A Faculty Development Program for Teachers of Internationally Educated Health Care Professionals

Workshop A

Educating for Cultural Awareness

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International Medical Graduates

● FACT: In 2002, 23% of physicians practicing in Canada obtained their medical degrees outside of Canada (AIPSO, 2004)

● FACT: In 2001/2002, 2039 of the 8684 residents training in Canada held MD degrees earned outside of Canada (Association of Canadian Medical Schools, 2003)

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1. Agenda

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2. Introductions

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3. Exercise: Establishing Group Norms

BRAINSTORM:

What type of environment enhances your ability to learn?

DISCUSS PROPOSAL:

All in agreement?

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4. What Would Be Helpful for You to Learn in This Workshop?

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4. Educating for Cultural Awareness Involves:

● Helping teachers develop an understanding of their own ethno-cultural backgrounds, beliefs, attitudes and values (self-awareness)

● Fostering acquisition of a greater understanding of and empathy for the cultural backgrounds and life experiences of IEHCPs (cultural diversity awareness)

● Promoting the development and integration of self-awareness and cultural diversity awareness into the teacher’s activities (skill development)

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● Framing cultural competence as a process of life-long learning for educators and health professionals alike

● Developing cultural awareness and responsiveness involves developing qualities and approaches as opposed to a concrete set of tasks or expert knowledge

4. Educating for Cultural Awareness Involves (Cont’d):

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4. Rationale

“Learning to think, act, lead and work productively in partnership with people of different cultures, styles, abilities, classes, nationalities, races,

sexual orientations and genders goes beyond acquiring new skills and attitudes…It requires

that the individual give up familiar ways of thinking, expectations, roles, and operating

patterns which they have come to assume are routine for all.”

Salmond, 2000

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5. Internationally Educated Health Care Professionals (IEHCPs)

● Canadian citizens who pursued their training outside of Canada

● Citizens of other countries with international health professions degrees in Canada on work visas

● Immigrants to Canada who have health professions degrees from institutions outside of Canada who are hoping to practice

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5. Integrating IEHCPs Into the Canadian Health Care System

BRAINSTORM:

What skills and experiences do IEHCPs bring to Canadian health care systems?

What challenges might they face in their integration to Canadian health care?

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5. Skills and Experiences of IEHCPs

● Knowledge of other countries, cultures, and health care systems

● Clinical expertise, often specialized

● May be older with more life experiences

● Knowledge of diseases less common in Canada

● Diagnostic and treatment knowledge less reliant on technology

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5. Potential Challenges to Practice for IEHCPs

● A number of entry routes to licensure and practice

● Adjustment to new cultures, health beliefs and health care systems

● Language issues even for those fluent in English

● Personal adjustment issues: loss of self-identity, extended family support, and/or self-esteem problems

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5. Potential Challenges to Practice for IEHCPs (Cont’d)

● Discrimination and racism

● Lack of training in cross-cultural communication strategies, certain bodies of medical knowledge, or clinical skills

● Familiarity with different educational styles

● Economic challenges

● Lack of institutional support for cultural or religious needs

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BRAINSTORM:

What have you learned by working with IEHCPs?

5. Potential Challenges to Practice for IEHCPs (Cont’d)

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5. Challenges for Teachers of IEHCPs

● A lack of knowledge of cross-cultural educational strategies

● Working with learners who do not speak English as a first language

● A lack of cultural awareness and sensitivity to the backgrounds, cultural patterns and needs of their internationally educated learners

● A lack of institutional support for the teacher or the IEHCP

Workshop Component 1:

Developing Cultural and Self-Awareness

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1. Culture as a Tapestry

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1. Weaving and Key Characteristics of Culture

● It is learned, not innate

● It is transmissible, through language and symbols

● It is dynamic, changing to respond to need

● It is selective, creating boundaries, limits

● It is ethnocentric (centred on itself)

● It has interrelated facets – it is a complex system where change in one area affects other areas

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BRAINSTORM:

What other than culture influences our beliefs and behaviours?

