Valuing Cultural Competence in the Delivery of Health Care Services University of South Florida College of Nursing Tampa, Florida October 14, 2009 Time:

Valuing Cultural Competence in the Delivery of Health Care

Services

Valuing Cultural Competence in the Delivery of Health Care

ServicesUniversity of South Florida

College of NursingTampa, Florida

October 14, 2009Time: 9:00am-1:00pm

PRESENTERSPATRICK C. COGGINS PH.D., JD., LLD (HON.)

DAVID C. SOLAR, M.Ed.

P.C. COGGINS & ASSOCIATES, LLCMULTICULTURAL EDUCATION INSTITUTE, STETSON UNIVERSITY

Managing Cultural Competence in the Delivery of Health Care

WORKSHOP PURPOSE

To provide participants from the College of Nursing with experiential and practical applications that will enable nursing and other health care professionals to bridge existing gaps in cross-cultural interactions with ethnically and racially diverse patients and consumers in the USF and Greater Tampa Bay communities.

QUESTIONS TO BE ANSWERED

What is Cultural Competence?

Why is Cultural Competence necessary in the delivery of health care?

What are the benefits to be derived from using the case study method in learning about Cultural Competence?

What Cross Cultural values should drive nursing practices?

Which issues and strategies are research based?

What are the benefits to be derived from the use of a Cultural Assessment regimen by nurses and health care professionals?

© 2009, P.C. Coggins & Associates

SPECIFIC OBJECTIVES AND OUTCOMES

Understand the concept of Cultural Competence, specifically, the new CDC definitions which include the following Four Elements: 1) Cultural Diversity Awareness, 2) Culturally Competent Behaviors, 3) Cultural Sensitivity, and 4) Cultural Assessment (Coggins, CDC).

Apply experiential strategies that will increase the participants’ understanding of the practical application of:

Culture through semantic mapping (Leahy).

Commonalities vs. Differences through the Venn Diagram (De Anda).

Engage in experimental activities that apply innovative Cultural Assessment methods that are grounded in Culturally Competent Behaviors and Perspectives.

Review the seven (7) levels of Cultural Competence and their relevance to the delivery of Health Care.

Understand cross-cultural issues with respect to: a) Cultural generalizations about ethnic groups, b) Being adept to changing generalizations about ethnic groups, and c) Practical strategies to enjoy responsive interactions with cross-cultural and cross ethnic patients/clients.

Focus on the barriers to Culturally Competent Services.

Build an authentic Cross-Cultural Communication system that supports Cultural Competence in the workplace.

Understand the application of validated strategies through the use of relevant case studies that are appropriate for health care settings.

Other topics agreed on.

Managing Cultural Competence in the Delivery of Health Care

THE BASICS THE CONTINUUM OF WORKING ACROSS CULTURES

Cultural Destructiveness

Cultural Incapacity

Cultural Blindness

Cultural Pre-Competence

Culture Competence

Cultural Proficiency

Cultural Empowerment

Cultural Competence and Its Implications for Nursing Education

Cultural Competence Definitions Cultural Destructiveness:

Forced assimilation Subjugation Rights Privileges

For dominant groups only the AttitudesPoliciesPractices Create uneasiness, disconnect and are destructive to

the cultural group.

Cultural Incapacity: inability of systems to respond to the needs, interests, and preferences of culturally and linguistically

diverse groups.

Institutional or systemic bias; practices of discrimination in hiring and promotion; disproportionate allocation of

resources that may benefit one cultural group over another;

Subtle messages that some cultural groups are neither valued nor welcomed;

Lower expectations for some cultural, ethnic, or

racial groups.

Cultural Competence and its Implications for Nursing Education

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Cultural Blindness: Differences ignored, “treat everyone the same” Only meet needs of dominant groups. Focus on assimilation ignores cultural strengths Blaming the victim Little value placed on training and resources that

enhance cultural and linguistic competence. Workforce lack diversity are recognition of culture’s

perception and response to disease and illness.


