOWLEDGE
• SKILLS
• ATTITUDES
• Gilbert, J. (ed) (2003). Principles and
  Recommended Standards for Cultural Competence
  Trainings of Health Care Professionals. Los
  Angeles, CA California Endowment.

18
State of the Field

• Training occurs in different contexts
• 1) Embedded in the curricula of health
  professions schools
• Continuing education, e.g., grand rounds,
  webinars, online training modules, distance
  learning
• On-site trainings for all/some health care
  staff, including clinicians

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How Long Does Training Last?

• Within or outside the health professions schools,
  there is no consensus on length.
• A training session may last 45 minutes, a half
  day, one day, five days in the U.S., every
  conceivable format is embraced.
• A growing number of federal grants in health care
  in the U.S. require such training.

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Why We Need a Full Day

• It is necessary to allow adequate time out for
  staff to disengage from the intensity of their
  everyday work and to engage in cultural
  competence learning. Those involved in delivering
  training should have time to establish trust
  and rapport and to be aware of wider
  organisational factors which impact on the
  training.
• Papadopoulos, I., Tilki, M., Lees, S (2004).
  Promoting Cultural Competence in Healthcare
  Through a Research-Based Intervention in the UK.
  Diversity in Health and Social Care, 1(2)
  107-116(10)

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Format of Training

• To address participants knowledge, attitudes and
  skills, training should include a broad range of
  activities and approaches.
• A growing consensus in the field supports a move
  away from sharing only facts.
• Try small group work, role plays, film clips,
  lively discussions and demonstrations (e.g. how
  to use telephonic interpreters).

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Teaching cultural competence

• Different methods include Case study
  discussions these elicit many views and
  participant interactions occur Role play reveals
  hidden attitudes and challenges behavioursVideo
  materials this enables portrayal of many
  perspectives, demonstrates non-verbal
  communication and raises awareness.
• Bhui, K. et al (2007). Cultural competence in
  mental health care a review of model
  evaluations. BMC Health Services Research
  7(15), http//www.biomedcentral.com/content/pdf/14
  72-6963-7-15.pdf

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How to Set Up a Training

• Set goals and objectives.
• Select and invite participants.
• Limit numbers if possible to 35 or 40.
• Try to schedule a full day if feasible.
• Avoid classroom set-up of chairs (rows) as this
  makes adults feel back in school.
• Plan for multimedia format if possible.

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Effective Practices for Training

• Determine diversity and cultural competence
  goals, measure current performance against
  needs, design training to address the gap,
  implement the training, assess training
  effectiveness, and strive for continuous
  improvement. Higher level evaluations measuring
  whether employees have transferred learning from
  training to their jobs are paramount ... to
  convince stakeholders of training's value.
• Curtis, E., Dreachslin, J., Sinioris, M. (2007).
  Diversity and Cultural Competence Training in
  Health Care Organizations Hallmarks of Success.
  Health Care Manager, 26(3)255-262

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How to Prepare for a Training

• Conduct needs assessment from participants and
  the organization(s).
• Gather input from the local community.
• Determine cultural/linguistic demographics of
  target populations served by the agency.
• Select stories/examples/case studies/
• anecdotes that match target populations.

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How to Execute a Training

• Focus on PRACTICAL and RELEVANT information.
• Plan for and solicit lively, open discussions
• Avoid information overload.
• Include many small group activities.
• Vary the format and pace look for participant
  fatigue and switch modes.
• Remember a training is NOT a conference!

27
The Most Common Mistakes

• The single most common error seen in cultural
  competence trainings is an overload of
  information (knowledge) with no activities
  designed to effect changes in attitudes or
  skills.
• However, in the U.S. another extreme has emerged
  trainings focused entirely on changing
  attitudes, with almost no emphasis on knowledge
  or skills.

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Target Populations

• Often, training is requested/offered because of
  immigrants and refugees who do not speak the
  dominant language
• In fact, cultural competence training should
  address all diverse populations, taking into
  account, e.g., ethnicity, age, gender, religion,
  socio-economic status, sexual orientation,
  disability, etc.