1. Weaving and Key Characteristics of Culture (Cont’d)

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2. What Other Than Culture Influences Our Beliefs and Behaviours?

● Personalities

● Self-awareness

● Past experiences

● Economic status

● Education

● Physical environments

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● Our identities are more complex than our cultural associations; we are neither solely influenced by one culture nor completely a product of our cultures

2. What Other Than Culture Influences Our Beliefs and Behaviours? (Cont’d)

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3. Exercise: Cultural Awareness

BRAINSTORM:

How would you describe cultural awareness and responsiveness?

In what ways can a teacher demonstrate cultural awareness?

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3. Cultural Awareness Defined

“An appreciation and consciousness of differences among groups with simultaneous

acknowledgment of the uniqueness of each individual.”

Salmond, 2000

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3. Cultural Awareness Guiding Principles

“Maintenance of a broad, objective, and open attitude toward individuals and their cultures” and avoiding “seeing all individuals as alike”

This requires willingness “of individuals and institutions to unearth, examine and shed light on their underlying assumptions about people

whose cultures differ from their own”

Wells, 2000

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3. Cultural Awareness in Action

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3. Cultural Awareness (Cont’d)

BRAINSTORM:

What are potential barriers to teaching in culturally aware and responsive ways?

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3. Cultural Awareness?

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3. Cultural Awareness? (Cont’d)

● Are there any problems with this comment?

● How much, and how quickly, can we expect those from other countries to change?

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4. What are Our Cultures?

How do they affect us?

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4. Discovering Cultural Values Through Proverbs

● Examples:

– Cleanliness is next to godliness

– A stitch in time saves nine

– Waste not, want not

● Others?

● Values in the proverb?

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5. Thinking About How We Think

● What: Note what word was triggered. Try not to censor yourself

● Where: Try to identify where you think the message came from

● Significance: Did you make any judgment about the message – Was it good? Bad? Happy? Sad? Beautiful? Ugly? Etc…

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6. Our Cultures

● We all belong to multiple cultures and sub-cultures

● Our cultures, as well as our personality, socio-economic status, education and physical environments, shape our perspective, or vantage

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6. The Blind Ones and The Matter of the Elephant

● What does this story say to you?

● Can you think of examples in your personal or professional life where these multiple versions of the experience exist?

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6. Our Cultural Vantage Point

“ ‘Vantage’: any observing mind has a specific point of view, and that point of view has physical, psychological, and cultural dimension that restrict

how much can be observed at any moment”

Bonder, Martin & Miracle, 2001

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6. Culture & Bias

● “Bias”: preferences, instinctive orientations or beliefs that shape our responses to each situation, some of which are rooted in heritage (LaMountain & Abramms, 1993)

● Being aware of our biases helps us to manage them better, making us more effective when working with people from less familiar cultural backgrounds

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7. Exercise: Reaching Consensus

● Groups of 3-4

● Read worksheet individually. Write “A” if you agree with the statement as is, or “D” if you disagree

● Once all have completed the list, review as a group

● On points of discrepancy among group members, discuss concerns and re-write the sentence in a way that all can agree

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7. Exercise: Reaching Consensus (Cont’d)

● Large group discussion: Each small group offers one sentence they altered, with an explanation of why the change was necessary

● Do you think this exercise would be different in more of a diverse group?

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8. Exploring Medical Culture

“Biomedicine is characterized as both a part of the larger culture, reflecting its mainstream norms, values, and beliefs, and as a culture in itself,

based on the classical scientific model, with its own language, structure, norms, values, and

beliefs.”

Loustaunau & Sobo, 1997

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8. Exploring Health Care CultureNatal Culture

Health Care Culture

Specialty Culture

Others?

Kagawa-Singer & Kassim-Lakha, 2003

Workshop Component 2:

Cultural Diversity Awareness and Sensitivity

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1. Exposure to Various Cultures

● Individual exercise

● With a partner, discuss which groups were easiest, and which were more challenging to answer, reflecting on why this was the case

● Larger group: Insights? Questions?