Cultural Pre-Competence: Refers to the willingness to explore cultural issues

Assess needs of organization and individuals for effective cultural and linguistic resources

Hiring practices that support diverse workforce

Token representation on going boards, administrative positions

No clear plan to achieve individual and organizational cultural competence.


Cultural Competence: Refers to the organization recognizing individual and cultural differences

seek advice from diverse groups, hire culturally unbiased staff:Creates a mission statement for focus on

cultural and linguistic competence in all parts of organization.

Adapts evidence based promising practices that are culturally and linguistically competent.

Supports a common definition of cultural and linguistic competence.


Cultural Proficiency: Implement changes to improve services based upon cultural needs, do research and teach staff new approaches to being culturally and linguistically competent.Cultural Competence is integrated and held as a

core value in the organization.Develop and publish core values that support

cultural and linguistic competence.Develop and publish all health promotion

materials and communications that are sensitive and adapted to the cultural and linguistic needs of the population served.



CULTURAL COMPETENCE IN HEALTH CARE INSTITUTIONS

The ultimate level is Cultural Empowerment Cultural Empowerment is reflected in a

philosophy that the student/staff is a co-equal partner in the educational and learning process.

The organization’s Cultural Proficiency is actualized in intake, assessment, treatment planning, treatment process and treatment completion and follow up:


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The student/individual is consulted at every phase of the learning interaction/process.

The individual sees the integration of his/her culture and linguistic needs and attributes in learning, advising and social processes.

The individual is empowered to initiate and integrate cultural concerns in learning, classroom, advisory and social processes.

The individual respects and actively supports the infusion of his/her culture and linguistic dimensions in the learning, advising and social processes.

The interaction is characterized but mutual respect , mutual praise, acceptance of differences, recognition of similarities and mutual striving to achieve one’s best potentials through empowerment.

Organizations mission, policies and procedures reflect cultural empowerment

CULTURAL COMPETENCE IN HEALTH CARE SETTINGS – CULTURAL EMPOWERMENT

Advocate on behalf of the diverse populations served by the University organization.

Maintain partnerships with diverse groups in education, health, and community based and racially diverse organization.

Integrates as part of client assessment an assessment of the cultural background and dynamics of the client (Coggins & Bell, 2007 Model)

Progress in maintaining cultural and linguistic competence is discussed at each policy advisory and teaching decision making process.



Institutes cross cultural hiring and staff development in cultural competence.

Consumers begin to see and feel the presence of cultural and linguistic competence through sign (s), publications, interactions with the staff.

Continuous assessment of infusion of cultural competence in all operations.

Collect and analyze data using variables that impact on culturally and linguistically diverse groups.


The Cultural Competence Continuum in Nursing and Health Care Practice

*

(Cross 2002, Coggins 2007)

*Cultural Empowerment

added by Coggins (2006)

9© 2009, P.C. Coggins & Associates

Exercise 1: CLOSED EYE EXERCISE

Instructions:1. Fold the paper and make four

separate parts.2. Close your eyes and use only

one piece of paper. Using your Magic Marker or pen, please draw yourself with your eyes closed.

3. Now, get a second paper and draw yourself with your eyes open.

4. Now, close your eyes once more and listen for the ethnic group you are asked to draw.


Exercise 2: What is Culture?

“Culture represents the histories, attitudes, behaviors, languages, values, beliefs and uniqueness, which distinguishes each racial or sub-cultural group in a society. Each of us has a historical heritage and a contemporary heritage that comprises our present culture.” (Coggins, 2004)Definition of CulturePlease define in your own words the term of culture and indicate what values are expressed in the definition._______________________________________________________________________________________________________________________________________________________________________________________

© 2009, P.C. Coggins & Associates17

Exercise 3: Understanding Culture

Let us complete a concept map Native American Culture

Question – By changing the center what happens?

Task 1: Using the sheet of paper, map or web the concept of Native American

Culture.

Please put the word Native American Culture in the center of the paper.

Review your concept map and check to see if you have at least seven elements of the culture.

Task 2: Now working in groups, concept map the term Native American Culture by

combining all of the elements and information developed by each member of the group.

