Chapter 5Chapter 5Hallmarks 0f Cultural Hallmarks 0f Cultural Competence in Health Care Competence in Health Care ProfessionalsProfessionals

To identify challenges for health care professionals and their organizations in “walking the talk” of cultural competence

To describe how shared values in the health care professions provide the foundation for cultural competence

To use the Grubb Institute’s transforming experiences framework to describe role development of culturally competent health care professionals

To engage in an activity-based process of self-discovery and action planning that is grounded in the Grubb Institute’s transforming experiences framework to develop and improve individual cultural competence

Chapter ObjectivesChapter Objectives

Requires:1.Honest self-reflection2.Willingness to accept feedback3.Willingness to disclose truth about own values, beliefs and behaviorsCultural competence is grounded in an attitude and state of mind.

Personal Journey of Personal Journey of Cultural CompetenceCultural Competence

Ethical nature of health professional’s role (especially true for clinicians) demands cultural competence, yet that may not be the case in real world practice.

Acknowledging need for training can be viewed as admission of unethical behavior

For training to be effective, a gap must be acknowledged

Dilemma for Health Dilemma for Health Care ProfessionalsCare Professionals

Professional organizations espouse a value system (hierarchy of beliefs)

Value-based foundations permeate the work life and career of health care professionals

Practicing cultural competence – understanding one’s self and celebrating richness of each individual – requires self reflection

Professional Values as a Foundation Professional Values as a Foundation for Cultural Competencefor Cultural Competence

Human comfort level with homogeneity and lack of differentiation

Without challenging this fear and engaging with “the other”, personal transformation is not possible

Fear of differenceFear of difference

Avolio and Hannah (2008) – 5 constructs model of developmental readiness:Learning goal orientation – seeing ourselves as works-in-progress and using positive and negative feedback about our cultural competence to develop our full potentialDevelopmental efficacy – having confidence in our own ability to be culturally competent

Readiness for Self-DevelopmentReadiness for Self-Development

Self-concept clarity – knowing ourselves as we really are and demonstrating a balanced and realistic sense of our strengths and areas for development as culturally competent health care professionals

Readiness for Self-Development Readiness for Self-Development cont.cont.

Self complexity – being cognizant of our own complexity as an individual, including an awareness of how our formative life experiences and our own diverse group identities such as ethnicity, generation, and gender influence who we are in the context of diversity

Metacognitive ability – being self-aware of what we really think about diversity, engaging in honest self-reflection about how our thinking affects our emotional responses and actions in the context of diversity, and regulating our own thinking through cognitive reframing.

Readiness for Self-Development Readiness for Self-Development cont.cont.

Figure 5.1 – Grubb Institute’s Transforming Figure 5.1 – Grubb Institute’s Transforming Experience FrameworkExperience Framework

Person = Desire

Core values form the foundation of transformative experienceWhat are your core values?

Grubb Institute’s Grubb Institute’s Transforming Experience Transforming Experience

FrameworkFramework

Context = Resources

Reservoir of abundant resources, including the challenges and opportunities within one’s boundariesVarious systems that have shaped one’s development as a person

Grubb Institute’s Grubb Institute’s Transforming Experience Transforming Experience

FrameworkFramework

System = Purpose

Structure for achieving shared purpose – changes in part of a system has an effect on the whole system

Grubb Institute’s Grubb Institute’s Transforming Experience Transforming Experience

FrameworkFramework

Role – resultant manifestation (behavior) of integrating person (desire), context (resources), and system (purpose).

Does not exist without person, context or system

Grubb Institute’s Grubb Institute’s Transforming Experience Transforming Experience

FrameworkFramework

Self-reflection Activity-based Organized by the Transforming

Experiences Framework Requires developmental readiness

Journey of Self DiscoveryJourney of Self Discovery

1. Group identity and personal experience – what does it mean to be ____?

2. Implicit bias assessment – Harvard Implicit website – https://implicit.harvard.edu

3. Cognitive reframing – think, feel, do –change the thought that starts the chain

Person: Who Am I?Person: Who Am I?

What do your group identities mean to you?• Race, Ethnicity, Gender, Sexual Orientation

Ask a classmate who does not share the same identity group to interview you • Don’t stray from that identity to other group

identities Reflect on what you think, feel, and do during the

interview Is it easier to identify ‘what it means to be’ for

your majority/in group or minority/ out group identities? Why or why not?

What did you learn about yourself through this exercise?

What does it mean to be?What does it mean to be?