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2. Ethnocentrism and Stereotypes

● How we each experience cross-cultural interactions is shaped, in part, by our ability to challenge ethnocentrism and stereotypes

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2. Building on the Tapestry

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3. Ethnocentrism

“Ethnocentrism involves using one’s own standards, values, and beliefs to make

judgments about someone else. The standards against which others are measured are understood

to be superior, true, or morally correct.”

Loustaunau & Sobo, 1997

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3. Ethnocentrism (Cont’d)

“The tendency to use one’s own culture as the yardstick against which other cultural practices

are measured and judged. This ethnocentric tendency is likely to result in cultural imposition.”

Wells, 2000, citing Campinha-Bacote & Ferguson, 1991

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3. Is Ethnocentrism an Issue in Health Care?

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3. Is Ethnocentrism an Issue in Health Care? (Cont’d)

● What is the physician assuming in this statement?

● What are the problems with this assumption?

● Is it possible that health care professionals drop their cultural backgrounds when they walk into the clinic, the hospital, or the school?

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● Transfers into medicine via the basic tenets of science, where scientific knowledge is understood as ‘correct’ or ‘true’

● Assumes that medical knowledge is outside of cultural considerations. Medical knowledge is considered the correct way to explain illness phenomenon (Loustaunau & Sobo, 1997)

● Health care professionals are assumed to be homogenous (Beagan, 2000)

3. Is Ethnocentrism an Issue in Health Care? (Cont’d)

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4. Introducing Stereotypes

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4. Introducing Stereotypes (Cont’d)

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4. Case Studies

● “Everything You Need to Know About…”

● “Too Sensitive?”

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4. Building on the Tapestry

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5. Stereotypes

“Stereotypes are generalizations or categorizations about a particular group based

on some common feature (e.g. appearance, ethnicity, gender, etc.). Stereotyping is a common phenomenon… Categorization is a useful way to

cope with the myriad stimuli that occur in our environment. Stereotyping groups of individuals is

a way of extending the natural tendency to categorize.”

Bonder, Miracle & Martin, 2001

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5. Stereotypes (Cont’d)

● Viewing all members of a cultural group as alike, homogenous, leaving no room for individual variation or exception to common cultural patterns (Wells, 2000)

● Believing that all persons from a given culture prescribe to all characteristics attributed to that culture (Kemp & Rasbridge, 2004)

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5. Stereotypes (Cont’d)

● Relying solely on basic and imperfect markers of identity (such as ethnicity or gender) to set expectations about and interpretation an individual’s behaviours (Turbes, Krebs & Axtell, 2002)

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5. Stereotypes (Cont’d)

● Statements that rely on stereotypes often start with (or imply) “Africans are…” or “Muslims all…”

● Help us deal with complex information or insufficient information, but are destructive, obscuring the rich cultural tapestry from our comprehension (Kohls, 1984)

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6. Exercise: The Iceberg

When meeting someone new:

● What is immediately apparent?

● What is not immediately apparent?

● What are the implications of this when working with people from other cultures?

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7. What Are the Pitfalls of Stereotyping?

● Judging another too soon (Brownlee, 1978)

● Generalizing from a non-typical group within a larger society (Brownlee, 1978)

● Generalizing from the dominant or powerful group within a culture

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7. Pitfalls of Stereotyping (Cont’d)

● Forgetting the possibility of variation and change within the group

● Reliance on stereotypes lead to cultural misunderstandings, prejudice and discrimination, which can be enshrined in policy (Helman, 2001)

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8. Exercise: Stereotypes and Group Dynamics

● Five volunteers

● For discussion: Should we serve beer and chips at the orientation barbeque?

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8. Exercise: Stereotypes and Group Dynamics (Cont’d)

● Debriefing:

– Personal insights?

– Larger group insights?

– Withdrawal? Anger? Aggression?

– What clued you onto this response?

– Volunteers – guess labels, then remove

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9. Taking Difference into Account

● What does it mean to take difference into account without relying on stereotypes?