Task 3: Select a reporter to share the results of the group.

Task 4: In the space provided below reflect on what you have learned about the role

of provider with respect to understanding diverse cultures.© 2009, P.C. Coggins & Associates

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Exercise 4: Defining Cultural Competence

1. Please write your definition of Cultural Competence!

• Then! Join a group of six individuals and come up with a group definition of Cultural Competence.

• Post your group’s Definition on the news print and be prepared to share your definitions with the group.

Group’s Definition of Cultural Competence


Exercise 5: Assessing Your Cultural Competence

Model Your Commitment to Culturally Competence By: Yes No

1. Including Ethnic Content in the Nursing School Curriculum?

2. Teaching about major Cultures across the Nursing Curriculum?

3. Having Celebrations that include all Cultures?

4. Using Diverse Language in all Nursing School communication ?

5. Focus of Cultural Competence in the policies and procedures of the College of Nursing.

6. Retention focuses on relevant culture issues of patients/ students.

7. Has in place and monitors a mechanism for resolving interracial and intergroup complaints and conflicts.

Subtotal =© 2009, P.C. Coggins & Associates20

1. What key concepts should be considered in enhancing the Cultural competence of the Nursing Educator/Nursing Professional?

2. What key concepts and words can be used in the development of an assessment instrument in “Cultural Competence?”

Exercise 6: Group Questions


Exercise 7: Developing an Assessment Instrument for

Cultural CompetenceTask 1: Working in your groups of 6 and using the information you have learned thus far, please develop five questions that you would ask to get deeper into the culture of the patient/student.

Task 2: List Questions that you would include in assessment of the patient.

1.

2.

3.

4.

5.

Activity 1: Be prepared to post your questions on the newsprint.

2: Select a member of your group to share the information with the entire group.


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Exercise 8: Practical Application of the

Assessment ProcessTask 1: Now that you have developed an instrument

with questions that you believe are relevant and valuable, now move to the next task.

Task 2: Role play by selecting one person being the

a) Nurse/Professional, b) One person the patient/client/student/co-worker.

Task 3: The remaining members of the group must

keep time and provide feedback on how long the role players took to cover the assessment questions.

Task 4: The other group members should take turns

to experience the assessment process as either a) Nurse/Professional b) Patient/Client/Student.


Facilitator’s Processing of Assessment Play

The Facilitators will explore the following Questions/issues:1. How long did it take to complete each role pay using the five questions?

2. What was the shortest time recorded?3. What did each participant learn about assessing the

deep culture of an individual?4. Any other comment and feedback from the

participants.

Final Note from Facilitator

The ultimate goal is to develop the habit of assessing and knowing the student’s (staff’s) cultural background.

Rationale: Dr. Coggins taught a student for one (1) semester after which he assessed the students culture and discovered she was a “Seneca Indian member”. The student said, “It would have been nice if I knew that fact and included her culture in the content of the class”. For example, the inclusion of the Iroquois Nation’s contributions towards our US Constitution.© 2009, P.C. Coggins & Associates

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Summary of Components Which Comprise the

Definitions1. Cultural Diversity Awareness – Acquisition of

knowledge of the history and cultural characteristics of diverse groups (your patient/client/student).

2. Cultural Competent Behaviors – Habit of exhibiting appropriate behaviors with diverse individuals/groups. Always relevant and positive actions – Just Do It – Beyond Saying it.

3. Cultural Sensitivity – Be flexible, kind, non-harsh, non discriminatory- driven by genuine respect for the patient/client/student. (Feeling a sense of being cared for)

4. Cultural Assessment – To assess cultural needs of the client/student by asking appropriate questions, using data to enhance the treatment and services of patients/clients.


Exercise 9: Culturally Related Questions

1. Please answer the questions as briefly and concisely as possible by jotting down areas, concepts, or topics. “I would consider myself as a ‘Culturally Competent’ person because I…” __________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Supervisor/individuals/nurses and University staff could increase their “Cultural Competence” by developing or enhancing the following skills:__________________________________________________________________________________________________________________________________________________________________________________________________________________

3. The College of Nursing in the University I work for can ensure Cultural Competence between supervisors and workers, and with patients/clients/students by:__________________________________________________________________________________________________________________________________________________________________________________________________________________


The Mulatto: What are the Connections?

