Cultural Competence for Non-Clinicians

1
Cultural Competence for Non-Clinicians
2
Learning Objectives

• At the conclusion of this workshop participants
  will be able to
• Recognize the different types of settlement
  stressors experienced by new immigrant families
  and the negative impact these have on health.
• Identify how the social determinants of health
  affect immigrants and refugees.
• Describe culture, cultural competence, and the
  benefits of cultural
• competence
• Recognize the impact of personal biases,
  prejudice, and
• discrimination on the ability to deliver
  excellent service to
• patients, families and colleagues.
• Describe the relationship between cultural
  competence and
• service excellence.

3
New Immigrant Support Network

• Key aim is to improve access to quality health
  care and health information for new immigrant
  children and their families
• Year 1 internal focus on providing cultural
  competence education to healthcare providers and
  other staff, will continue through February 2011
• Champion initiative
• Train-the-Trainer Workshops
• Research and evaluation are ongoing

4
Translation

• 300 health-related patient education resources
  and other materials, e.g. consent to treatment
  form, into 5-9 languages
• Audio files created into all of these languages
• AboutKidsHealth.ca website translated into French
  and Chinese
• --Languages include French, simplified Chinese,
  traditional Chinese, Arabic, Spanish, Tamil,
  Urdu, Portuguese, Punjabi
• CIC provided input into languages to choose for
  translation

5
So why are you here today?
6
Health Disparities and the New Immigrant
Population

• Disparities are differences in health outcomes.
• Health disparities prevalent in new immigrant
  population, regardless of language, culture,
  race, health, disease beliefs.
• Youre here to better understand health
  disparities, how they affect the new immigrant
  population, and how you can contribute to
  cultural competence initiatives, including
  service excellence.

7
Miniature Earth
If we could turn the population of the earth into
a small community of 100 people keeping the same
proportions we have today, it would be something
like this. Miniature Earth Video
8

• The Health of New Immigrants
• How would you describe the health status of new
  immigrants upon arrival in Canada?
• The Healthy Immigrant Effect
• New immigrants arrive in Canada with better
  health scores and five years later have lower
  health scores than average Canadians .
• Why?

9
Walkabout Activity

• Walk around and review the posted data and
  statement clusters.
• After 10 minutes youll be asked to stand beside
  a cluster that is of most interest to you.

10
Definitions

• Social Inequities in Health Disparities judged
  to be unfair, unjust and avoidable that
  systemically burden certain populations.
• Marginalized Confined to an outer limit, or
  edge (the margins), based on identity,
  association, experience or environment.
• Racialized Groups Racial categories produced by
  dominant groups in ways that entrench social
  inequalities and marginalization. The term is
  replacing the former term known as visible
  minorities.

11

• Immigrant Experience

12
The Importance of Cultural Competence at SickKids

• Increasing Immigration
• Toronto is the destination of choice for 45.7 of
  all new immigrants to Canada (Stats Canada, 2006)
  
• By 2031, 63 of Torontos population will be
  members of racialized groups (Stats Canada, 2010)
• Culturally competent health care is one strategy
  for addressing and ideally reversing health
  disparities.

13
Immigrant Experience

• What are some challenges you think new immigrants
  may face during resettlement?
• Skills and credential recognition
• Racism/discrimination
• Language
• Access to affordable housing
• Access to appropriate community and settlement
  supports

14
Immigrant ExperienceResettlement Challenges

• Underemployment/unemployment
• Low socioeconomic status
• Lack of family/social support
• Lack of familiarity with the healthcare system
• Mental health (Post-traumatic stress disorder,
  depression)
• Inconsistent public policy between levels of
  government

15
Immigrant ExperienceResettlement Challenges

• Challenges directly related to healthcare
  include
• Healthcare coverage
• Access to and navigation of the healthcare
  system
• Lack of significant knowledge of and sensitivity
  to diverse healthcare needs
• Health Literacy

16
Sources of Health Disparities

• A review of over 100 studies regarding healthcare
  service quality among diverse racial and ethnic
  populations found three main areas that caused
  disparities
• Clinical appropriateness, need and patient
  preferences
• How the healthcare system functions
• Discrimination Biases and prejudice,
  stereotyping, and uncertainty (Institute of
  Medicine, 2002)

17
New Immigrant Health Disparities

• During their first decade in Canada, immigrants
  are far more likely than the native-born to
  develop tuberculosis.
• Crisis and conflict create mental suffering for
  refugees, who constitute about 10 of the
  immigrant population.