● What does this approach assume?

● Which approach is most likely to support the education of an IEHCP?

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9. Taking Difference into Account (Cont’d)

● Use generalization as a starting point, as opposed to using stereotype as an endpoint, the closed door after which no new information is sought (Galanti, 1997 in Kemp & Rasbridge, 2004)

Workshop Component 3:

Skill Development

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1. Cross-Cultural Communication

● Review: “Culture can be seen as an integrated pattern of learned beliefs and behaviors that can be shared among groups and include thoughts, styles of communicating, ways in interacting, views of roles and relationships, values, practices, and customs” (Betancourt, 2003)

● Focus is now shifting to culture and communication

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2. Exercise: Active Listening● Find a partner. Designate first talker

● Talker: Discuss a matter of personal interest or importance without interruption for 2 minutes, while the partner listens (without writing)

● Listener: Verbally summarize

● Talker: If inaccurate, corrects, and the listener re-summarizes

● Repeat until mutual understanding

● Switch roles

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2. Exercise: Active Listening (Cont’d)

● Large group discussion: What was striking about this process?

● How might this conversation differ in cross-cultural contexts?

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3. Effective Communication

● The key to effective cross-cultural interactions, whether with an IEHCP, a client from a different background than your own, or in your personal life, is communication

● A process by which two individuals exchange ideas, feelings, and meanings, through verbal or non-verbal means, intentionally or unintentionally

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3. Effective Communication (Cont’d)

● Intercultural communication: two or more persons who do not belong to the same culture attempt to communicate – happens all the time!

● The involved persons might not apply the same values, beliefs, assumptions and behavioural strategies to shape their verbal and non-verbal communication strategies

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3. Effective Communication (Cont’d)

“Obtaining knowledge about the preferred levels [and style] of…communication can help avoid

misinterpreting the communication behaviors of people from other cultures.”

Kim, 2002

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3. Features of Communication

● Pure communication is impossible, as we all bring prior associations to the communication process

● We communicate in many ways, and much of our communication is unconscious

● We see what we expect to see

● We don’t see what we don’t expect to see

● We all perceive things differently

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3. Features of Communication (Cont’d)

BRAINSTORM:

What are the implications of these ideas about communication when working with internationally

educated health care professionals?

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3. What Are Barriers to Effective Cross-Cultural Communication?

● Assuming similarity – that gestures and words have universal meaning

● Different non-verbal cues – variance in the extent to which cultures rely on non-verbal cues and what gestures indicate

● Verbal language use – the amount of talking/silence, use of names, slang & idioms, taboo topics, terminology

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4. Exercise: Communication Styles Simulation

● Seven volunteers for the simulation

● Read your communication task privately

● As a group, pick a location and food for a conference social event

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4. Exercise: Communication Styles Simulation (Cont’d)

● Debriefing:

– Was the style easy? Why or why not?

– What did you assume about each other?

– Larger group: Impact of the assumptions on the dynamic?

– How could this affect your work with IEHCPs?

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5. Culture & Communication Self- Awareness

● Knowing one’s own communication preferences is helpful.

● It is also helpful to identify communication styles that tend to trigger your own negative emotional responses; through awareness, we can consciously attempt to lessen the impact of these triggers.

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5. Exercise: Communication Values

● Fill in worksheets individually

● In partners, discuss the questions on the handout

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6. Effective Cross-Cultural Communication

BRAINSTORM:

What qualities do effective cross-cultural communicators embody?

What are some of the strategies by which we can bridge cross-cultural communication barriers?

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6. Tuning into Communication Conflicts

BRAINSTORM:

How do you know when a communication conflict is happening?