Jane, who is a very smart and friendly 20-year-old woman was experiencing severe depression, pains in her chest, and anxiety. She was told by her supervisor to, “stop acting up and take time off to straighten out her behavior... no more outbursts will be tolerated!” So her mother encouraged her to go to the hospital for help. Upon arriving at the hospital, Jane was asked by the nurse, “in case of an emergency, who should we contact?” Jane said, “my mother who is standing right here next to me.” The nurse said, “are you sure this is your mother? She is black and darker than you.”

Upon hearing the nurse’s comment, the mother was annoyed and demanded to see the supervisor or the doctor. The doctor came out and inquired about what was going on. The doctor shouted, “can’t you people conduct yourself properly?” Jane blurted, “we are fine, the problem is with this clerk who refuses to take down the information I provided about my mother!” Sensing a problem, the doctor said, “take the woman’s information down, okay?” The nurse did, and Jane’s mother strolled off to the waiting room.


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The Mulatto: What are the Connections?

Answer the following questions:

1. What were the cultural competence issues that were raised in this case?

2. What were the cultural needs of Jane and her mother?

3. What behaviors would have been more culturally sensitive and appropriate for caregivers?


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How to Heal

You are a caregiver. A middle-aged Korean woman with chronic back problems is admitted into your hospital. She speaks little English. Her husband speaks English and translates for her. When the husband is present, the patient denies pain. when the husband leaves the room, the patient admits to having pain.

You believe that the husband has little faith in the U.S. medical community. The husband says that he believes that pain medications interfere with the patient’s body’s “natural healing process” and he places the pain medication out of the patient’s reach. Instead, he provided his wife with herbal teas to help her “heal.”

You want to help the patient be more comfortable, but can’t get her to acknowledge the pain in her husband’s presence. You feel that the husband has no clinical experience to dictate how his wife should handle her pain. 29


How to Heal: Questions

Questions:

1. What are the issues from the patient’s perspective? From the husband’s perspective?

2. What are the possible “cultural” issues in this case?

3. Brainstorm how you could handle this situation more effectively.

4. How does the use of the husband as an interpreter impact the situation?

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A 19-year-old Hmong Male

A 19-year-old, English-speaking, Hmong college student, born and raised in the United States to Hmong immigrant parents, developed progressive liver failure requiring a liver transplant. He agreed to be placed on the transplant waiting list, but his family members, when presented with this information, rejected his decision, saying, “If you have this transplant, you will no longer be our son!”


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Answer the following questions:

1. What is your first reaction to this scenario?

2. Think about how you would proceed with this patient. What would you recommend in this case?

A 19-year-old Hmong Male


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Exercise 10: Processing the Case Studies

Basic Cultural Competence Principles

1. One size does not fit all.

2. Focus on Differentiated Cultural Interventions.

3. Assessing the Cultural Background to Find out the root causes and perception of Illness/Disease:

______________________________________________________________________________________________________________________________________________________________________

4. Using Best Practices to determine

______________________________________________________________________________________________________________________________________________________________________

5. Any other observations and comments.

______________________________________________________________________________________________________________________________________________________________________Facilitator’s Note: The College of Nursing is encouraged to Build Cultural Competence among staff by using the “Case Method” to discuss and explore common solution to creating a culturally competent school and clinic.


Why does this gap exist among ethnic groups in the USA in our nursing schools/departments/colleges?

1.________________________________________________________________

2.________________________________________________________________

Exercise 11: Examination of the Racial/Ethnic Gap Between Minority

and Majority Groups

Note: Culture is everything; we need to understand that humans have commonalities as well as differences. Avoid focusing on only differences. Also recognize the commonalities we share as humans.


Documents

Valuing Cultural Competence in the Delivery of Health Care Services University of South Florida College of Nursing Tampa, Florida October 14, 2009 Time: