Session 4: Cultural Competency & Providing Culturally ...



ELDER Project

Fairfield University School of Nursing

Cultural Diversity

Cultural Competence

Session 4

Objectives:

At the end of this session, the participants will be able to:

1. Define and discuss components associated with cultural competence.

2. Explore the LEARN Model and how it relates to culturally competent care.

3. Apply the concepts of the LEARN Model to selected case studies.

4. Identify care taker responsibilities associated with providing culturally competent care.

Food Presentation…………………………………………….………..………5-10 minutes

Depending on one or two presenters

Cultural Competence…………..……………………………………..…………..30 minutes

A. Definition: “The ability of systems to provide care to patients with diverse values, beliefs and behaviors including tailoring delivery of care to meet patients’ social, cultural and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background or English proficiency.”

The Commonwealth Fund, New York, NY, 2002.

Cultural competence requires expansion of the ability to provide services effectively to people of all cultures, races, ethnic backgrounds and religions in a way that respects the worth of the individual and protects and preserves their dignity.

B. Components of Cultural Competence: diverse values, beliefs, behaviors and delivery of care

1. It is unrealistic to think that we can gain in-depth knowledge about health affecting beliefs and practices of every ethnic or cultural group you are likely to encounter.

2. It is valuable for us to have some understanding of common basic conceptions of health and illness held by various cultures.

3. There is a strong need to enhance communication and promote the integration of patients’ and providers’ perceptions of needs and solutions into the therapeutic process.

4. The LEARN Model is a communication framework that can be used to help healthcare providers improve communication, heighten awareness of cultural issues in medical care and obtain better patient acceptance of care.

C. Challenges to Culturally Competent Practice

1. Cultural competence is an approach, not a technique, in which each patient is seen as an individual. No two people embrace or practice their culture in the same way – the importance lies in gaining their perspective.

2. Be willing to ask the patient questions about their cultural beliefs and preferences.

3. View each encounter as an opportunity to add to one’s culturally competent skill set.

Cultural competence starts with awareness, grows with knowledge, is enhanced with specific skills and is polished through cross-cultural encounters.

D. The LEARN Model:

A communication framework that can be used by healthcare providers to overcome communication and cultural barriers to delivering quality patient care. It is composed of five steps:

1. Listen

o Listen with empathy and understanding to your patient’s perception of the problem.

o Encourage your patient to discuss their understanding of the cause and effects of their illness and to describe the treatment and resources they feel will help them get well.

o Questions that can be used to get this information can include:

▪ “What do you feel may be causing your problem?”

▪ “What do you feel might help or hinder your recovery?”

▪ “How do you feel the illness is affecting you?”

2. Explain

o Explain your perceptions of your patient’s illness, the recommended plan of care and management of self-care.

o Explain what you have in mind in terms the patient can understand.

o Take into consideration literacy level, cultural beliefs and past experiences, which may affect understanding and acceptance of any suggestions you give.

o Try to link your explanation to something the patient already knows.

o Do not ask if they understand or have any questions, rather talk about a particular point to which the new information can be applied.

3. Acknowledge

o Acknowledge your patient’s feedback and understanding of the illness and plan of care.

o Talk about the differences and similarities with your observations to help promote patient involvement.

o Areas of differences should be recognized and differences resolved.

o Whenever possible, integrate your patient’s suggestions into the care approach. This will give them a sense of control and commitment.

o If the patient’s suggestions appear harmful, explain the consequences.

4. Recommend

o Recommend a plan of care that fits within the patient’s parameters. The more involved your patient is in the development of the plan of care, the more interested they will be in its outcome.

o Listen to the patient’s concerns and agree on solutions that will enhance commitment.

5. Negotiate

o Negotiate a mutually agreed upon treatment plan.

o Form a partnership in the decision-making process. This is a key step and can lead to a variety of patient-specific approaches that will increase the chance of a successful recovery and healthier life.

E. Case study applications of the LEARN Model

The following case studies can be used to help illustrate application of this model of communication.

LISTEN:

A 28 year-old Vietnamese woman, social worker student, first seen in the doctor’s office due to weight loss, mood swings, nervousness, sweaty palms and an increase in bowel movements. She has lived in the U.S. for the last 5 years with her mother, brother and sisters. She has a history of depression with a previous suicide attempt. She was also diagnosed as legally blind 10 years ago. Upon physical exam and lab work, the doctor diagnosed her as having mild hyperthyroidism and she was started on medication. She eventually developed abdominal pain, mute attacks where she couldn’t even open her mouth, twitching and palpitations with chest pain. She said the medicine made her feel weak and fatigued so she stopped taking it. Additional lab work was drawn and came back normal. There was no physical explanation of her symptoms. It was felt she had anxiety and depression because of her disability and life stress. She started counseling and relaxation training. During her next visit, she was very agitated. She talked about a childhood experience when her family felt her blindness was due to demonic possession and a healer was called. They attempted exorcism, but it failed; the blindness persisted. The family then thought it was a sign that her illness was punishment for something that occurred in a past life. She was locked in a back room for several years before her immigration. She said she didn’t hold these beliefs anymore, but worried that she was a good person. The doctor gave her reassurance. She moved out to campus housing and her condition started to improve.