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What Doesnt Work

• TO AVOID (at all costs)
• Telling participants what to think or how to
  feel.
• Simply standing in front of a series of
  PowerPoint slides and talking.
• Pre-empting honest discussion by making it
  painfully clear what the trainers biases are.

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Cookbook or Recipe Training

• MANY organizations want trainers to describe
  certain populations and their beliefs/practices.
• This approach does not work culture is too vast
  and patients are too idiosyncratic.
• Culture-specific guidance leads to stereotypes.
  
• There is no recipe book for cultural competence.
• Trying to describe a population often deeply
  offends participants from the group described.

31
Trainers Self-Awareness

• The workers need not be, as is often assumed,
  highly knowledgeable about the cultures of the
  people they work with, but must approach
  culturally different people with openness and
  respect a willingness to learn. Self awareness
  is the most important component in the knowledge
  base of culturally competent practice.
• Papadopoulos, I., Tilki, M., Lees, S (2004).
  Promoting Cultural Competence in Healthcare
  Through a Research-Based Intervention in the UK.
  Diversity in Health and Social Care, 1(2)
  107-116(10)

32
What Some Participants Feel

• Many participants want training but
• A backlash of political correctness can taint
  the training people may be prejudiced against
  it before walking in the door.
• Many cultural competence trainings are mandatory,
  creating further resentment.
• Some poor training has further tainted the field
  and its reputation.

33
Who Is the Trainer?

• There are no national standards in the U.S. for
  cultural competence trainers.
• Anyone can call themselves a trainer.
• Many trainers have few if any qualifications.
• Many health care organizations use in-house staff
  to train, yet they too lack knowledge, expertise
  and experience.

34
Knowledge, Skills, Attitudes

• Faculty development is particularly important
  because most instructors have not themselves been
  taught culturally competent care. Faculty must be
  able to teach and to model culturally competent
  care. Both faculty and students must improve
  their knowledge, skills, and attitudes, all of
  which are a substantial challenge, especially the
  last.
• White, A.A., Hoffman, H.L. (2007).
  Culturally Competence Care Education Overview
  and Perspectives. American Academy of Orthopedic
  Surgeons. 15(1), S80-S85.

35
Language Sample Questions/Feelings from Staff
Who Attend Trainings

• Why dont they just speak English?
• I dont see the problem. If someone speaks two
  languages, they can interpret.
• I know a bit of Spanish and I use hand gestures.
  Whats wrong with that?
• It costs too much to get interpreters.
• We dont have time to deal with this.

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Culture Typical Staff Misunderstandings

• We cant learn all those different cultures!
• These patients need to learn the culture of THIS
  country.
• They are costing us extra money.
• We need the resources for OUR citizens.
• Why are they always late to appointments or
  no-shows?

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First Things First

• Its important before a training to recognize who
  will attend and how they feel about diverse
  populations (and vice versa).
• Participants are largely unaware of laws and
  standards for linguistic/cultural competence.
• Health care staff today are often rushed,
  confused, stressed and worried.
• We have to recognize that resources may be VERY
  limited.

38
Know the Audience

• Trainers should know/find out as much as possible
  about the audience why they want/need training,
  local demographics, current attitudes, barriers
  (or perceived barriers) to services and quality
  care.
• Trainers should support respectful, yet open,
  dialogue on issues that are often very sensitive.
• Trainers must become aware of their own cultural
  incompetence and insensitivity in order to
  connect effectively to the audience.

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Culture is ALL OF US

• Culture isnt about minoritiesEvery time we
  talk about cultural competence it has to do with
  race and not about gender, religion,
  socioeconomic status, educational status. Its
  always about race. I dont think we had any other
  minority patients. . . . I dont want to say that
  I was offended, but I think that we really narrow
  the idea of cultural competence by having the
  only minority patient be about cultural
  competence.
• Millera, E., Green, A.R. (2007). Student
  reflections on learning cross-cultural skills
  through a 'cultural competence' OSCE. Medical
  Teacher, 29(4) e76 - e84

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Thank you!

• Marjory Bancroft, MA
• Ellicott City, Maryland, U.S.A.
• mbancroft_at_cultureandlanguage.net
• 410-750-0365
• Nataly Kelly
• Nashua, New Hampshire, U.S.A.
• natalyekelly_at_yahoo.com
• 603-891-1101