18
Immigration

• What is Canadas immigration policy?
• Why do families immigrate here?
• What is culture shock?
• What do hospital staff need to consider to
  provide service excellence to new immigrant
  patients?

19
Immigration

• Immigrant Someone who moves to another country
• Refugee An individual who flees their homeland
  due to fears of persecution based on race,
  religion, nationality, membership in a particular
  social group, or political opinion or activity
  (CIC, 2009)
• Permanent resident is an immigrant or refugee who
  has been granted the right to live permanently in
  Canada
• Refugee claimant is a person who has made a claim
  for protection as a refugee. (Canadian Council
  for Refugees, 2004)
• Non-status immigrants are individuals who have
  made their home in Canada but lack formal
  immigration status

20

• Immigrant Experience
• Immigrant Experience Video

21
Social determinants of health
22
Health Equity Terminology

• Equal means the same to ignore differences
• Equitable aims to produce the same opportunity
  for positive outcomes
• Disparities refers to the differences in outcomes
• Equitable Access refers to the ability or right
  to approach, enter, exit, communicate with or
  make use of health services

23
Social Determinants of Health

• The term social determinants of health emerged
  from researchers efforts to examine specific
  mechanisms underlying the different levels of
  health and incidence of disease experienced by
  individuals with differing socio-economic status.

24
Social Determinants of Health
Early life Aboriginal status
Education Employment working conditions
Food security Gender
Health care services Housing
Social safety net Income its distribution
Social exclusion Unemployment employment security
Raphael, D. (Ed.). (2008). Social Determinants of
Health Canadian Perspectives (2nd ed.).
Toronto Canadian Scholars' Press Incorporated.
25
Culture and Cultural Competence
26
Key Questions

• What is culture?
• What is cultural competence?
• Why is cultural competence important at SickKids?
  
• Who does cultural competence help?

27
What is Culture?

• Dynamic Created through interactions with the
  world
• Shared Individuals agree on the way they name
  and understand reality
• Symbolic Often identified through symbols such
  as language, dress, music and behaviours
• Learned Passed on through generations, changing
  in response to experiences and environment
• Integrated Span all aspects of an individuals
  life
• Nova Scotia Department of Health (2005)

What does culture mean to you?
28
Common Assumption

• Everyone who looks sounds the same...IS the
  same
• Being aware of cultural commonalities is useful
  as a starting point
• BUT
• Drawing distinctions can lead to stereotyping
• Making conclusions based on cultural patterns can
  lead to desensitization to differences within a
  given culture
• (Garcia Coll et al., 1995 Greenfield, 1994
  Harkness, 1992 Long Nelson, 1999 Ogbu, 1994)

29
Iceberg Concept of Culture
Like an iceberg, nine-tenths of culture is out of
conscious awareness. This hidden part of
culture has been termed deep culture.
30
Iceberg

• Above Ice

Festivals Clothing
Music Food Literature Language
Rituals
Beliefs Values
Unconscious Rules Assumptions
Definition of Sin Patterns of
Superior-Subordinate Relations Ethics
Leadership Conceptions of Justice Ordering of
Time Nature of Friendship
Fairness Competition vs Co-operation Notions of
Family Decision-Making Space Ways of
Handling Emotion Money Group vs Individual
31
Visible and Non-Visible Aspects of Culture
32
What are visible and non-visible aspects of
culture?
ChristopherI suppose something that would not be
perceived immediately would be my having cancer.
I don't have it anymore, I've been treated for
it, but nonetheless, my experience with it has a
large say in who I am. I am a humble person and I
don't feel as if I love to share everything with
everyone, just like my experience with cancer,
though I suppose now I am telling everyone who
reads this about my experience.I come off
frequently as either being very formal and polite
or as being coldhearted. The real me, however, is
very emotional and understanding. When I got
chemotherapy I saw children not even five years
old with more severe cases of cancer or
intestinal problems and I felt . . . I knew
something was wrong with this, with young,
innocent children being sick in the way they
were, and I wished I could take their pain and
suffering from them. From then on, I look at
people with a different outlook, and I see how
ignorant many people are from events like that,
and it lifts me to a new level of understanding.

33
What are visible and non-visible aspects of
culture?
OmarI know that I shouldn't but sometimes I
wonder how other people look at me. What do they
see first? My brown-ness, my beard, my cap, my
clothes, the color of my eyes, the design of my
T-shirt? I think that people see my skin color
first. They probably see me as a brown guy. Then,
they might see my black beard and my white kufi
(prayer cap) and figure out I am Muslim. They see
my most earthly qualities first. Brown, that's
the very color of the earth, the mud from which
God created us. Sometimes I wonder what color my
soul is. I hope that it's the color of heaven.

34
Personal Reflection Sheet

• Reflect on a time when your own cultural biases
  or assumptions influenced your interactions with
  others
• (with family, friends, in the hospital, outside
  of the hospital, etcetera)

35
What is Cultural Competence?

• A set of congruent behaviours, attitudes and
  policies that come together to enable a system,
  organization or professionals to work effectively
  in cross-cultural
• situations.
• (Terry Cross, 1988)

36
Actions that Support Cultural Competence

• Examine own values, beliefs assumptions
• Recognize conditions that exclude people such as
  stereotypes, prejudice, discrimination and racism
• Reframe thinking to better understand other world
  views
• Become familiar with core cultural elements of
  diverse communities

37
Actions that Support Cultural Competence

• Develop a relationship of trust by interacting
  with openness, understanding and a willingness to
  hear different perceptions
• Create a welcoming environment that reflects and
  respects the diverse communities that you work
  with and that you serve
• (A Cultural Competence Guide for Primary Health
  Care Professionals in Nova Scotia)
• 
  

38
Why is Cultural Competence Important at
SickKids?

• Patient Safety
• Cultural competence in health care is linked to
• patient safety. When culturally competent care is
  absent,
• the risk of preventable adverse events can
  increase.
• Adverse Events include
• Unnecessary hospital admissions
• Misdiagnosis
• Ordering of inappropriate,unnecessary tests or
  invasive procedures
• Discrimination potentially leading to substandard
  quality of care

39
Why is Cultural Competence Important at SickKids?

• Family-Centred Care
• Culture is an integral component of the family
  unit, and thus an integral component of
  family-centred care.
• Equity
• New immigrants were almost two and half times
  more likely to report difficulties accessing
  immediate healthcare than were Canadian-born
  residents. (Sanmartin and Ross, 2006)
• Quality
• A critical relationship exists between culture,
  language, and the safety and quality of care of
  patients from minority racial, ethno-cultural,
  and language backgrounds. (Johnstone and
  Kanitsaki, )
• Growing Diversity
• Growing cultural and linguistic diversity of
  population and patients/families

40
Cultural Competence
40

• We would not accept substandard competence in
  other areas of clinical medicine, and cultural
  competence should not be an exception.
• Dr. Joseph Betancourt, 2006

41
Benefits of Cultural Competence

• Higher cultural competency scores predicted
  higher quality of care for children with asthma
  (Lieu et al., 2004)
• A culturally competent smoking cessation
  intervention resulted in a higher rate of smoking
  cessation among African Americans (Orleans et
  al.,1998)
• More culturally competent physician behaviour
  resulted in patients who reported higher levels
  of satisfaction and were more likely to share
  information (Paez et al., 2009)

42
Service Excellence
43
Service Excellence Icebreaker

• Define what service excellence in your job means.
• Identify challenges you experience providing
  service excellence at work.
• Describe something you believe would help you
  deliver service excellence