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6. Tuning into Communication Conflicts (Cont’d)

● Impatience and annoyance is a clue to a potential misunderstanding

● If questions seem intrusive or personal, recognize that this is considered essential in some cultures to build trust

● Exact mimicking does not suggest comprehension

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6. Tuning into Communication Conflicts (Cont’d)

● Hesitation to follow recommendations may indicate a hidden cultural barrier

● Treat others as they would like to be treated

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7. Bridging Cross-Cultural Communication Barriers

● Continually discover, reflect and clarify your own identities, preferences, biases

● With this awareness, consciously decide not to act on stereotypes

● Listen actively with respect, even if you disagree

● Increase your knowledge of various cultural patterns (see recommended reading)

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7. Bridging Strategies (Cont’d)

● Treat each individual as unique

● When confused, seek out more information or feedback

● Tolerate ambiguity

● Establish trust and show concern

● Be sensitive to the need to ‘save face’

● Humour and patience is key

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7. Bridging Strategies (Cont’d)

● Be attentive to non-verbal messages, while remaining aware that what gestures offend you might have different meanings.

● When unsure, ask for clarification

● Avoid language with unsure or questionable connotations

● Walk in another’s shoes (cognizant that you will still feel with your own feet)

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8. Exercise: Cultural Awareness Revisited

● Review your earlier ideas

● How would you describe a culturally aware and responsive teacher?

● What potential resources available here can help you learn about other cultures?

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8. Exercise: Cultural Awareness Revisited (Cont’d)

● What specific strategies can teachers use to further their self-awareness?

● How can you integrate cultural awareness into your teaching?

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8. How Can We as Teachers Become More Culturally Aware & Responsive?

● Access cultural information from reputable sources, including IEHCP learners

● Continue developing cross-cultural communication and teaching skills

● Commit to regular self-assessment via reflection

● Evaluate/seek feedback about your teaching skills regularly, including from peers and learners

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8. Effective Cross-Cultural Teaching

● Utilize your scientific mindedness. Develop a hypothesis based on observation and experience before information gathering

● Example: A new IEHCP in your tutorial group is quiet. Why might this be? Which possibility is most likely and why? How will you test your hypothesis?

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8. Effective Cross-Cultural Teaching (Cont’d)

● Cultivate your sense of when generalizations are appropriate, and when you need to individualize

● Example: A Polish IEHCP is starting to work in Family Medicine. Do you know what issues may present? Will they present with this learner?

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8. Effective Cross-Cultural Teaching (Cont’d)

● Use knowledge about cultural groups, their environments and useful educational techniques as baseline for comparison, not assumed to hold true

● Example: You know that in traditional Muslim cultures, men do not examine women. You have a new Muslim IEHCP in Family Medicine. How will you sort out their learning needs/comfort?

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9. Cultural Awareness in IEHCPs

BRAINSTORM:

How can we support IEHCPs in their adjustment and cultural awareness skill development?

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9. Supporting Cultural Awareness in IEHCPs:

● Create opportunity and prioritize time for IEHCPs and Canadian learners to attend similar training, specific to cross-cultural care

● Encourage regular self-assessment and reflection:

– Videotape yourself in action & review with colleagues

– Through a journal

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9. Supporting Cultural Awareness in IEHCPs (Cont’d) :

● Have the IEHCP keep a journal of cross-cultural experiences that were difficult and/or successful – both the situation and their own actions and reactions. Review periodically with the IEHCP or a group of learners, as a non-evaluative activity

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9. Supporting Cultural Awareness in IEHCPs (Cont’d) :

● Utilize some of the communication resources here to help IEHCPs develop a sense of their own communication values and preferences

● Assist the IEHCP in locating resources well- suited to their learning needs

● Role model culturally responsive approaches to care

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10. Case Studies

● “The Quiet Student”

● “Sexuality in the Clinical Setting”

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11. Communication Skills Competency

Howell’s (1982) model:

● Unconscious incompetence

● Conscious incompetence

● Conscious competence

● Unconscious competence

Note: Competence suggests an endpoint, a complete mastery. Being culturally responsive is a life-long process

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“Exposure and comfort are as important as knowledge”

LaMountain & Abramms, 1993

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11. Moving Forward

(A) Exercise: Individual Action Planning

OR

(B) Exercise: Group Action Planning