Explicit bias – attitudes that we are aware of

Implicit bias – attitudes that operate outside of our conscious awareness

Exploring Our BiasesExploring Our Biases

Web based self assessment tool We share common biases that favor

society’s in-groups Our implicit biases are a better

predictor of our behavior than our self-reported explicit biases

http://www.youtube.com/watch?v=n5Q5FQfXZag

Implicit Association Test (IAT)Implicit Association Test (IAT)

Implicit Bias and Clinical Decision MakingImplicit Bias and Clinical Decision MakingSource: Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L., Iezzoni L.I., Banaji M.R. (2007). Implicit bias among physicians and Source: Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L., Iezzoni L.I., Banaji M.R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, Sep 22(9), 1231-1238.its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, Sep 22(9), 1231-1238.

Clinical vignette: patient in ER with an acute coronary syndrome: race randomized• Respondents-medical residents in Atlanta & Boston

Questionnaire to measure explicit bias 3 IATs to measure implicit bias• Race preference• Perceptions of cooperativeness

• With medical procedures• In general

ResultsResultsSource: Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L., Iezzoni L.I., Banaji M.R. (2007). Implicit bias among physicians and its prediction of Source: Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L., Iezzoni L.I., Banaji M.R. (2007). Implicit bias among physicians and its prediction of

thrombolysis decisions for black and white patients. thrombolysis decisions for black and white patients. Journal of General Internal Medicine, Sep 22Journal of General Internal Medicine, Sep 22(9), 1231-1238.(9), 1231-1238.

No Explicit race preference or perception of cooperativeness

However, IATs revealed:• Implicit preference for whites • Implicit stereotypes of blacks as less

cooperative with medical procedures and less cooperative in general

“As physicians pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis”

Race and the BrainRace and the BrainKluger, J. (2008). Race and the brain. Kluger, J. (2008). Race and the brain. TimeTime Oct 20, 36. Oct 20, 36.

MRI Brain scans of white IAT test takers • M. Banaji, Ph.D., Psychologist, Harvard & L. Phelps, Ph.D,

cognitive neuroscientist, NYU• greater activation of the amygdala-a region that processes alarm-

when showed images of black faces than when shown white faces Given longer processing time, the anterior cingulate cortex

and the dorsolateral prefrontal cortel-regions that temper automatic responses- can moderate amygdala activation

Exposure to images of friendly faces can also help control the amygdala

“The more you think about people as individuals, the more the brain calms down” Dr. Phelps

ReflectReflect “The Implicit Association Test is controversial because

many people believe that racial bias is largely a thing of the past. The test’s finding of a widespread, automatic form of race preference violates people’s image of tolerance and is hard for them to accept. When you are unaware of attitudes or stereotypes, they can unintentionally affect your behavior. Awareness can help to overcome this unwanted influence.”

Anthony Greenwald, Ph.D.

Source: http://projectimplicit.wordpress.com/

Intervention: Cognitive ReframingIntervention: Cognitive ReframingThe Think, Feel, Do ChainThe Think, Feel, Do Chain

• Think• Feel• Think Again• Do

Cognitive Reframing IllustrationCognitive Reframing IllustrationThinking Again Thinking Again

Scenario: Baby Boomer resistance to EMR To ‘behave as if’ change what you do• Instead of a ‘work around’: offer incentives for

buy in; training, peer mentoring, etc.

Cognitive Reframing IllustrationCognitive Reframing Illustration‘‘Behave as if’Behave as if’

Context: What Influences Me?Context: What Influences Me?Lifeline Graph Lifeline Graph

Source: Eclipse Consultant Group (2004)Source: Eclipse Consultant Group (2004)

Observation – employees, patients, staff interactions, teamwork, environment

System: What Structure Do I System: What Structure Do I Operate In?Operate In?

What did you learn about your strengths and areas for development as a culturally competent health care professional?

What actions can you take to improve your performance?

Role: How do I want to Role: How do I want to operate?operate?

What are the personal strengths I discovered through the self-exploration exercises?

What actions can I take to build on these strengths?

What are personal shortcomings I learned about through the self-exploration exercises?

What actions can I take to address these shortcomings?

Example: I have friends from many different ethnic groups

Example: I can talk openly to my friends about our cultural similarities and differences.

Example: I have an implicit bias that favors straight over gay.

Example: I can attend diversity training seminars to learn more about sexual orientation.

Table 5.1 – Journey of Self-Discovery: Table 5.1 – Journey of Self-Discovery: Action PlanAction Plan

Attitude Cognitive reframing Explicit biases Hallmarks Implicit biases Model of developmental readiness Transforming experiences framework Value system

Key TermsKey Terms