44
Service Excellence at SickKids

• Strategic Objective Lead in world class quality
  and service excellence
• Service excellence focuses on exceeding
  expectations and being accommodating and flexible
  to the needs of those who rely on us, including
  children and families who come to us for care,
  and  staff members who access our services.
  (SickKids, 2010)
• SickKids will establish guiding principles for
  service excellence across both clinical and
  non-clinical areas and ensure that these
  principles become ingrained in our culture and
  are evident in our day-to-day interactions.
  (SickKids, 2010)

45
Success Factors for Service Excellence

• An emphasis on formal corporate and strategic
  planning
• A commitment to embrace and improve quality of
  care, involving
• Asking patients and families what they want
• Listening to patients and families
• Providing excellent service in light of patients
  and families requirement.
• A commitment to organizational flexibility and
  change, as well as improved organization climate.
• A focus on continuously reducing costs and
  improving productivity through ensuring patient
  safety, reducing length of stay
• An uncompromising attitude toward improving
  information systems
• 
  
  (Brathwaite, 1993)

46
Linking Service Excellence and Cultural
Competence

• Cultural competence and service excellence
  involve
• Willingness to learn what patients/families need
  and want, and to modify how you provide services
  to meet those needs
• Sensitivity to differences and embracing the
  pluralism of ideas
• Accepting and respecting patient/family
  differences
• Respectful communication with patient /family
• Willingness to adapt ones communication style to
  meet the needs of others and utilizing the
  patients preferred and most effective means of
  communication

47
Linking Service Excellence and Cultural
Competence

• A commitment to flexibility in the provision of
  care and services
• Recognizing healthcare access barriers, and
  helping patients/families overcome them
• Commitment to achieving health equity
• Demonstrating awareness, respect and sensitivity
  in eliciting sensitive information from patients
  and families
• Accurate identification and documentation of
  population and clients language preferences,
  level of proficiency and literacy
• Continuously engaging in reflective practice by
  reflecting before action, reflecting in action
  (during patient interactions) and reflecting on
  action (after patient interactions) (RNAO)

48
Mini Cases What would you do?

• You are having lunch with colleagues. A
  discussion of issues on the unit begins and
  someone mentions the new employee, who is an
  immigrant. Three people begin talking about how
  hard it is to understand her and a discriminatory
  comment is made.
• You have just finished coordinating a return
  visit for a patient and family who was having
  difficulty understanding your instructions due to
  a language barrier. After they leave, a
  colleague makes a discriminatory comment
  regarding the family.

49
Clinical Cultural Competence and Family-Centred
Care
50
Cultural Competence and Family-Centred Care

• Family-Centred Care
• Recognzing family as
• the constant in a childs
• life
• Facilitating child/family
• and professional
• collaboration
• Sharing information
• Understanding
• developmental needs
• Recognizing family
• strengths and
• individuality

• Culturally Competent
• Family-Centred Care
• Exploring and respecting
• child and family beliefs,
• values, meaning of illness,
• preferences and needs
• Recognizing and honouring
• diversity
• Implementing policies and
• programs that support
• meeting the diverse health
• needs of families
• Designing accessible
• service systems

• Culturally
• Competent Care
• Understanding the
• meaning of culture
• Knowing about
• different cultures
• Being aware of disparities
• and discrimination that
• affect racialized groups
• Being aware of own
• biases and
• assumptions

• Family-Centred Care
• Recognizing family as
• the constant in a childs
• life
• Facilitating child/family
• and professional
• collaboration
• Sharing information
• Understanding
• developmental needs
• Recognizing family
• strengths and
• individuality

(Adapted from Saha, Beach, Cooper, 2008)
51
Family-Centred Care
Culturally Competent Care
52
Cultural Competence Communication Strategies
53
Cross Cultural Communication
54
Assigning Meaning
54
What it means to me What it might mean to another
Not making eye contact
Saying YES
Spending time on small talk
Arriving late for an appt/class/work
Needing to consult family
55
Joy Luck Club
55
56
Context of Communication
56
Low Context
High Context

• North American culture
• Most of the information is made explicit in
  language used
• Information is often repeated for emphasis to
  ensure understanding (if it is relevant and
  important it must be stated, if it is not stated
  it is not relevant)

• Asian and Latin American cultures
• Is less explicit, most of the message is in the
  physical context or internalized in the person
• More emphasis on what is left unspoken, more
  likely to read into the interactions

57
Context of Communication
57
High Context
Low Context

• More responsibility on the listener to hear, to
  interpret and then to act
• More need for silence longer pauses (to reflect,
  understand the context and process the message)

• The responsibility for communication lies with
  the speaker it is better to over communicate and
  be clear then to leave things unsaid
• Silence and pauses often misunderstood as signs
  of agreement or lack of interest
• (Hall, 1976)

58
Collaborative Conversations
58

• 2 Key Ingredients
• Two concerns on the table
• Win/win solutions
• (Greene, 2006)

• 3 Steps
• Empathy Attempt to understand the other
  persons perspective
• Define the Concern Express your concern
• Invitation To generate solutions that address
  both concerns

59
Collaborative Conversations
59
3 2 Key phrases
Empathy - Understanding Two concerns Ive noticed . . . Help me understand . . Tell me more . . Can you explain that a bit more? What else are you thinking?
Define the Problem What Im thinking . . . Im concerned that . . . Ive been considering . .
Invitation to generate solutions Win/win solutions Would you be open to . . .. Could we consider . . . . What can we do about this? Lets consider . . . What about . . . I wonder if there is a way . . . .
60
Things to Consider
60

• How can having a collaborative conversation with
  someone contribute to Service Excellence?
• Other points to consider
• Power Dynamics
• Experience and Expertise
• Communication Styles

61
Health Literacy
61
62
Health Literacy
62

• Health literacy is the ability to access,
  understand and act on information for health
  (Canadian Public Health Association)
• It involves the ability to obtain, process and
  understand basic health information (Ratzan and
  Parker, 2000)
• Canadians with the lowest literacy scores are two
  and a half times as likely to see themselves as
  being in fair or poor health (Rootman
  Gordon-El-Bihbety, 2008).

63
Health Literacy
63

• It involves appropriate use of translated
  materials and resources such as interpreter
  services
• It is not enough to give the family a pamphlet in
  their own language

64
Costs of Not Providing Interpretation in Health
Care
64

• A literature review described inequitable care
  with regard to three specific areas
• Adverse events
• Patients who do not speak English are more likely
  to experience serious medical errors
• Inappropriate tests and procedures
• Hospital Utilization
• (Access Alliance, 2009)

65
How to Assess a Familys Need for an Interpreter
65

• Pay attention to non-verbal cues
• Ask the family to repeat back to you their
  understanding of what youve just told them

66
Interpreter ServicesSickKids Policy
66

• Interpreter Services
• Request must be related to direct patient care,
  with the focus on medical information
• The request must be made by a healthcare
  professional
• 24-48 hours notice must be provided

67
Telephone InterpretationSickKids Policy
67

• SickKids uses Language Line
• Recommendations for use of Language Line
• Urgent/stat or same day requests when information
  is crucial and must be conveyed immediately
• Language assistance for less common languages
• Requires the department cost centre code

68
Cross-Cultural Communication Strategies
68

• Assume differences
• Listen to stories
• Share your intent, your purpose, your thinking
• Ask for clarification
• Be sincere and respectful
• Acknowledge your own ethnocentrism
• Take risks and be prepared to apologize

69
Conclusion

• Cultural Competence is an integral component of
  service excellence as it acts to
• Create organizational flexibility and change and
  improve organizational climate.
• Continuously reduce costs and improve
  productivity by enhancing patient safety.
• Create an attitude toward improving information
  systems.
• Improve the quality of care.

70
EVALUATION AND COMMITMENT TO CHANGE
71
Questions?
72
THANK YOU!!
73
References

• Anderson, J. M., Blue, C., Holbrook, A., Ng, M.
  (1993). On chronic illness Immigrant women in
  Canadas workforce a feminist perspective.
  Canadian Journal of Nursing Research, 25(2),
  7-22.
• Canadian Council for Refugees (2005)
• Citizenship and Immigration Canada (2009)
• Cross, T. (1988). Service to minority
  populations Cultural competence continum. Focal
  Point, 3, 1-4.
• Free Country Media Production (n. d). Medicine
  Box Healthcare and the New American. Retrieved
  May 18, 2010 from http//video.google.com/videopla
  y?docid-5106027191893998854
• Greenfield, P. (1994). Independence and
  interdependence as developmental scripts
  Implications for theory, research, and practice.
  In P. Greenfield R. Cocking (Eds.),
  Cross-cultural roots of minority child
  development (pp.1-37). Mahwah, NJ Lawrence
  Erlbaum.
• Institute of Medicine (2002).
• Harkness, S. (1992). Human development in
  psychological anthropology. In T. Schwartz, G.
  White, C. Lutz (Eds.), New directions in
  psychological anthropology (pp. 102-122). New
  York Cambridge University Press.

74
References

• Hyman, S. E. (2001). Mood disorders in children
  and adolescent. Biological Psychiatry, 49(12),
  962-969.
• Kodjo, C. (2009). Cultural competence in
  clinical communication. Pediatrics in Review,
  30, 57-64.
• Lien, T., Finkelstein, J., Lozano, P., Chi, F.,
  Quesenberry, C. (2004). Cultural competency and
  other predictors of asthma care quality for
  medicaid insured children. Pediatrics, 114(1),
  102-110.
• Long and Nelson (1999)
• Meadows, D. (2001). The miniature earth project.
  Retrieved November 1, 2009 from
  http//www.miniature-earth.com/me_english.htm
• Nova Scotia Department of Health. (2002). A
  cultural competency guide for healthcare
  professionals in Nova Scotia. Retrieved November
  12, 2010 from http//www.healthteamnovascotia.ca/c
  ultural_competence/Cultural_Competence_guide_for_P
  rimary_Health_Care_Professionals.pdf
• Orleans, C. T., Boyd, N. R., Binglar, R., Sutton,
  C., Fairclough, D., Heller, D., McClatchey, M.,
  Ward, J. A., Graves, C., Flesisher, L., Baum,
  S. A self help intervention for African American
  smokers tailoring cancer information service for
  a special population. Prev. Med. 1998, 27(5),
  S61-S70.

75
References

• Ogbu, J. (1994). Racial stratification and
  education in the United States Why inequality
  persists. Teachers College Record, 96(2),
  264-298.
• Paez, K., Allen, J., Beach, M. C., Carson, K.,
  Cooper, L. A. (2009). Physician cultural
  competence and patient ratings of the patient-
  physician relationship. Journal of General
  Internal Medicine, 24(4), 495-498.
• Pollick, H. F., Rice, A. J., Echenberg, D.
  (1987). Dental health in recent immigrant in the
  newcomer schools, San Francisco, American Journal
  of Public Health, 77(6), 731-732.
• Raphael, D. (Ed.). (2008). Social Determinants of
  Health Canadian Perspectives (2nd Ed.). Toronto
  Canadian Scholars Incorporated
• Saha, S., Beach, M. C., Cooper, L. A. (2008).
  Patient centeredness, cultural competence and
  healthcare quality. Journal of National Medical
  Association, 100(11), 1275-1285.

76
References

• Sanmartin, C. Ross, N. (2006). Experiencing
  difficulties in accessing first contact health
  service in Canada. Healthcare Policy, 1(2),
  103-119.
• Statistics Canada (2006). Community profiles
  Toronto. Retrieved May 20, 2010 from
  http//www12.statcan.ca/census-recensement/2006/dp
  -pd/prof/92-591/details/page.cfm?LangEGeo1CMAC
  ode1535__Geo2PRCode235DataCountSearchText
  torontoSearchTypeBeginsSearchPR35B1AllCusto
  m
• Statistics Canada (2010). Projections of the
  diversity of Canadian population. Retrived June
  1, 2010 from http//www.statcan.gc.ca/daily-quotid
  ien/100309/dq100309a-eng.htm
• Times Magazine. (2010). Teens in America Class
  pictures. Retrieved May 21, 2010 from
  http//www.time.com/time/photogallery/0,29307,1698
  621_1509347,00.htmlixzz0lISMnQdm