The attribution of the illness to possession of evil spirits is consistent with the religious traditions of her culture (Hinduism, Buddhism, Confucianism and Taoist religions). The failed exorcism suggested evil was present from a former life, which brought shame to the family. This justified confining her in the house as a child. The psychological burden placed on her resulted in somatization of complaints. Mental illness would be another mark on the family. After coming to the US and obtaining medical care, the patient had a change in attitudes and perception of self-worth. Careful probing and the open, nonjudgmental attitude of the doctor allowed the patient to share her background and acknowledge these experiences. It was only then that she could initiate steps towards improvement, like moving out and continuing her studies in a helping profession, which confirmed her goodness.

EXPLAIN:

A mother brought her 21-month-old Mexican-American male child with recurrent onset of fever, runny nose and noisy breathing into the clinic. He was sleeping restlessly and making sighing noises while asleep. Physical exam showed swollen mucus membranes and a nasal discharge, diagnostic of an upper respiratory track infection. The mother was concerned because 2 months ago the baby has a seizure that she associated with a high fever. She felt it precipitated “susto”, a fright disease evidenced by sighing and restless sleep. She wanted something to control the fever and prevent worsening of “susto”.

The doctor explained what an upper respiratory tract infection was and its effects on breathing. He suggested a decongestant and confirmed the relationship of fever to seizures and recommended antipyretics. He demonstrated the use of sponge baths to reduce fever and emphasized the importance of fever control in preventing seizures. He also suggested that the mother consult a folk healer about her questions about “susto”. The patient was seen in follow up with no further problems.

“Susto” in Latin-American folk illness is caused by fright. The source can be anything from a simple startle response to an encounter with spirits. Children are especially susceptible. Symptoms vary but include sighing and restless or poor sleep patterns. The doctor gave detailed biomedical explanations of the portion of the patient’s condition that he was able to treat and recommended consultation for the portion that lay outside the medical model.

ACKNOWLEDGE:

A 25-year-old Vietnamese woman was seen for a routine prenatal exam. Part of the exam included having blood work drawn. She returned with symptoms of weakness, fatigue, and stuffy and running nose. She felt it was due to blood removal; it weakened her system and caused illness. Her doctor was also Vietnamese and recognized the belief and acknowledged it, but also explained how much blood volume she actually had and compared it to blood donation, a larger volume without symptoms. She was pleased with the explanation and was less fearful and her symptoms went away.

The Chinese medicine influence in the patient’s response to the blood test is very important here.

RECOMMEND:

A 38 year-old Mexican-American male was seen for a chronic genitourinary problem. He experienced hematuria and right flank pain two years ago. He had recurrent episodes over the last 18 years of this pain and dysuria and was diagnosed with urinary track infections. Tests revealed a hydronephrotic area on the right kidney. Surgery was recommended but the patient was reluctant. He was concerned his blood was “low” and he would have trouble in surgery because of it. The doctor discussed the expected blood loss with surgery in relation to the total blood volume of the body. The doctor suggested delaying surgery until the patient could “build up” his blood with medications. The patient accepted this option and underwent an uneventful partial right nehrectomy.

Blood is “hot” in the Latin culture. It is also associated with strength in health and in a sexual sense. The patient felt the need to build up his blood to have reserve strength for the operation. The doctor was able to alleviate the patient’s concerns with his explanation and recommend treatment accepted by the patient to prepare himself.

NEGOTIATE:

A 48-year-old black male was seen for severe high blood pressure, congestive heart failure and advanced renal insufficiency. He had reached a stage in which dialysis was his only hope for survival. He initially refused saying he was a devout Christian and felt God would heal him instead. His doctor acknowledged the importance of God’s influence but suggested that opportunity for dialysis may be God’s way of survival. He pointed out there was nothing in the bible against dialysis and God helps those who help themselves. He consented and has a functional shunt and is doing well.

The patient practiced fundamental Protestantism, which believes direct intervention and control of health by God is supported in the Old Testament. The doctor was able to call on other aspects of Christian beliefs and that God sometimes works through other people. Dialysis and the doctors might be instruments God was using to intervene on his behalf. By using beliefs from the patient’s own religious background, the doctor was able to negotiate acceptance of recommended biomedical treatment.

F. Caretaker’s Responsibilities

1. Cultural interaction is created in verbal and nonverbal behavior, such as

o Spoken word

o Eye gaze/eye contact

o Head movements

o Facial gestures

o Touch

o Body posture/ postural orientation

o Interactional space

2. Seven lessons to learn about cross cultural communication:

o Don’t assume sameness

o What it thought of as normal behavior may only be cultural

o Familiar behaviors may have different meanings

o Don’t assume what we meant is what was understood

o Don’t assume what we understood is what was meant

o We don’t have to like or accept different behaviors, but making an effort to try to understand where it comes from is important

o Most people do behave rationally – discovering the rational is important

3. Caretaker responsibilities:

o Learn to use a few phrases of greeting and introduction in the patient’s native language. It conveys respect and demonstrates a willingness to learn about their culture.

o Reinforce verbal interaction with visual aids and materials written in the patient’s language.

o Repeat important information more than once.

o Always give reasons or the purpose for a treatment or prescription.

o Make sure the patient understands by having them explain it themselves.

o Avoid saying “you must” - rather, teach patients their options and let them decide, i.e. “Some people in this situation would…”

Conclusion: Effective communication enhances patient satisfaction, health outcomes, adherence to treatment and job satisfaction.

Activity: Case Study Presentations……………………………………………15 minutes

Case Study 1 Re-evaluate Ethics and Values from a Different Cultural Perspective

Case Study 2 Family Relationships; Truth Telling

Case Study 3 Conflicts about Disability, Right to Refuse Treatment

* Facilitator can choose any one or all (3). Each case study has a set of discussion questions. Choose one to discuss with the large group OR break the group into (3) smaller groups and allow discussion time. Have a representative from each group present their findings to the group as a whole.

Case 1: Re-evaluating Ethics and Values from a Different Cultural Perspective

An adolescent, unmarried girl in Saudi Arabia was brought to a hospital for an unrelated spinal problem when her American doctors discovered that she was pregnant. Two of the doctors, familiar with the gender expectations of young women, knew the pregnancy would bring great dishonor to the family and that punishment could bring death to the girl. They arranged for her to have an abortion in a neighboring country. They told her parents that treatment for the spinal problem was only available in this other country. A third doctor, who had only been in Saudi Arabia a short time, felt that he could not be part of this deception. The other two doctors urgently convinced the third doctor that the girl would be in serious danger if her pregnancy were revealed to her family. The third doctor reluctantly agreed to say nothing. At the last minute, as the girl started to board the plane, the doctor uncontrollably felt he could not go through with what he felt was an ethical violation of truth-telling and told the father that the girl was pregnant. The father immediately grabbed the girl and left with her. Several weeks later, the third doctor ran into the girl’s brother and asked about her condition. The boy shook his head and explained that the girl was dead. The family’s honor had been restored. The distraught doctor left Saudi Arabia.

Discussion questions:

1. What were the conflicting values the three physicians disagreed upon?

2. Did the third doctor make a mistake by telling the family or was he just doing what he felt was ethically imperative?

3. How might re-examining his ethics have helped the doctor make a better decision?

4. As the physician, what would you have done? How would you justify your actions?

Case 2: Family Relationships, Truth-telling

Mrs. Lee was a 49-year-old Cantonese-speaking woman who had emigrated years ago from China to the U.S. She lived with her husband and youngest son, Arnold, 22. Studies revealed that Mrs. Lee suffered from lung cancer that had metastasized to her lymph nodes and adrenal glands. Arnold did not want Mrs. Lee’s diagnosis known to her. Eventually, the cancer spread to her brain. Her physician, knowing her poor prognosis, suggested a DNR to her son, who refused to even discuss the possibility with his mother. Arnold felt that his role as son and family member meant he must protect his mother from “bad news” and loss of hope. He believed telling her the dim prognosis would be cruel and cause unnecessary stress. Though futile, the son insisted that all heroic methods be used, including a ventilator, to save his mother’s life. He accused the house staff and physician of racism and threatened litigation. As a family member, he considered himself, not the doctors or patient, responsible for his mother’s treatment. He felt an overwhelming family responsibility to save his mother from such an early and “bad death” as well as from perceived inadequate treatment.

Discussion questions:

1. Had you been the physician, what would you have done?

2. Explore Arnold’s point of view. What might he have been thinking?

3. How did cultural differences in the telling of bad news, treatment limits and the role of family differ between provider and patient?

4. How did Mrs. Lee’s age and her son’s sense of responsibility to the family affect her care?

5. What might have been some culturally competent options for the house staff?

6. How do the ethics of “informed consent” and autonomy fit into the beliefs of Mrs. Lee and her family?

Case 3: Conflicts about Disability, Right to Refuse Treatment

A Hmong child was born with a clubfoot. Doctors felt that the foot would cause social embarrassment and make ambulation difficult and recommended an operation to reshape the foot. The family believed that the foot was a blessing, a reward for ancestral hardships. Because the family believed “fixing” the foot would bring shame and punishment to the family and Hmong community, they refused treatment. The family went to the Supreme Court to defend their right to refuse treatment. They won.

Discussion questions:

1. What outcome would you like to have seen with this case? Why?

2. In this case, the operation did not involve life or death. Would the impact of the decision been different if it had?

References:

American Medical Student Association. Cultural Competency in Medicine. Retrieved October 6, 2010 from portals/0/documents/cultural_competency_in_medicine.doc.

Galanti, G. Cultural Diversity in Healthcare. Retrieved July 13, 2010 from .

Yeo, G. (2010). Culture Med Ethnogeriatrics Overview Assessment. Retrieved October 6, 2010 from .

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